HEMORRHAGE

CONTROL
WOUNDS:
• Wound is caused when any tissue
(Skin, Muscle, Bone, etc. ) is torn or cut
by an injury.
• DEPTH of the wound is more
important than AREA.
 
TYPES OF WOUND:
• OPEN WOUND
• CLOSED WOUND
OPEN WOUND:
• INCISED WOUND
• LACERATED WOUND
• PUNCTURED WOUND
• GRAZE OR ABRASION
• GUN SHOT WOUND
• AVULSION AMPUTATION

CLOSED WOUND:
• CONTUSED WOUND
 Introduction
• Review types of injuries
• Review Tactical Combat Casualty
Care
• Evaluate and control bleeding
• Take home message:
HEMORRHAGE CONTROL
SAVES LIVES
Core Skills Control Bleeding 4
 Sources of Bleeding
• Arterial
- Rapid, profuse and pulsating
- Bright red in color
• Venous
- Steady flow, nonpulsating
- Dark red or maroon in color
• Capillary
- Slow and oozing
- Often clots spontaneously, not dangerous

Core Skills Control Bleeding 5

 BLEEDING:
• BLEEDING RESULTS DUE TO RUPTURE OF
BLOOD VESSELS.

TYPES OF BLEEDING:
• EXTERNAL BLEEDING
• INTERNAL BLEEDING
VARIETIES OF BLEEDING:
ARTERIAL BLEEDING:
• BLOOD COMES FROM AN ARTERY.
• BLOOD IS BRIGHT RED IN COLOUR.
• BLOOD COMES IN JETS & IT CORRESPONDS TO
HEART BEAT.
• BLOOD LOSS IS RAPID & PROFUSE & CAN CAUSE
DEATH QUICKLY.
 TYPES OF WOUNDS

CONTUSED

INCISED

PUNCTURED

BURNS
LACERATED
 External Bleeding

Core Skills Control Bleeding 8

 Types of External Bleeding

• Lacerations
• Abrasions
• Puncture wounds
• Amputations
• Avulsions
Core Skills Control Bleeding 9
 Laceration

Core Skills Control Bleeding 10

 Abrasion

Core Skills Control Bleeding 11

 Puncture Wound

Core Skills Control Bleeding 12

 Amputations

Core Skills Control Bleeding 13

 Avulsion

Core Skills Control Bleeding 14

MANAGEMENT:
• STOP BLEEDING.
• HANDLE GENTLY.
• WASH YOUR HANDS THOROUGHLY.
• REMOVE ANY FOREIGN BODY, IF POSSIBLE.
• DO NOT REMOVE EMBEDDED OBJECTS.
• DON’T DISTURB BLOOD CLOTS.
• PLACE CLEAN DRESSING & BANDAGE
FIRMLY.
• SHIFT TO HOSPITAL.
VENOUS BLEEDING:
• BLOOD COMES FROM A VEIN.
• BLOOD IS DARK RED IN COLOUR.
• BLOOD FLOWS AS A CONTINUOUS
STREAM & MAY BE PROFUSE.
CAPILLARY BLEEDING:
• BLOOD COMES FROM CAPILLARIES.
• BLOOD OOZES.
• COLOUR IS LESS RED THAN ARTERIAL BLOOD.
• NOT SERIOUS.
NATURES RESPONSE TO INJURY:
RESTRICTS BLOOD FLOW TO THE AREA BY:
• CONTRACTING THE ENDS OF CUT BLOOD
VESSELS.
• FORMATION OF BLOOD CLOTS WITH THE HELP
OF CLOTTING FACTORS, FIBRINOGEN, ETC.
SIGNS & SYMPTOMS OF BLEEDING:
• FAINT & GIDDINESS.
• COLD & CLAMMY SKIN.
• WEAK & RAPID PULSE.
• SHALLOW BREATHING WITH GASPS &
SIGHS.
• PROFUSE SWEATING.
• THIRST.
• BLURRED VISION.
• UNCONSCIOUSNESS.
MANAGEMENT:
EXTERNAL BLEEDING CAN BE CONTROLLED BY:
• DIRECT PRESSURE.
• ELEVATION.
• INDIRECT PRESSURE ON PRESSURE POINTS.
• SPLINTING.
• INFLATABLE SPLINTS.
• BLOOD PRESSURE CUFF.
• TOURNIQUET.
DIRECT PRESSURE:
CAN BE APPLIED BY:
• FIRST AIDER’S HAND.
• DRESSING & FIRST AIDER’S HAND.
• PRESSURE DRESSING.
• PRESSURE TO BE APPLIED FOR 10 TO 30 MINUTES.
• AFTER CONTROL, APPLY FIRM BANDAGE.
• NEVER REMOVE EXISTING BANDAGE IF BLEEDING
RECURS. APPLY ANOTHER OVER IT.
ELEVATION:
• GRAVITY HELPS TO LOWER BLOOD PRESSURE &
BLEEDING IS SLOWED.
• NOT TO BE USED IN CASES OF FRACTURES & SPINAL
INJURIES.
PRESSURE POINTS:
• PRESSURE POINT IS A SITE WHERE MAIN ARTERY LIES
NEAR THE SURFACE OF THE BODY, DIRECTLY OVER A
BONE.
• PULSATION CAN BE FELT IN THESE AREAS.
• THERE ARE 22 PRESSURE POINTS(11 ON EACH SIDE).
• OF THESE 11 ARE USED TO CONTROL PROFUSE
BLEEDING.

