Bleeding, Wounds & Burns

Types of bleeding

• Arterial (bright red, pulsatile): oxygen-rich blood from an artery, spurting with each heartbeat. It's life-threatening and needs control now.
• Venous (dark red, steady): oxygen-poor blood from a vein. It flows steadily instead of spurting. Still serious, but usually easier to control than arterial.
• Capillary (oozing): a slow ooze from small vessels in the skin. It usually stops on its own with direct pressure.

Direct pressure: for bleeding that isn't life-threatening

Spurting or fast-pooling bleeding from an arm or leg skips this card and goes straight to a tourniquet (below).

• Technique: press hard and steadily right on the wound, with gloved hands and clean cloth or gauze
• Duration: at least 10 minutes of continuous pressure, no peeking. Don't lift to check whether it's stopped.
• If bleeding continues: add more layers on top and keep pressing. Pulling off the first layer tears up the clot that's started.
• Re-bleeding: if it starts again when you let go, press for another 10 minutes
• If pressure isn't controlling it: on an arm or leg, put on a tourniquet. In the groin or armpit, where a tourniquet can't go, pack the wound. Raising the limb isn't a bleeding-control step.

Pressure dressing

• Once the bleeding's controlled, wrap an elastic bandage (an ACE wrap or similar) over the gauze pads
• The wrap keeps steady pressure on so the clot stays put
• Watch for signs it's too tight: cold fingers or toes, numbness, tingling, color changes

Tourniquet application

When to use: For obviously life-threatening bleeding from an arm or leg (spurting or pulsing, blood pooling fast, soaking through dressings, an amputation, the patient getting shocky), put a tourniquet on immediately. Don't wait for direct pressure to fail. Direct pressure is for bleeding that isn't clearly life-threatening, or to buy time while the tourniquet's being readied.

• Indication: obviously life-threatening bleeding from an arm or leg (tourniquet first), or limb bleeding that direct pressure doesn't control
• Location: high and tight, above the wound and at least 2-3 inches from it, never on a joint. When you can't see the wound well, go as high on the arm or leg as it'll go.
• Tightness: tighten until the bleeding stops completely and the pulse below the tourniquet (distal pulse) is gone
• If bleeding continues: put a second tourniquet on just above or beside the first
• Document time: write the time it went on directly on the patient's skin (the forehead works) or on the tourniquet
• Don't remove it in the field: once it's on, it stays on. Loosen it and you risk massive re-bleeding.
• Types: commercial tourniquets (CAT, SOFTT-W) work better than improvised ones

Improvised tourniquet

• Use material at least 2 inches wide, like a belt or rolled cloth
• Windlass technique: wrap it around the limb above the wound, put a stick through the loop, and twist to tighten
• It won't work as well as a commercial one, but it can work in an emergency
• Write down the time it went on

Wound packing: junctional hemorrhage

When to use: wounds where a tourniquet can't go, like the groin (inguinal crease) or armpit (axilla)

• Technique: pack clean gauze tightly into the wound
• Maintain pressure: don't stuff the gauze in and walk away. Keep constant pressure on it.
• Hemostatic gauze preferred: gauze impregnated with kaolin or chitosan helps the blood clot
• Duration: at least 3 minutes of sustained pressure with hemostatic gauze. Plain gauze needs about 10 minutes of sustained pressure.
• Dressing: once the bleeding's controlled, leave the packing in and put a pressure dressing over it
• Never pack: chest or abdominal wounds. Packing doesn't reach the bleeding, and it delays care. Neck wounds get sustained direct pressure only, never packing.

