Massive Bleeding

When dealing with trauma that involves injuries from gunshot wounds, stabbings, blasts, or even vehicle collisions, a working knowledge of the MARCH protocol can possibly mean the difference between life and death. This is what the Lodestone Training and Consulting Medical classes are all about: getting the working knowledge of MARCH out to the real first responder.  That means you! 

In this article, I will focus on the “M” in the MARCH protocol, which deals with massive bleeding. Everybody knows that losing blood is a bad thing, and I’ve always had the opinion that knowing why something is bad may give a greater sense of urgency to someone who only views it as a dogma that needs no explanation. In order to grasp the urgency of controlling massive bleeding, it is important to understand some of the basics of what blood is, why it is essential to the human body and how massive blood loss or hemorrhage affects a person and can ultimately lead to their death. Towards the end of the article, I will explain basic methods of stopping massive blood loss. If, at the end of reading this article, you’re more confused than when you started, then just stop all bleeding at all costs anyway! 

Blood carries out many different functions that may or may not be directly applicable for my purpose now, but I will gladly write more about it if the demand exists. Blood is a source of life. It is one of the precious mediums through which we live and function on a day-to-day basis. Blood exists in our circulatory or cardiovascular system, which is a complex system of arteries, veins, and capillaries. For this purpose, we’ll start at the heart. Blood, or more specifically, red blood cells carried in the blood, go from the heart to receive oxygen at the lungs, where they are then returned to the heart, which pumps these oxygenated blood cells through the arteries to be distributed to every part of the body through a process called perfusion. The larger arteries are nearest to the heart (the aorta), and get progressively smaller and spread out to every organ, tissue, and cell that needs oxygen in order to stay alive via the arterial system. When they reach their destination and at their smallest point, they become capillaries. The red blood cells go through these capillaries where they exchange the oxygen they’re carrying for carbon dioxide and other wastes that are then transported from the capillaries to the venous system, again starting from small veins to big veins, and back to the heart, where the same process is repeated. 

Blood loss is the most common, yet the most preventable cause of death due to gunshot or penetrating trauma. An average-sized, adult male carries around 5-6 liters of blood and an average adult female around 4-5 liters. Of course, these numbers vary with body composition, age, fitness, etc. It suffices to say that after a certain amount of blood loss, death will inevitably come. Like I described in the previous paragraph, blood is needed in order to carry oxygen to the various cells that make up the various tissues and vital organs of the body, and to remove waste through perfusion. With an inadequate amount of blood to perfuse the body, the body goes through a process called “shock” that ultimately leads to death. Shock has been described as a “momentary pause in the act of dying.” How quickly death comes to a person experiencing massive blood loss depends on how much blood is lost and how soon adequate treatment is received. As we proceed further, I will be focusing specifically on wounds sustained on the extremities (arms and legs). 

Again, our purpose here is to discuss how to give a person experiencing massive blood loss the best possible chance of survival. If you look at what veins and arteries are, they are essentially interconnected hoses. Pinch off a conventional water hose or apply sufficient pressure to it, and the water is shunted or significantly restricted. The same holds true with our “biological hoses.” If a wound that presents significant bleeding is identified, immediately put pressure above the wound, or “proximal” to the wound (proximal being closer to the heart, and distal being further from the heart). Anatomically, your major blood vessels run on the inside of your arms and legs. On the arm, from the armpit down past the bicep muscle, and down to the palm. On the leg, from the groin, down to the inside of the knees, to the inside of the ankle. Adequate and sufficient pressure in these areas, while if not completely stopping, will significantly decrease the blood loss, and help preserve as many red blood cells as possible. 

Tourniquets have been proven to be the best method of definitive blood flow stoppage on extremity wounds. The ways tourniquets operate are by completely cutting off all distal pulses. For example, a wound causing blood loss from a radial artery on the left arm will present as blood gushing or spurting from that wound rhythmically with the heartbeat. Placing a tourniquet two to three inches above the wound and sufficiently tightening it will effectively stop the pulse and circulation below the tourniquet. In many instances, if the wound is located below the elbow or the knee, the tourniquet may need to be applied above either joint. The reason for this is that below those joints are two bones that will need to be compressed, compared to only one above the joints. Full amputations and partial amputations (a limb only hanging on by tendons or ligaments) should require tourniquet placement without hesitation. After placing a tourniquet, it is essential to recheck it often to make sure it’s holding the same tension. Moving or shifting the patient can cause the tourniquet to loosen up, and if you’re not constantly reassessing it, he or she can continue to slowly bleed out. Stopping blood loss is the priority. I say again: Stopping blood loss is the priority. 

The idea that you use a tourniquet as a last resort is an outdated, and potentially deadly notion for a person experiencing massive blood loss. Putting on a tourniquet doesn’t automatically mean that the affected limb will be lost and require amputation. It has been shown that a limb can still be saved without circulation for up to three to four hours. As a general rule, leave the tourniquet on for up to two hours before trying to reduce it. I’ll explain the method of reducing a tourniquet in another article. One reason why you do not want to be hasty in removing or reducing a tourniquet prematurely on a casualty is because you can destroy their clotting abilities. A couple of other important elements that flow through your blood in addition to red blood cells are, a protein, called fibrinogen, and cell fragments, called platelets. These elements assist in clotting, so it’s vital to understand that the urgency to stop massive bleeding is not limited only to preserving red blood cells. And, if you prematurely remove or improperly reduce a tourniquet, bleeding will resume, and these clotting factors that were built up at the bleeding site will wash out. Preserving the ability to clot, which is the body’s natural way to stop minor bleeding, is also very crucial to positive patient outcome. If in doubt, leave the tourniquet on. It’s better to lose a limb than lose a life. 

Other ways to stop bleeding are by clamping the blood vessels themselves. This can be complicated without proper equipment, though. Another thing to look out for and be aware of is internal bleeding. When you get a guy that has sustained some kind of injury, take care of all bleeding that you can see. Then do a head-to-toe assessment of the casualty and sweep him or her from top to bottom, remembering to check the back also. Any severe internal bleeding will be visible with massive swelling in the abdomen, and/or difficulty breathing from bleeding inside the lung space. Unfortunately, there is very little anyone can do with this. Your best bet is immediate evacuation. This guy or gal needs surgery ASAP. Early recognition is important. 

To recap: When an injury occurs that results in massive bleeding, all efforts immediately go to preventing further blood loss. Begin by placing pressure above the affected area to stop or slow the bleeding down. Next, apply a tourniquet or constricting device two to three inches above the wound or above the elbow or knee joints. Keep the tourniquet in place until medical personnel arrive. Make sure that any other wounds that are bleeding get treated also. Even minor cuts contribute to blood loss. Don’t get fixated on the most obvious and gruesome looking injury and neglect any other injuries. Again, it’s my hope that by understanding some of the physiology behind blood and blood loss, the act of stopping blood loss becomes more urgent to you, and you understand that death may occur if you hesitate.

Thanks for reading, 

Doc Pete