• BRACHIAL ARTERY - FOR BLEEDING FROM UPPER LIMB.

• FEMORAL ARTERY - FOR BLEEDING FROM LOWER LIMB.
• CAROTID ARTERY - FOR BLEEDING FROM NECK.
• TEMPORAL ARTERY - FOR BLEEDING FROM SCALP.
• FACIAL ARTERY - FOR BLEEDING FROM FACE.
• SUB CLAVIAN ARTERY - FOR BLEEDING FROM CHEST
WALL & ARMPIT
PRESSURE POINTS
 Brachial Pressure Point

Core Skills Control Bleeding 23

 Brachial Pressure Point

Core Skills Control Bleeding 24

 Femoral Pressure Point

• To control severe
bleeding of thigh
and lower leg
• Located at front,
center part of
crease in the groin

Core Skills Control Bleeding 25

APPLICATION OF INDIRECT PRESSURE
NOTE:
• PRESSURE POINT TECHNIQUE IS USED ONLY AFTER
DIRECT PRESSURE & ELEVATION FAILS TO CONTROL
BLEEDING.
• RELAX THE MUSCLES OF THAT AREA, WHICH WILL
HELP IN APPLYING PRESSURE BETTER.
• CONTINUE PRESSURE TILL BLEEDING IS CONTROLLED
OR TILL MEDICAL HELP ARRIVES.
• RELEASE PRESSURE ONCE IN 15 MINUTES AND
REAPPLY.
• SPLINTING
• INFLATABLE SPLINTS
• BLOOD PRESSURE CUFF
• TOURNIQUET : APPLIED AS A LAST RESORT, AS IN
CASES OF AMPUTATION, ETC.
• MINOR BLEEDING:
• CONTROLLED BY ELEVATION & DIRECT PRESSURE.
• MAJOR BLEEDING:
• EXTERNAL BLEEDING:
• BRING SIDES OF WOUND TOGETHER & PRESS FIRMLY.
• POSITION THE PATIENT IN A COMFORTABLE POSITION.
• ELEVATE THE INJURED PART IF POSSIBLE.
• IF DIRECT PRESSURE FAILS, APPLY PRESSURE ON PRESSURE
POINT FOR 10 TO 15 MINUTES.
• APPLY CLEAN PAD, LARGER THAN THE WOUND & PRESS
FIRMLY, TILL BLEEDING IS CONTROLLED.
• IF BLEEDING CONTINUES, DO NOT REMOVE SOAKED PAD, BUT
APPLY MORE PADS.
• BANDAGE FIRMLY.
• TREAT SHOCK.
• SHIFT TO HOSPITAL AS A PRIORITY.
CMAST 29
 Splints
• Immobilization of the injured extremity is one of the
best ways to stop bleeding

• Broken bone fragments may lacerate blood vessels

• Muscular activity will increase rate of blood flow

Core Skills Control Bleeding 30

 Tourniquets
• Early use of a tourniquet in the
setting of forceful arterial bleeding,
such as an amputation, may be life-
saving
• STOP THE BLEEDING!

