G’day everyone and welcome back to another blog. Recently, Paradise First Aid were proud to announce that, in partnership with Med Response Pty Ltd, we will now be the first and currently the only providers of the Stop the Bleed workshop based on the east coast of Australia. Director Andy and I have been signed off as the trainers to deliver this course, with Bonogin Valley Rural Fire Brigade members being the first recipients of this excellent training.

So what is ‘Stop the Bleed’? This international campaign has its roots in the USA where, following a number of terrorist and domestic mass casualty incidents, authorities determined that a number of casualties who died could, potentially, have been saved through the correct management of dangerous bleeding. In particular, it was the Sandy Hook mass shooting in Newtown, Connecticut which was the catalyst for a meeting of minds to determine protocols in dealing with these events. This culminated in what became known as ‘The Hartford Consensus’ where, in April 2013 the American College of Surgeons convened in collaboration with other federal agencies to create a protocol for a policy to enhance survivability from active shooter and intentional mass casualty events.

One of the components of the Hartford Consensus was that it identified three levels of responders: immediate responders; professional first responders; and trauma professionals. It is at the immediate responder level that the campaign is directed – those individuals who are present at the scene and who can immediately control any bleeding with their hands or other equipment that may be available. Having this knowledge and skills greatly increases the survivability of the casualties affected, because in as little as ten minutes (some say less than five), we can bleed to death from an arterial bleed.

Back here in Australia, the Australian Resuscitation Council also updated their guidelines on the management of bleeding. Whilst sustained direct pressure is still the initial treatment for a bleed, there is now more emphasis on the use of tourniquets and haemostatic dressings. Again, as a result of terrorist actions and mass casualty incidents overseas, as well as the involvement in wartime activities in both Iraq and Afghanistan, the development of bleeding management techniques has further evolved and progressed from what was previously taught in first aid courses.

Using techniques and research gathered in a military context and applied in a civilian setting, the whole bleeding management philosophy has changed. Whilst I’d normally dive into some pathophysiology of bleeding, this time I’m keen to concentrate solely on the treatment aspect. So let’s have a closer look at the management of bleeding.

External Bleeding

The use of pressure on or around the wound is usually the fastest, easiest and most effective method of controlling bleeding. If direct pressure alone does not stop the bleeding, other methods may be considered. It should be noted here that there is no evidence to suggest that elevating the limb that is bleeding will help control the bleeding, rather it has the potential to cause more pain or injury.

Bleeding should be managed as severe or life threatening in the following situations:

Amputated or partially amputated limb (above the wrist/ankle)
Shark attack, propeller strike, major trauma to the body
Bleeding not controlled by local pressure
Bleeding with signs of shock (pale, sweaty, pulse >100/min, capillary refill >2sec and/or decreased level of consciousness)

Management of bleeding

In all cases, first aiders must use standard precautions, such as gloves and safety glasses, if readily available. Where possible, laying down the patient and immobilising the bleeding limb will assist in the controlling of the bleeding.

Direct Pressure

Sustained direct pressure is the first option when controlling a bleed. This can be achieved by wadding a triangle bandage (or other similar material) into a pad and firmly applying pressure on to the wound with your hands. Be warned that some wounds may have more than one bleeding point, depending on the length or severity of the wound. A pressure bandage can then be applied to maintain the direct pressure.

If the bleeding continues, apply a second pad and a second, tighter, bandage. Ensure both bandages have been correctly applied. It may be necessary to remove both bandages to reassess and ensure that a specific bleeding point hasn’t been missed. The application of firmer pressure using one or two pads will be more beneficial than continually layering up further pads.

Useful tip – a rolled up gauze or crepe bandage placed directly over a wound, with a roller bandage over the top of this can result in an incredible amount of pressure being directly applied to a wound with excellent results.

Arterial Tourniquet

Arterial tourniquets are used where direct pressure is not working for life-threatening bleeding from a limb. Ideally, it should be applied to the ‘meaty’ part of the limb, not over a joint, and should be applied as per manufacturer’s directions (or 5cm above the bleeding point if no instructions). Tourniquets should not be covered up by clothing or bandages and the time of application should be noted on the tourniquet or clearly communicated to emergency/paramedic personnel.

There are several commercially available tourniquets on the market and the effective use is optimal when first responders are trained in correct and proper application techniques. If the initial application of the tourniquet does not result in the bleeding being controlled, check that it has been applied correctly and, ideally, not over clothing or wetsuits. If bleeding continues, a second tourniquet should be applied, ideally above the first. If correctly applied tourniquet/s have failed to control bleeding, consider using a haemostatic dressing.

A note on improvised tourniquets – whilst something is better than nothing, improvised tourniquets are unlikely to stop all circulation to the injured limb. Where possible, improvised tourniquets should be tightened using a twisting rod or stick under the improvised band to mimic the windlass of a commercial tourniquet.

A note on elastic venous tourniquets – as the name suggests, they’re for cutting off venous circulation, that is, the blood that returns to the heart. Using this for an arterial bleed will be about as effective as throwing a handful of sand in the face of your patient. In other words, don’t use them! The arterial blood will still flow through, but as the venous blood can’t return to the heart, it will pool in the vicinity of the wound. This is bad!!!

Haemostatic Dressings

Haemostatic dressings are impregnated with agents that help stop bleeding. They can be impregnated with agents such as kaolin or chitosan, or can also be a type of treated cellulose. Without going too deeply into detail, the substance that is impregnated into the dressing interacts with the clotting factors of the blood at a cellular level, increasing the chances of the blood clotting and therefore stopping.

Whilst commonly used in surgical and military settings, haemostatic dressings are becoming more and more common in civilian settings. They are of most value in severe, life-threatening bleeds from a part of the body where a tourniquet is not able to be applied and direct pressure hasn’t worked, or when used in conjunction with a tourniquet that hasn’t completely stopped the bleed.

In order to be effective, haemostatic dressings need to be applied as close as possible to the wound bleeding point. This may necessitate the first responder physically packing the wound so as to force the dressing as close as possible to the bleeding point of the wound. These dressings are then held with direct manual pressure before the application of a bandage, if available.

There are still some folk in the community that are reluctant to use tourniquets. This can possibly be as a result of a lack of knowledge, ingrained teachings from previous first aid course attendances, or from the thought of potentially causing further injury to the patient. However, the need to control bleeding is paramount. The risks associated with the application of tourniquets and haemostatic dressings are significantly lower than the risk of not doing anything for uncontrolled severe or life threatening bleeding. As always, this is a first aid treatment and not definitive care, the patient should always be transported by ambulance to a hospital.

Hopefully, this blog has highlighted the importance of stopping the bleed. The workshop that we offer goes into a lot more depth and in three and a half hours you’ll be given a lot of information, as well as the ability to practice applying a tourniquet and applying a haemostatic dressing to our very realistic wound simulators. If this interests you, please don’t hesitate in getting in touch with us. It will be run at our Helensvale training centre, or, if your venue is suitable, we can come to you. As always, stay safe and thanks for reading.