IMMEDIATE TREATMENT FOR A BLEEDING WOUND

ELEVATION If a patient’s limb is bleeding, raise it. This will usually control venous bleeding. If his wound is in the upper part of his body, sitting him up may help, but be careful that he does not faint.

DIRECT PRESSURE Press a large dressing firmly over his wound and wait five minutes. This is usually much more effective than a haemostat. Don’t do anything more until you have waited for at least five minutes, unless a torrent of blood pours from the dressing. If bleeding stops, be thankful and don’t meddle with the dressing.

PRESSURE POINTS These are much less effective than direct pressure. Press: (1) the patient’s carotid artery against the transverse process of his 6th cervical vertebra. (2) His temporal artery against his skull just in front of his ear. (3) His subclavian artery against his first rib. (4) His brachial artery against the middle of his humerus. (5) His femoral artery over his mid–inguinal point.

HAEMOSTATS If bleeding continues after after five minutes, a large vessel may have been injured, probably an artery, more likely from a tear rather than complete transection. When an artery is completely divided, bleeding usually stops. Secure the bleeding vessel with a haemostat. This is hardly ever necessary.

CAUTION! (1) Get proximal control by pressing on a pressure point first. (2) The vessel must be clearly visible. Don’t jab the haemostat blindly into a pool of blood. Be sensible about where you apply a haemostat. Some vessels accompany important nerves. For example, don’t crush a patient’s ulnar nerve in trying to clamp his ulnar artery.

When the haemostat is in place, incorporate it in the dressings. Don’t remove it and try to tie the vessel until he is in the theatre.

PACKING a Use this to control deep inaccessible bleeding when the above methods fail. Pack the wound with broad strips of folded gauze. If necessary, hold it in place with deep sutures taking a bite of the uninjured tissue well wide of the edges of the wound.

Figure 55.1: IMMEDIATE TREATMENT FOR A BLEEDING WOUND. A, the methods you see here will usually control arterial and venous bleeding from a wound like this one. B, raise the patient’s bleeding limb and press on the wound. C, and D, apply a pressure dressing. A roll of bandage kept firmly in place is a convenient way of doing this. Kindly contributed by Peter Safar

TEMPORARY SUTURES In some situations, such as the face, temporary haemostatic sutures may be useful. Don’t let them strangle the tissues.

FIRST AID TOURNIQUETS The few first aid indications for a tourniquet are: (1) When other methods of controlling bleeding have failed, bleeding threatens the patient’s life, and the risk of losing his limb can be accepted. (2) A rapidly increasing arterial haematoma in a closed injury. (3) Some cases of snake bite.

CAUTION! (1) A tourniquet is too often applied by first aid workers in a way which impedes the venous return, and so increases bleeding instead of stopping it. (2) Record the time at which it was applied. (3) It must be supervised and released every 15 minutes.

If a patient arrives with an effective tourniquet that has been in place more than two hours (rare), he is in serious danger of the crush syndrome. The sudden release into his circulation of toxic metabolites, especially myoglobin from his injured muscles, may cause renal failure and kill him. So, if an effective tourniquet has been in place for many hours, and his limb is ischaemic, amputate it at or above the level of the tourniquet.

Figure 55.2: THE SURGICAL ANATOMY OF THE ARTERIES. A, the pressure points. If direct pressure on a wound fails to control bleeding, press here to control it. B, the chances of gangrene if you tie an artery. Modified from ’Techniques Elementaires Pour Medecins Isoles’ with kind permission.