Core Skills Control Bleeding 31

 Amputations

Core Skills Control Bleeding 32

 Tourniquets
• Use a commercial tourniquet, such as the Combat
Application Tourniquet, if available
• If not available, then use..
– Cravat
– Belt
– Rope
– Strap from LBE
– Any available material

Core Skills Control Bleeding 33

 Combat Application Tourniquet
▪ The C-A-T was selected as the primary tourniquet
for every soldier.

WINDLASS

SELF ADHERING BAND

WINDLASS STRAP
CMAST 34
C-A-T Step 1

Place the wounded

extremity through
the loop of the
Self-adhering
Band
C-A-T Step 2

Place tourniquet
above the injury
site
 C-A-T Step 3

Pull the free-

running end of the
Self-adhering
Band tight and
securely fasten it
back on itself.
Hemorrhage Control

COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

Improvised Tourniquet

CMAST 39
 Tourniquet Application
• Place tourniquet between the heart
and wound
• Wrap tourniquet around extremity
• Tighten UNTIL BLEEDING
STOPS

Core Skills Control Bleeding 40

 INTERNAL BLEEDING:
THIS IS SUSPECTED WHEN YOU DETECT:
• WOUNDS THAT HAVE PENETRATED THE SKULL.
• BLOOD IN EARS & NOSE.
• PATIENT VOMITING OR COUGHING BLOOD.
• PENETRATING WOUND OF CHEST & ABDOMEN.
LARGE AREA OF BRUISED ABDOMEN.
• ABDOMINAL TENDERNESS, RIGIDITY OR SPASM.
• BLOOD IN URINE.
• RECTAL OR VAGINAL BLEEDING.
• FRACTURES.
DIAGNOSIS:
• HISTORY OF SUFFICIENT INJURY TO CAUSE INTERNAL
BLEEDING.
• HISTORY OF MEDICAL CONDITION WHICH CAN CAUSE
INTERNAL BLEEDING. (PEPTIC ULCER, ETC.)
• PAIN & TENDERNESS OVER THE AFFECTED AREA.
• SIGNS & SYMPTOMS OF SHOCK.
• BLEEDING FROM BODY ORIFICES.
MANAGEMENT:
• LAY THE CASUALTY DOWN, WITH HEAD LOW & TO ONE SIDE, SO
AS TO ENSURE GOOD BLOOD SUPPLY TO THE BRAIN.
• RAISE THE LEGS IF THERE IS NO FRACTURE.
• CONTROL ALL SERIOUS EXTERNAL BLEEDING.
• LOOSEN CONSTRICTIVE CLOTHING.
• REASSURE.
• CHECK VITAL SIGNS & RESPONSIVENESS AT 10 MINUTES
INTERVALS & RECORD.
• IF UNCONSCIOUS, ENSURE OPEN AIRWAY & RESUSCITATE IF
NEEDED.
• AFTER RECOVERY PUT IN RECOVERY POSITION.
• KEEP CASUALTY COVERED.
• KEEP RECORD OF ANY SPECIMEN PASSED OR VOMITED & SEND
THE SAMPLES TO HOSPITAL.
• SHIFT TO HOSPITAL ON PRIORITY.
• DON’T GIVE ANYTHING TO EAT OR DRINK.
 Life Saving &

Life Threatening Process

 BLOOD
TRANSFUSION

Prof. M.C.Bansal
MBBS., MS., FICOG., MICOG.
Founder Principal & Controller,
Jhalawar Medical College & Hospital Jjalawar.
MGMC & Hospital , sitapura ., Jaipur.
 History of Transfusions
• Blood transfused in humans since mid-
1600’s
• 1828 – First successful transfusion
• 1900 – Landsteiner described ABO
groups
• 1916 – First use of blood storage
• 1939 – Levine described the Rh factor
First human blood transfusion

Philip (1825)
Discovery of ABO type

Landsteiner
(1900))
 Blood Transfusion
Successful blood transfusion is relatively recent

• Crossmatching

• Anticoagulation

• Plastic storage container

Cross matching
1. Matching blood components between a Pt & a D

is a direct compatibility test.

