8.5. EXTREMITY INJURY/CONTROL OF EXTERNAL BLEEDING

Related titles

Absent.

Purpose of assistance

1. Minimization of blood loss due to bleeding from the limb.
2. Prevention of hemorrhagic shock due to bleeding from a limb.
3. Minimizing pain and further damage from potential fractures or dislocations.

Description of the patient

Inclusion criteria

1. Bleeding from the limb (external bleeding) due to injury.
2. Potential limb fracture or dislocation.

Exclusion criteria

Absent.

Management of the patient

Status assessment

1. Assess for obvious external deformity, shortening, rotation, or instability.

2. Neurological status of the limb:

a) sensitivity to light touch;
b) presence of distal mobility of the limb.

3. Condition of the vessels of the limb:

a) pallor;
b) pulse;
c) capillary filling;
d) volume of bleeding/blood loss with assessment of blood color (venous or arterial) and presence/absence of pulsation.

Treatment and intervention

(also note the picture below)

1. Control bleeding.

1.1. Press directly on the wound, then apply a pressure bandage.

1.2. If direct pressure/tight bandage does not work:

a) if the site of bleeding allows applying a tourniquet, apply a tourniquet to the limb:

• • • • the tourniquet should be located 4-5 centimeters higher than the upper edge of the wound. Do not apply a tourniquet in the joint area. The tourniquet should be applied until the bleeding stops completely and there is no distal pulse on the limb;
      • if bleeding continues, apply another tourniquet proximal to the first;
      • for injuries to the thigh, apply two tourniquets next to each other and gradually tighten them until the distal pulse disappears;

b) if the site of bleeding does not allow applying a tourniquet (i.e. injury to the connection), tightly bandage it with a hemostatic bandage and apply direct pressure.

1.3. Damage to the groin/axillary area:

a) apply direct pressure to the wound;
b) if bleeding continues, tightly bandage it with a hemostatic bandage and apply direct pressure;
c) consider using hemostatic connection device if available.

2. Control the pain (see the “Pain Control” guideline).

2.1. Analgesia should be carried out strictly only for suspected fractures.

2.2. If the tourniquet is used, the patient may need pain medication to control pain from the tourniquet.

3. Stabilization of suspected fractures.

3.1. Administer analgesia before starting to move a possible fracture.

3.2. When the distal pulse disappears, the anatomical position of the limb should be carefully given.

3.3. Use immobilization splints to immobilize a possible fracture.

3.4. If possible, elevate the broken limb above the level of the heart to minimize swelling.

3.5. Apply cold locally to minimize swelling for suspected fracture or soft tissue injury, do not apply ice directly to the skin.

3.6. Reassess distal pulse and neurologic function after each fracture/dislocation manipulation or splinting.

Patient safety

1. When using a hemostatic tourniquet:

a) make sure it is tight enough to cover the distal pulse to avoid compartment syndrome;
b) make sure the tourniquet is clearly visible and other professionals will be able to see it or recognize its presence;
c) do not cover the tourniquet with bandages or clothes.

2. Specify the application time on a visible place on the patient’s body.

3. In the case of applying a bandage or a tourniquet, conduct a periodic examination for timely detection of possible resumption of bleeding. Check if the bandage is bleeding or if bleeding continues distal to the tourniquet. DO NOT remove tourniquet or bandage to assess bleeding.

Useful information for training

Key points

1. A tourniquet is the primary means of stopping bleeding, and it can later be replaced by a tight bandage after an initial examination and sheltering of the patient. The tourniquet should not be removed if:

a) transportation time is short (less than 30 minutes);
b) amputation or condition close to amputation;
c) patient’s unstable condition or serious polytrauma ;
d) unstable clinical or tactical situation.

2. If the tourniquet is replaced with a tight bandage, leave the loose tourniquet in place in case it is necessary to use it if bleeding resumes.

3. Survival is significantly increased if the tourniquet is used before the development of shock.

4. Commercial/proven harnesses are more suitable than improvised ones.

5. In the absence of hemostatic bandages, tampon the wound with an ordinary bandage.

6. The use of pressure points on the artery is not an effective method of bleeding control.

7. The amputated part of the limb must be transported together with the patient for possible re-implantation:

a) it should be kept cool, but dry;
b) put the amputated part in a plastic bag;
c) put the bag with the amputated part in another an ice pack;
d) there should be no direct contact of the amputated part with ice.

Key elements of documentation

1. Vital signs, absence of a pulse after applying a tourniquet, compression bandage or splint.
2. Documentation of the fact of the absence of a distal pulse after applying a tourniquet.
3. Time of applying a hemostatic tourniquet.

Criteria for the effectiveness of aid provision

1. Correct application of hemostatic tourniquet (site, absence of distal pulse).
2. Correct marking of the location and time of application of the hemostatic tourniquet, as well as informing other specialists of the EMD system about its presence.
3. Correct application of immobilization splints for fractures.

Control of external bleeding at the pre-hospital stage

* The use of a hemostatic tourniquet to control bleeding on the limb is strictly recommended when direct pressure is ineffective or impractical; Use proven commercial hemostatic tourniquets. Avoid using narrow, elastic or rubber tourniquets. Use improvised harnesses if commercial harnesses are not available. Do not release the tourniquet until the patient arrives at the hospital.

** Local application of a hemostatic agent in combination with direct pressure in the presence of bleeding in places where it is impossible to apply a tourniquet, and creating only one pressure on the wound is not effective and practical. Apply hemostatic agents in the form of a special bandage created for tamponing wounds. Use only hemostatic agents that have been proven to be effective and safe to use (laboratory proven).
Source: Bulger et al. 2014