Operational Medicine 2001
Field Medical Service School
Student Handbook

Hemorrhage Control

FMST 0423

17 DEC 99

TERMINAL LEARNING OBJECTIVE:

1.      Given a casualty with life-threatening hemorrhage in a simulated environment (day and night) and the standard Field Medical Service Technician supplies and equipment, manage life-threatening hemorrhage, per the references. (FMST.04.24)

ENABLING LEARNING OBJECTIVES:

1.  Without the aid of references and given a list, select the correct purposes for bandages,

     per the student handout. (FMST.04.24a)

2.      Without the aid of references and a given list, select the correct purposes for dressings, per the student handout. (FMST.04.24b)

3.      Without the aid of references and a given list, identify the criteria for reinforcement

      and/or replacement of dressings, per the student handout. (FMST.04.24c)

4.      Without the aid of references and given a FMST MOLLE Medic bag and a simulated casualty, identify, treat, and monitor the casualty with life-threatening hemorrhage, per the student handbook. (FMST.04.24d)

OUTLINE:

A.     Hemorrhage

1.  Definition – the rapid loss of a large amount of blood from the body

2. There are generally only two avenues for significant blood loss:

a.       Loss of blood externally from wounds:

1.      External loss of blood, especially from wounds that damage the large vessels of the extremities are a common source of massive hemorrhage in combat.

2.      Fortunately, hemorrhages of this nature are usually easy to control

3.      Because these wounds may be fatal within 60-120 seconds, their treatment is the only time that deviation from securing an airway as the first priority of treatment should be considered.

a)       Rationale – you can bleed to death in less than one minute from a massive wound to a main vessel.  The body can go up to 4 minutes without oxygen before permanent damage occurs.

b)      Once the hemorrhage is controlled, the establishment of the airway once again becomes the primary concern.

b.      Loss of blood internally into the chest cavity, abdomen or pelvis.

1.      Occurs frequently with blunt trauma or blast injuries.

2.      Difficult to adequately treat in the field environment.

3.      High rate of mortality associated with internal chest, abdominal, or pelvic bleeding.

3. Treatment of Extremity Wounds:

a.       To stop the hemorrhage of an extremity wound, the initial effort is always focused at applying direct pressure to the site of the bleeding wound. 

b.      If direct pressure does not work, point compression of the proximal artery should be attempted while better control of bleeding is obtained at the wound. 

c.       If this does not work and the wound is still bleeding, a tourniquet should then be applied. 

1.      Do not allow the casualty to lose a significant amount of blood before deciding to use a tourniquet. 

2.      In a combat environment, the use of a tourniquet to control massive bleeding may be your first option. 

d.      If a damaged vessel can be directly visualized, a hemostat may be utilized to clamp the vessel to prevent further bleeding. 

1.      If the vessel cannot be directly visualized, this procedure cannot be performed.

2.      A wound should never be explored with a hemostat in an attempt to find the bleeding vessel. Exploration may cause further damage and promote additional bleeding.

3.      Treatment of Internal Wounds: 

1. Unlike bleeding from an extremity, blood loss into the major body cavities of the chest or abdomen cannot be controlled in the field.

2. Internal bleeding requires surgery under general anesthesia at an Echelon III Medical Facility (Fleet Hospital).  These patients should be medevac’d immediately.

3. Despite aggressive treatment and fluid replacement therapy, casualties with major internal vascular injuries frequently die in the field.

B.     Dressings:

1. Definition – either a commercially manufactured absorbent material or improvised materials used to cover and protect wounds from further injury, infection, or physical contamination.

2. Purpose:

a.       Promote hemostasis

b.      Protect the wound from mechanical injury

c.       Immobilize soft tissue wounds (large wounds)

d.      Protect the wound from further external contamination

e.       Provide physical and psychological support to the patient

3. Types:

 a.  4”x7”

1.      Military manufacturer

2.      Holds 300ml of blood when saturated

3.      Known as the “small” battle dressing

b.      7 1/2”x8”

1.      Military manufacturer

2.   Holds 750ml of blood when saturated

2.      Known as the “medium” battle dressing

c.       11 ¾”x11 ¾”

1.      Military manufacturer

2.      Holds 1000ml of blood when saturated

3.      Known as the “large” battle dressing

d.      18”x22”

1.      Military manufacturer

2.      Holds 2500ml of blood when saturated

3.      Known as an “abdominal” battle dressing

C.     Bandage

1. Definition - a piece of gauze, either commercially manufactured or improvised. It can be applied to wrap or bind a body part or dressing.

2. Purpose

a.       Hold dressings and splints in place.

b.      Provides additional pressure to the dressing or splint.

c.       Protects the dressing.

d.      Promotes homeostasis.

e.       Provides physical and psychological support to the patient.

3. Types:

a.       Kerlix

1.      Advantages

a.       Extremely absorbent

b.      Weave of material makes roll stretchable without elastic

c.       Sterile

d.      Good for packing cavities

2.      Disadvantages

a.       Looses bulk when wet

b.      Catches foreign bodies very easily

             b.  Ace wrap

1.      Advantages

a.       Can be applied quickly

b.      Gives pressure to the entire affected area

c.       Provides excellent support for sprains and strains

2.      Disadvantages

a.       Can decrease peripheral circulation

             c.  Cravats or Triangular Bandages (37”x37”x52”)

1.      Advantages

a.       The most versatile bandage /dressing made. Called by some the workhorse of the aid bag.

b.      Comes in small packages with safety pins.

c.       Two can be used solely together for hemorrhage control by:

1)      Using one for a dressing

2)      Using one for the bandage

2.      Disadvantages

a.       Has very little absorbency potential

            d.  Expedient (improvised) Dressings and Bandage

1.      Examples include:

a)      Patients clothing

b)      Patients equipment

2.      The only limitations are on the health care provider’s imagination.

D.     Application Principles

1. Do no further harm to the patient

a.       Assess circulation before and after applying bandages and dressings

b.      Assess neurological status before and after applying bandages and dressings

c.       Support all suspected fractures

2. Control bleeding (insure the dressing is tight enough)

3. Apply as aseptically as possible

4. Dressings will always cover all of the wound

5. Bandages will always cover all of the dressing:

a.       Keeps the dressing clean

b.      Provides pressure to the entire wound

c.       Prevents the dressing from getting caught on anything

6. Try to prevent neurovascular compromise

7. Avoid skin to skin contact

8. Leave the fingers and toes exposed if the injury permits

E.      Reinforcement Principles

1. Never remove the first dressing if possible.

2. When dressing is saturated add the next one on top of the first.

3. If the second dressing becomes saturated, the application of a tourniquet to control the bleeding might be necessary.

4. Remember that dressing saturation could be due to improper placement/pressure techniques.

REFERENCE (S):

1.  Tactical Emergency Care                                                        

2.  Emergency War Surgery                                                        

3.  Advanced Special Operations Medical Training Course       

Field Medical Service School
Camp Pendleton, California

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Operational Medicine 2001
Health Care in Military Settings

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