2. The red cells & Plasma are cross matched thru

Major and Minor cross match, defined as to an
amount of Antibody react with Antigen
A. Major‘: the patient's serum & the donor's
RBCs.
–large amount of Antibody has greater impact

B. Minor’: the patient's RBCs & the donor's

serum.
BLOOD TYPES
 WHAT IS ANTIGENS ?
An antigens is a substance that causing
the formation of antibodies

WHAT IS ANTIBODYS ?
Antibodies is a protein substance
develop in the body in response to the
presence of an antigen that has entered
the body
 PURPOSE OFBLOOD
TRANSFUSION
THERAPY
* REPLACEMENT
* THERAPEUTIC
1.To restore intravascular volume with
whole blood or albumin.
2. To restore the oxygen capacity of
blood by replacing red blood cells.
3. To replace clotting factor and
correction of anemia
 Blood Transfusion

Type of Transfusion ：
■ Whole Blood ；

■ Blood Component ；

RBC PLT FFP Leukocyte concentrate

■ Plasma Substitutes ；
Use of whole blood is considered to be a waste of
resources
 DEFINITIONS
BLOOD PRODUCT = Any therapeutic substance prepared from
human blood
WHOLE BLOOD = Unseparated blood collected into an
approved container containing an anticoagulant preservative
solution

BLOOD COMPONENT = 1. A constituent of blood , separated

from whole blood such as
• Red cell concentrate
• Plasma
• Platelet concentrates
2. Plasma or platelets collected by apheresis
3. Cryoprecipitate prepared from fresh frozen plasma
 Differential Centrifugation
First Centrifugation
Closed System

Whole Blood Satellite Satellite Bag

Main Bag Bag 2
1
Firs
t

Platelet-
RBC’s rich
Plasma
Differential Centrifugation
Second Centrifugation

RBC’s Platelet-rich
Plasma
Second

Platelet Plasma
RBC’s Concentrat
e
 Whole Blood
• Storage
– 4° for up to 35 days
• Indications
– Massive Blood Loss/Trauma/Exchange Transfusion
• Considerations
– Use filter as platelets and coagulation factors will not
be active after 3-5 days
– Donor and recipient must be ABO identical
 Blood Components
THE PRBC
Storage
-2–6OC
Unit of issue
- 1 donation ( unit or pack )
Administration
- ABO & Rh compatible
- Never add medication to a unit
- Complete transfusion within 4 hrs of
commencement

M 1
e
m
Indications
- Acute blood loss with > 20% loss of
blood volume

Trauma
Surgery - Trigger – 10gm% - 8gm%
Rate of development of anemia,
General condition and type of
surgery

Radiotherapy
 Platelets
• The platelets are separated from the plasma by
centrifugation.

• Platelets are supplied either as single donor units or as a

combination of multiple donors.

• One unit of platelets will increase the platelet count of a 70

kg adult by 5 to 10,000/mm³.

• Platelet viability is optimal at 22° C but storage is limited to

4-5 days.

• Platelets have both the ABO and HLA antigens. ABO

compatibility is ideal but not required. (incompatibility will
shorten the life span of the platelet)
• Storage Platelets
– Up to 5 days at 20-24°
• Indications
– Thrombocytopenia, Plt <15,000
– Bleeding and Plt <50,000
– Invasive procedure and Plt <50,000
• Considerations
– Contain Leukocytes and cytokines
– 1 unit/10 kg of body weight increases Plt count by 50,000
– Donor and Recipient must be ABO identical
Platelets

