Bleeding Major bleeding may be a life-threatening condition requiring immediate attention. Bleeding may be external or internal.

Bleeding may be from an ARTERY, a major blood vessel which carries oxygen-rich blood from the heart throughout the body. It may be from a VEIN, which carries blood back to the heart to be oxygenated or bleeding may be from a CAPILLARY, the smallest of our body's blood vessels. ARTERIAL bleeding is characterized by spurts with each beat of the heart, is bright red in color (although blood darkens when it meets the air) and is usually severe and hard to control. ARTERIAL bleeding requires immediate attention! VENUS bleeding is characterized by a steady flow and the blood is dark, almost maroon in shade. Venus bleeding is easier to control than Arterial bleeding. CAPILLARY bleeding is usually slow, oozing in nature and this type of bleeding usually has a higher risk of infection than other types of bleeding. FIRST AID FOR BLEEDING IS INTENDED TO:

STOP THE BLEEDING PREVENT INFECTION PREVENT SHOCK

How to control bleeding

Apply DIRECT PRESSURE on the wound. use a dressing, if available. if a dressing is not available, use a rag, towel, piece of clothing or your hand alone. IMPORTANT: ONCE PRESSURE IS APPLIED, KEEP IT IN PLACE. IF DRESSINGS BECOME SOAKED WITH BLOOD, APPLY NEW DRESSINGS OVER THE OLD DRESSINGS. THE LESS A BLEEDING WOUND IS DISTURBED, THE EASIER IT WILL BE TO STOP THE BLEEDING!

If bleeding continues, and you do not suspect a fracture, ELEVATE the wound above the level of the heart and continue to apply direct pressure. If the bleeding still cannot be controlled, the next step is to apply PRESSURE AT A PRESSURE POINT. For wounds of the arms or hands, pressure points are located on the inside of the wrist ( radial artery-where a pulse is checked) or on the inside of the upper arm (brachial artery). For wounds of the legs, the pressure point is at the crease in the groin (femoral artery). Steps 1 and 2 should be continued with use of the pressure points. The final step to control bleeding is to apply a PRESSURE BANDAGE over the wound. Note the distinction between a dressing and a bandage. A dressing may be a gauze square applied directly to a wound, while a bandage, such as roll gauze, is used to hold a dressing in place. Pressure should be used in applying the bandage. After the bandage is

in place, it is important to check the pulse to make sure circulation is not interrupted. When faced with the need to control major bleeding, it is not important that the dressings you will use are sterile! use whatever you have at hand and work fast!

A SLOW PULSE RATE, OR BLUISH FINGERTIPS SIGNAL A BANDAGE MAY BE IMPEDING CIRCULATION.

OR

TOES,

Signs and symptoms of INTERNAL BLEEDING are:

bruised,swollen, tender or rigid abdomen bruises on chest or signs of fractured ribs blood in vomit wounds that have penetrated the chest or abdomen bleeding from the rectum or vagina abnormal pulse and difficulty breathing cool, moist skin

First aid in the field for internal bleeding is limited. If the injury appears to be a simple bruise, apply cold packs to slow bleeding, relieve pain and reduce swelling. If you suspect more severe internal bleeding, carefully monitor the patient and be prepared to administer CPR if required (and you are trained to do so). You should also reassure the victim, control external bleeding, care for shock (covered in next section), loosen tight-fitting clothing and place victim on side so fluids can drain from the mouth. The term hemorrhage is used in the medical field to describe bleeding. Many different types of hemorrhages may occur, each requiring different levels of medical treatment. The least concerning hemorrhages are those characterized as minor traumatic bleeding. These result from small wounds, and the amount of blood loss is not considered dangerous. In addition, the bleeding stops on its own without the need for medical intervention. The only area of concern is the possibility of infection setting in, which is a concern with all types ofhemorrhage. Severe traumatic bleeding is a greater cause for concern. With severe hemorrhages, a cloth used to cover the wound will become soaked in blood within a manner of seconds. If the bleeding is not stopped and the wound is not tended to, the person can die within a few minutes from loss of blood. Hemorrhages may also be categorized as externalized bleeding. This is characterized by blood flowing from orifices that are naturally found on the body, such as the ears, nose, mouth, urethra, vagina, or anus. With these hemorrhages, the bleeding starts internally and is caused by disease or trauma. This is not the same as internal bleeding, however, which refers to hemorrhages that occur inside the body and cannot be seen from the outside.

