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

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  

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  

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