• Thrombocytopenia

(< 50,000)
• Platelet dysfunction

• Each unit increase 5,000

PLTs after 1 H
 Plasma
• Contents—Coagulation Factors (1 unit/ml)
• Storage
– FFP--12 months at –18 degrees or colder
• Indications
– Coagulation Factor deficiency, fibrinogen replacement, DIC,
liver disease, exchange transfusion, massive transfusion
• Considerations
– Plasma should be recipient RBC ABO compatible
– In children, should also be Rh compatible
– Account for time to thaw
– Usual dose is 20 cc/kg to raise coagulation factors approx 20%
 Fresh Frozen Plasma (FFP)

• Coagulation factor deficiencies

• 1 ml increases 1% clotting
factors
• Being used as soon as possible
• Albumin, hetastarch,
crystalliods are equally
effective volume expander but
safer than FFP
• After use of 5 U of RBCs,
matching 2 U of FFP
Dosage & Administration for
FFP
Dosage - 10-15 ml/Kg(Approx 2-3
bags for an adult)

Administration - Thawed at +37o C

before transfusion
ABO compatible
Group AB plasma can be used for all
patient
 Plasma Substitutes

Dextran
• Most widely used
• Low/Middle M.W. (40,000-70,000)
• Massive transfusion could impair coagulation
• Occasional ALLERGIC reaction
Hydroxyethyl Starch Formulation (HES)
• More stable
• Containing essential electrolytes
• No allergic reaction

--Volume Expander
 Cryoprecipitate
• Description
– Precipitate formed/collected when FFP is thawed at 4°
• Storage
– After collection, refrozen and stored up to 1 year at -18°
• Indication
– Fibrinogen deficiency or dysfibrinogenemia
– vonWillebrands Disease
– Factor VIII or XIII deficiency
– DIC (not used alone)(Disseminated intravascular
coagulation)
• Considerations
– ABO compatible preferred (but not limiting)
– Usual dose is 1 unit/5-10 kg of recipient body weight
• Although blood transfusions can be
life-saving, they are not without risks.
The most serious risks are
transfusion reactions and infections.
 Transfusion Complications
• Acute Transfusion Reactions (ATR’s)
• Chronic Transfusion Reactions
• Transfusion related infections
 Acute Transfusion Reactions
• Hemolytic Reactions (AHTR)
• Febrile Reactions (FNHTR)
• Allergic Reactions
• TRALI(Transfusion related acute lung
injury)
• Coagulopathy with Massive transfusions
• Bacteremia
Can be fatal
 Symptoms of AHTR
• High fever/chills
• Hypotension
• Back/abdominal pain
• Oliguria
• Dyspnea
• Dark urine
• Pallor
 What to do?
If an AHTR occurs
• STOP TRANSFUSION
• ABC’s
• Maintain IV access and run IVF (NS or LR)
• Monitor and maintain BP/pulse
• Give diuretic
• Obtain blood and urine for transfusion reaction
workup
• Send remaining blood back to Blood Bank
 Febrile Nonhemolytic Transfusion
Reactions (FNHTR)
• Definition--Rise in patient temperature >1°C (associated
with transfusion without other fever precipitating
factors)
• Occurs with approx 1% of PRBC transfusions and
approx 20% of Plt transfusions
• FNHTR caused by alloantibodies directed against HLA
antigens
• Need to evaluate for AHTR and infection
 Allergic Nonhemolytic Transfusion
Reactions
• Etiology
– May be due to plasma proteins or blood
preservative/anticoagulant
– Best characterized with IgA given to an IgA deficient
patients with anti-IgA antibodies
• Presents with urticaria and wheezing
• Treatment
– Mild reactions—Can be continued after Benadryl
– Severe reactions—Must STOP transfusion and may require
steroids or epinephrine
• Prevention—Premedication (Antihistamines)
 TRALI
Transfusion Related Acute Lung Injury
• Clinical syndrome similar to ARDS
• Occurs 1-6 hours after receiving plasma-
containing blood products
• Caused by WBC antibodies present in
donor blood that result in pulmonary
leukostasis
• Treatment is supportive
• High mortality
 Transfusion Associated
Infections
• Hepatitis C
• Hepatitis B
• HIV
• CMV
– CMV can be diminished by leukoreduction,
which is indicated for immunocompromised
patients
 ThAnk You!
Hope you learned
something!