Hemostatic agents

• What they do: gauze impregnated with clotting agents (kaolin, chitosan) boosts the body's own clotting
• Products: QuikClot, Combat Gauze. Both are common in wilderness first aid kits.
• Application: pack it tightly into the wound and hold sustained pressure
• Dwell time: hold pressure for at least 3 minutes
• Removal: it can be rinsed out, but it's often left in for the trip out

Epistaxis (nosebleed)

• Position: lean forward so blood doesn't drain down the throat. Tilting the head back, the old advice, sends it straight there.
• Pressure: pinch the soft part of the nose, below the bone, firmly
• Duration: 10-15 minutes of continuous pressure
• Cold compress: ice or a cold compress on the bridge of the nose and the face
• After control: no nose-blowing and no strenuous activity for hours
• When to evacuate: if it's still bleeding after more than 20 minutes of pressure, or it keeps coming back heavily, evacuate so a doctor can look at it

Wound assessment

• Mechanism: how did it happen? A clean cut or a crush? How contaminated is it?
• Depth: superficial (epidermis), partial thickness (dermis), full thickness (into the subcutaneous tissue)
• Contamination: clean (surgical), clean-contaminated, contaminated (soil, feces), dirty or infected
• Neurovascular status: is blood getting past the wound (distal)? Can they feel normally beyond it?
• Time elapsed: how long since the injury? Infection risk goes up after 8 hours. Write the time down and pass it on at the handoff.

Wound types and management

Abrasion (road rash)

• A shallow scrape of the skin surface
• Clean thoroughly. This is the most important step. Get out every bit of dirt and grit, with a brush if you have one.
• Cleaning it hurts. A local numbing spray can help, if you have one.
• Dress it with antibiotic ointment and sterile gauze

Laceration (clean cut)

• Fairly clean wound edges
• Irrigate and clean it thoroughly
• Dress it and keep it clean
• If it gapes, a clinic decides whether to close it. Evacuate wounds that need closure.

Puncture wound

• Small entrance, deep penetration
• High infection risk. Deep, airless wounds are where anaerobic bacteria (tetanus) grow.
• Don't close it. Closing it traps infection deep inside.
• Let it bleed and drain. That flushes it out.
• Soak it in warm water if you can, to help it drain
• If it's contaminated (soil, animal matter), they need tetanus prophylaxis

Impaled object

• Leave it in. The object may be plugging the bleeding it caused. Pulling it out can start a bleed you can't stop.
• Stabilize it in place with bulky padding (rolled clothing works) built up around it, so it can't rock or shift
• The only exception is an object that's blocking the airway or keeping you from doing CPR
• Evacuate. It comes out in a hospital.

Avulsion (tissue flap)

• Tissue torn and partly detached
• If the flap's still attached, lay it back in its normal position if you can
• If it's completely torn off, save it in a clean, moist container. It may be reattachable.
• Irrigate the wound and cover it loosely. Don't close it tightly.
• Evacuate urgently so a surgeon can look at it

Crush wound

• Tissue crushed by blunt force
• Contaminated, with a high infection risk
• Don't close it.
• Clean and dress it, and watch for signs of infection

Wound irrigation: the most important step

A clean wound is less likely to get infected.

• Volume: at least 500 mL to 1 L for dirty wounds. Keep going until the wound is visibly clean.
• Pressure: moderate pressure works best. Use a 20-60 mL syringe, or a squeeze bottle with a pinhole in the cap.
• Solution: clean drinking water works. Sterile saline is ideal if you have it.
• What not to use: don't irrigate the wound bed with hydrogen peroxide or iodine. They damage tissue and kill the cells that do the healing.
• Scrubbing: wipe gently with gauze or a brush to get debris out. Scrub hard and you damage tissue.

Wounds that need closure

In the field: you don't close wounds. That's a clinical decision, made at a clinic or hospital. Your job is to clean the wound thoroughly, dress it, keep it clean, and evacuate the ones that need closure, and a clinician decides what to do with a gaping one. The suture kit someone packed can stay packed.

