There is a great short (1 minute 39 seconds) video demonstrating one of the big problems we have in manging significant bleeding.
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EMRAPTV Episode 104: Neck Vascular Trauma Video
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We are taught to apply a large bandage with pressure. If that does not control the bleeding, which might be demonstrated by blood soaking the bandage, we are not supposed to remove the bandage, but apply more camouflage on top of the bandages that are already there and preventing us from assessing the bleeding.
This video demonstrates very clearly that the technique we are taught can be ineffective.
When I have a patient with a possible arterial bleed, I am comfortable not assessing the wound as long as the bleeding appears to be controlled.
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Look at the green sheet under the patient’s head at the beginning of the video.
Look at the same green sheet after a couple of minutes. There is such a thick layer of blood, that it does not appear to be the same sheet. As much as the anesthesia resident is doing what we are all trained to do, it has not been effective. The patient is still losing significant amounts of blood.
This is not a place for a tourniquet, but in dealing with similar bleeding to the arm, or leg, a blood pressure cuff can make a wonderful tourniquet. Direct pressure on the blood vessel is an alternative to a tourniquet and that is what they demonstrate.
In the movies, cutting the neck means almost instant death, but movies are not real. We deal with those who are still alive when we arrive. Our job is to keep as much of the patient’s blood in the patient until relieved by someone else.
Is an IV important?
No.
There is no research to suggest that fluids should be given until after bleeding is controlled.
Therefore, the number one job for the paramedics is to control the bleeding.
Then we can worry about an IV, but only if the bleeding continues to be controlled.
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I know. A lot of QA/QI/CYA departments will have a fit if this patient does not have at least one large bore IV placed by EMS. So will a lot of doctors and nurses.
Is worrying about being yelled at a good reason to kill patients?
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If we have to choose –
We can start the IV.
Or –
We can control the bleeding.
The unimportant one for the survival of the patient is the IV.
If I have another medic with me, we should both be working at controlling the bleeding, rather than one working on an IV and the other working on bleeding. Inevitably, the one working on the IV has a problem and needs the help of the one trying to control the bleeding. This often ends with the IV taking priority and the patient going to the morgue.
Avoid getting into that mess. Do not even attempt to get an IV until after bleeding is controlled.
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Go watch the video – more than once.
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I ran a call once where a guy at a poultry processing plant was engaging in horseplay with a coworker, and stabbed himself in the neck with a fillet knife, lacerating his right external carotid. The plant nurse had tried to hold direct pressure, and blood kept fountaining above the dressing. The first aid office looked like someone had exploded a gallon of red paint.
I asked to see the wound, had to physically remove the nurse because she refused to remove the dressing. The wound was less than an inch wide. I meant to put fingertip pressure below it, but my finger accidentally slid into the wound. I could feel the artery pulsing, so I just pinched it closed. Bleeding stopped almost immediately.
The guy lived and eventually recovered fully, but it was a close thing. After 19 units of blood in the hospital, a lab tech friend told me his hemoglobin was still only 9.3.
I wonder when hemostats will ever become part of trauma protocols in the field. I’ve had a lacerated brachial artery in the field that I could see (and could clamp given the appropriate scope of practice). Instead I used my Dragon Force(tm) hand grip and some elevation (because I was low man on the totem pole) during the thankfully short trip to the ED.
Seems like these severe bleeding situations would be appropriate occasions to use gauze impregnated with an hemostatic agent. Just watched a good lecture from King County EMS with Dr. Holcomb from Houston discussing the military experience with hemostatic agents and tourniquet use. One can view it at emsonline.net/ts/tuesday_2010.asp, it is included in the Feb. 2011 Tuesday Lectures (or use the link from my user name).
Great find on this video. Too bad they don’t allow the video to be embedded.