Common internal hemorrhages occur in the arteries, veins, and capillaries. Those affecting the arteries, which are responsible for carrying oxygen-rich blood to the heart, are referred to asarterial bleeding. These hemorrhages are difficult to control and are often life threatening. Internal hemorrhages affecting the veins, which return the blood to the heart, are calledvenous bleeding. These are easier to control than arterial hemorrhages, and while they do require medical attention, they are not as serious arterial bleeding. Bleeding from the capillaries, the smallest vessels in the body, is usually easier to control than arterial and venous hemorrhages. The slow nature of the bleeding from these vessels makes them highly susceptible to infection, however. Brain hemorrhages are another form of internal bleeding. With this type of bleeding, the blood may collect in the spaces between the brain and its membranes or within the brain tissue. These hemorrhages may affect one part of the brain or be located in only one hemisphere. If not treated properly and immediately, they can be fatal or cause permanent damage.

Three Main Types of Bleeding In preparing yourself to identify and treat different types of bleeding, you must first have a good understanding of the three distinct types of bleeding that a person can experience. Capillary Bleeding Capillaries are the smallest blood vessels in your body; they are about as thin as the hairs on your head. When a minor scrape or cut opens some capillaries, the bleeding is almost always very slow and small in quantity. Your body's natural clotting mechanism is able to stop most cases of capillary bleeding within seconds to minutes. Venous Bleeding Deep cuts have the potential to cut open veins. A cut vein typically results in a steady but relatively slow flow of dark red blood. The best way to stop most cases of venous bleeding is to put direct pressure on the wound. Arterial Bleeding

This is the least common and most dangerous type of bleeding. It involves bright red blood that comes out in large volume, and in spurts that correspond with each beat of your heart. In most cases of arterial bleeding, direct and extremely firm pressure on the wound is the best way of stopping it. If direct pressure is not applied, a severe arterial wound can cause you to bleed to death within a few minutes. How to Address Severe Bleeding 1. If possible, have the bleeding person lie down and position his or her head so that it is slightly lower than the trunk. Also, try to elevate his or her legs. Taking these measures will help to increase blood flow to the brain, which will decrease the chance of fainting. 2. If possible, elevate the body part that is bleeding. Doing so will reduce blood loss because the heart will have to work against gravity to pump blood to the injured area. 3. Remove large chunks of dirt and other debris from the wound, but if there is an impaled object, do not touch it. 4. Apply firm and direct pressure to the wound. In order of preference, use a sterile bandage, a clean cloth, clothing, or your hand to apply pressure. 5. Do not stop applying firm and direct pressure to the wound until the bleeding stops. When it does stop, use adhesive tape or clothing to secure the dressing (whatever you used) in place against the wound. 6. If the bleeding does stop and starts to seep through whatever you are using to apply pressure to it, do not remove whatever you are using. Rather, apply new absorbent material on top of it. 7. Once the bleeding has stopped, do your best to immobilize the injured area and leave everything as it is until professional treatment becomes available. Other First Aid Notes for Bleeding 1. The best treatment for a minor cut or scrape is to wash it thoroughly with water and plain soap. If possible, apply aloe or an antibiotic ointment onto the wound, and then cover with a bandage to keep it clean.

2. If a cut does not stop on its own with direct pressure for a few minutes, or it is clear that it is more serious than a minor cut or scrape, be sure to have a doctor look at it as soon as possible. Don't forget to do your best to stop the bleeding before you do anything else. 3. In the case of a puncture wound, stop the bleeding, if necessary, and visit your doctor or the hospital right away. Even if a puncture wound doesn't appear to be serious, it is important to take preventive measures to reduce your chance of experiencing an infection. 4. In the case of a blow to the head, especially either side of the head in the temple region, even if there is no bleeding, it is important to seek medical care immediately and to let the attending physician know where you were hit. Internal bleeding in the head region can be asymptomatic for the first several hours, and in some cases, can lead to death in just a day or two. All blunt injuries to the head require a thorough medical evaluation as soon as possible. 5. The vast majority of nosebleeds occur from blood vessels that line the cartilaginous septum that separates the right and left nasal chambers. To stop nosebleeds of this nature, sit or stand upright, then pinch your nose with your thumb and index finger for 5 to 10 minutes or less until the bleeding has stopped. Breathe through your mouth as you wait. If the bleeding does not stop within a reasonable time frame, it is best to seek medical care. In summary, the most important first aid guidelines for bleeding are: 1. The number one goal should be to stop the bleeding. 2. Never remove an impaled object - let a doctor do this. 3. Whenever bleeding cannot be stopped with direct pressure in a reasonable amount of time, seek medical care as soon as possible. 4. If you experience blunt trauma to your head, chest, abdomen, or pelvis, go for a thorough medical evaluation as soon as you can to make sure that you are not experiencing internal bleeding. This is especially important if you get hit on either side of your head in the temple region.

