Injuries — bleeding

Visible bleeding can occur at the same time as internal (hidden) bleeding or tension pneumothorax
Consider internal bleeding into abdomen, pelvis or chest
Young person or pregnant woman can lose a dangerous amount of blood without looking very unwell

Red Flags — Urgent Medical Consult
Increased RR or work of breathing Pulse weak and fast (adult — more than 100/min) or difficult to feel Capillary refill longer than 2 seconds Pale, cool, moist skin Restless, confused, drowsy, occasionally unconscious Low BP for age or relative to person's previously recorded values

Do not

Do not remove any object sticking out of a wound
Do not remove any bandages that blood soaks through. Apply another bandage on top and maintain pressure

Do First

Try to stop visible bleeding

Apply firm direct pressure with gloved hands with or without pad — Figure 2.18
If something in wound — apply pressure to pads above and below or around object
Reduce fractures or dislocations
Infiltrate site with lidocaine (lignocaine) 1% + adrenaline (epinephrine) 1:100,000 (eg scalp wounds) up to 50mL
When bleeding controlled — bandage pad in place, elevate (raise) part and immobilise if needed

If lot of blood has been lost — lie person down

Figure 2.18

Use pad in gloved hand to apply pressure to bleeding wound.

Check

Calculate age-appropriate REWS

Adult — AVPU, RR, O₂ sats, pulse, BP, Temp
Child (less than 13 years) — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp

Weight, BGL

Do

Urgent medical consult if signs of shock — see red flags
Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
Put in 2 IV cannula, largest possible or gain intraosseous access
Run blood if available otherwise Hartmann's solution or normal saline — adult 500mL, pregnant woman 1L, child 20mL/kg — doses

Reassess for more fluids

Give tranexamic acid if within 3 hours of injury

Adult — tranexamic acid IV — 1g (in 100mL compatible fluid) over 10 minutes THEN 1g (in 1000mL of a compatible fluid) over 8 hours — doses
Child — tranexamic acid IV — 15mg/kg up to 1g over 10 minutes THEN 2mg/kg/h for 8 hours, dilution 500mg in 500mL of compatible fluid and infuse at 2mL/kg/h (maximum dose 125mg per hour) — doses

Medical consult — send to hospital

On-going care

Monitor for signs of shock — see red flags
Check every 15 minutes

Pulse — consider more IV fluids if pulse more than 100/min (adult). Pain and anxiety also cause fast pulse
BP — give more IV fluids if systolic BP less than 90mmHg (adult)
RR — increase may be early sign of deterioration

Consider POC Test
Put in indwelling urinary catheter — female, male

If urine output less than 0.5mL/kg/hr — probably needs more fluids

Keep patient warm — aim for normal temp

Bleeding limb

Do

If firm pressure for 10 minutes and elevating limb doesn’t stop bleeding

Put BP cuff on arm/leg above and close to wound, blow up to 30mmHg above systolic BP — Figure 2.19

Leave for 30 minutes
Let BP cuff down for 2 minutes
Blow up again and leave for another 30 minutes
Repeat until more help arrives

AND/OR

Try to find bleeding point and stop by

Direct pressure and infiltration of lidocaine (lignocaine) + adrenaline (epinephrine) 1:100,000 up to 50mL
If this doesn't work and good view of blood vessel — suture or clamp, if skilled (put clamps on carefully or nerves that run beside blood vessels may be permanently damaged)

Figure 2.19

BP cuff used as tourniquet on elevated leg with uncontrolled bleeding.

If torrential bleeding that still hasn't stopped

Medical consult — about further management
Put on tourniquet, several centimetres proximal (above) to wound — do not remove

Record time applied

Send to hospital urgently

Best chance to save limb if arrive within 4 hours of putting on tourniquet

If on warfarin give vitamin K
Give tranexamic acid 1g in 0.9% sodium chloride (100mL) over 10 minutes if not already administered within 3 hours of injury, then 1g in 1000mL over 8 hours