Bleeding

Bleeding (hemorrhage) is the escape of blood from capillaries, veins, and arteries. Capillaries are very small blood vessels that carry blood to all parts of the body.Veins are blood vessels that carry blood to the heart.Arteries are large blood vessels that carry blood away from the heart. Bleeding can occur inside the body (internal), outside the body (external) or both. Blood is a fluid that consists of a pale yellow liquid (plasma), red blood cells (erythrocytes), white blood cells (leukocytes), and platelets (thrombocytes). Plasma is the fluid portion of the blood that carries nutrients. Red blood cells give color to the blood and carry oxygen. White blood cells defend the body against infection and attack foreign particles. Platelets are disk shaped and assist in clotting the blood, the mechanism that stops bleeding. There are three types of bleeding. Capillary bleeding is slow, the blood "oozes" from the (wound) cut. Venous bleeding is dark red or maroon, the blood flows in a steady stream. Arterial bleeding is bright red, the blood "spurts" from the wound. Arterial bleeding is life threatening and difficult to control. In small wounds, only the capillaries are damaged. Deeper wounds result in damage to the veins and arteries. Damage to the capillaries is usually not serious and can easily be controlled with a Band-Aid. Damage to the veins and arteries are more serious and can be life threatening. The adult body contains approximately 5 to 6 quarts of blood (10 to 12 pints). The body can normally lose 1 pint of blood (usual amount given by donors) without harmful effects. A loss of 2 pints may cause shock, a loss of 5 to 6 pints usually results in death. During certain situations it will be difficult to decide whether the bleeding is arterial or venous. The distinction is not important. The most important thing to remember is that all bleeding must be controlled as soon as possible. External Bleeding While administering first aid to a casualty who is bleeding, you must remain calm. The sight of blood is an emotional event for many, and it often appears severe. However, most bleeding is less severe than it appears. Most of the major arteries are deep and well protected by tissue and bone. Although bleeding can be fatal, you will usually have enough time to think and act calmly. There are four methods to control bleeding: direct pressure, elevation, indirect pressure, and the use of a tourniquet. Direct Pressure Direct pressure is the first and most effective method to control bleeding. In many cases, bleeding can be controlled by applying pressure directly (Fig. 3-1) to the wound. Place a sterile dressing or clean cloth on the wound, tie a knot or adhere tape directly over the wound, only tight enough to control bleeding. If bleeding is not controlled, apply another dressing over the first or apply direct pressure with your

hand or fingers over the wound. Direct pressure can be applied by the casualty or a bystander. Under no circumstances is a dressing removed once it has been applied. Elevation Raising (elevation) of an injured arm or leg (extremity) above the level of the heart will help control bleeding.

Figure 3-1 Direct Pressure

Figure 3-2 Pressure Points for Control of Bleeding Elevation should be used together with direct pressure. Do not elevate an extremity if you suspect a broken bone (fracture) until it has been properly splinted and you are certain that elevation will not cause further injury. Use a stable object to maintain elevation. Placing an extremity on an unstable object may cause further injury. Indirect Pressure In cases of severe bleeding when direct pressure and elevation are not controlling the bleeding, indirect pressure must be used. Bleeding from an artery can be controlled by applying pressure to the appropriate pressure point. Pressure points (Fig. 3-2) are areas of the body where the blood flow can be controlled by pressing the artery against an underlying bone. Pressure is applied with the fingers, thumb, or heel of the hand.

Pressure points should be used with caution. Indirect pressure can cause damage to the extremity due to inadequate blood flow. Do not apply pressure to the neck (carotid) pressure points, it can cause cardiac arrest. Indirect pressure is used in addition to direct pressure and elevation. Pressure points in the arm (brachial) and in the groin (femoral) are most often used, and should be thoroughly understood. The brachial artery is used to control severe bleeding of the lower part of the upper arm and elbow. It is located above the elbow on the inside of the arm in the groove between the muscles. Using your fingers or thumb, apply pressure (Fig. 3-2E) to the inside of the arm over the bone. The femoral artery is used to control severe bleeding of the thigh and lower leg. It is located on the front, center part of the crease in the groin. Position the casualty on his or her back, kneel on the opposite side (Fig. 3-2H ) from the wounded leg, place the heel of your hand directly on the pressure point, and lean forward to apply pressure. If the bleeding is not controlled, it may be necessary to press directly over the artery with the flat surface of the fingertips and to apply additional pressure on the fingertips with the heel of your other hand. Tourniquet A tourniquet should be used only as a last resort to control severe bleeding after all other methods have failed and is used only on the extremities. Before use, you must thoroughly understand its dangers and limitations. Tourniquets cause tissue damage and loss of extremities when used by untrained individuals. Tourniquets are rarely required and should only be used when an arm or leg has been partially or completely severed and when bleeding is uncontrollable. The standard tourniquet is normally a piece of cloth folded until it is 3 or more inches wide and 6 or 7 layers thick. A tourniquet can be a strap, belt, neckerchief, towel, or other similar item. A folded triangular bandage makes a great tourniquet. Never use wire, cord, or any material that will cut the skin. To apply a tourniquet (Fig. 3-3), do the following: 1. While maintaining the proper pressure point, place the tourniquet between the heart and the wound, leaving at least 2 inches of uninjured skin between the tourniquet and wound. 2. Place a pad (roll) over the artery. 3. Wrap the tourniquet around the extremity twice, and tie a half-knot on the upper surface.

4. Place a short stick or similar object on the half-knot, and tie a square knot. 5. Twist the stick to tighten, until bleeding is controlled. 6. Secure the stick in place. 7. Never cover a tourniquet.

Figure 3-3 Applying a Tourniquet 8. Using lipstick or marker, make a 'T" on the casualty's forehead and the time tourniquet was applied. 9. Never loosen or remove a tourniquet once it has been applied. The loosening of a tourniquet may dislodge clots and result in enough blood loss to cause shock and death. Do not touch open wounds with your fingers unless absolutely necessary. Place a barrier between you and the casualty's blood or body fluids, using plastic wrap, gloves, or a clean, folded cloth. Wash your hands with soap and warm water immediately after providing care, even if you wore gloves or used another barrier. Internal Bleeding Internal bleeding, although not usually visible, can result in serious blood loss. A casualty with internal bleeding can develop shock before you realize the extent of their injuries. Bleeding from the mouth, ears, nose, rectum, or other body opening (orifice) is considered serious and normally indicates internal bleeding.

The most common sign of internal bleeding is a simple bruise (contusion), it indicates bleeding into the skin (soft tissues). Severe internal bleeding occurs in injuries caused by a violent force (automobile accident), puncture wounds (knife), and broken bones. Signs of internal bleeding include: 1. Anxiety and restlessness. 2. Excessive thirst (polydipsia). 3. Nausea and vomiting. 4. Cool, moist, and pale skin (cold and clammy). 5. Rapid breathing (tachypnea). 6. Rapid, weak pulse (tachycardia). 7. Bruising or discoloration at site of injury (contusion). If you suspect internal bleeding, do the following: 1. Bruise (contusion) - Apply ice or cold pack, with cloth to prevent damage to the skin, to reduce pain and (edema) swelling. 2. Severe internal bleeding: a. Call local emergency number or medical personnel. b. Monitor airway, breathing, and circulation (ABCs). c. Treat for shock. d. Place casualty in most comfortable position. e. Maintain normal body temperature. f. Reassure casualty Nosebleed Nosebleeds (epistaxis) can be caused by an injury, disease, the environment, high blood pressure, and changes in altitude. They frighten the casualty and may bleed

enough to cause shock. If a fractured skull is suspected as the cause, do not stop the bleeding. Cover the nose with a loose, dry, sterile dressing and call the local emergency number or medical personnel. If the casualty has a nosebleed due to other causes, do the following: 1. Keep the casualty quiet, sitting with head tilted forward. 2. Pinch the nose shut (if there is no fracture), place ice or cold packs to the bridge of the nose, or put pressure on the upper lip just below the nose. Inform the casualty not to rub, blow, or pick his or her nose. Seek medical assistance if the nosebleed continues, bleeding starts again, or bleeding is because of high blood pressure. If the casualty loses consciousness, place them on their side to allow blood to drain from the nose and call the local emergency number or medical personnel. Foreign bodies in the nose usually occur among children. First aid consists of seeking professional medical attention. Nasal damage and the possibility of pushing the object farther up the nose can result from searching and attempts at removal by unqualified personnel. Casualties with severe external bleeding and suspected internal bleeding must be seen by medical personnel as soon as possible. All casualties with external and internal bleeding should be treated for shock. References 1. Karren, K. J. and Hafen, B.Q.: First Responder A Skills Approach, edition 3, Morton Publishing Company 2. American Red Cross Standard First Aid Workbook, edition 1991, American Red Cross 3. NAVEDTRA 10669-C, Hospital Corpsman 3 & 2