These wounds always need to be seen by a clinician:

• Bite wounds (dog, cat, human): high infection risk
• Puncture wounds: infection risk from anaerobic bacteria
• Heavily contaminated wounds (soil, feces)
• Wounds that are many hours old
• Wounds already showing signs of infection

Dressing

• Sterile gauze: cover the wound with clean or sterile gauze
• Non-adherent: non-stick gauze won't pull at healing tissue when you change it
• Cover completely: the whole wound, to keep dirt out
• Change frequency: daily, or whenever it's wet or soiled
• Observation: look for signs of infection every time you change it

Infection signs and evacuation

• Cellulitis: redness spreading past the wound edges, warmth, increasing pain
• Purulent discharge: pus draining from the wound
• Lymphangitis: red streaks running from the wound toward the heart. The infection is spreading.
• Fever: a sign the infection has gone systemic
• Swollen lymph nodes: near the wound, like the armpit for an arm wound or the groin for a leg wound

Tetanus and animal bites

• Tetanus risk: any wound contaminated with soil, feces, or animal matter. Check the patient's vaccination status.
• Booster needed if: more than 5 years since the last tetanus shot for a dirty wound, or more than 10 years for a clean one
• Animal bites: wash it right away, and hard. The infection risk is high (Pasteurella bacteria). Someone has to assess the rabies risk, and the bite gets reported to public health.
• Don't close animal bites: even a "minor" bite stays open, because of the infection risk

Recognizing internal bleeding

You can't see internal bleeding, but it can still cause massive blood loss.

• Abdominal signs:
  • A rigid, board-like abdomen (a sign of peritoneal irritation)
  • Distension (swelling)
  • Bruising over the abdomen
  • Grey-Turner sign: bruising on the flanks (sides)
  • Cullen's sign: bruising around the umbilicus (belly button)
  • Grey-Turner and Cullen's signs are delayed findings that take hours to appear, so not seeing them early doesn't rule out bleeding
• Other signs:
  • Blood in the stool (dark and tarry means upper GI bleeding, bright red means lower GI)
  • Blood in the urine
  • Vomiting blood (hematemesis)
• Shock without external bleeding: think internal bleeding. Look for pale, cool, sweaty (diaphoretic) skin, a rapid pulse, weak pulses, and confusion.

Field treatment of internal bleeding

• Position: flat on the back (supine). If the bleeding came from trauma, don't raise the legs. With no trauma, like a GI bleed, raising the feet 6 to 12 inches is an option if it doesn't hurt (Lesson 5).
• Keep warm: don't let them get cold. Hypothermia makes shock worse.
• Nothing by mouth: they may need surgery, and keeping them NPO (nothing by mouth) lowers the risk of aspiration. The exception is a fully alert, stable patient facing a wait of many hours, who can have small sips of water.
• Emergent evacuation: no field treatment will stop internal bleeding. Get them to a hospital.
• Monitor: watch for them getting worse. If they're unstable, take vitals every 5 minutes.

Specific internal bleeding scenarios

Aortic rupture or aneurysm

• Signs: severe tearing pain in the back or abdomen, shock, an elderly patient
• Prognosis: extremely high mortality, even with surgery
• Treatment: immediate evacuation, by helicopter if one is available

Pelvic fracture

• The pelvis has large blood vessels, so a fracture can cause massive internal bleeding
• Your actions: suspect it from the mechanism (a high fall, a crush, a high-energy impact). Do not press on or "stress" the pelvis. Keep the patient still. Evacuate emergently.
• What EMS may do: EMS may put on a pelvic binder to stabilize the pelvis and slow the bleeding

Stop the burning

• Remove from the source: put out flames (stop, drop, and roll if their clothing is on fire), and pull them away from the exhaust pipe, stove, or fire. Get sunburned patients into shade.
• Get jewelry and loose clothing off early: rings, watches, and bracelets come off before swelling starts. A ring on a burned finger becomes a tourniquet. Take off boots, socks, and any clothing around the burn that isn't stuck to it.
• Never peel off melted or stuck fabric: synthetic riding gear and fleece melt into the burn. Cool over it and cut around it. Leave the stuck material in place for the clinician.
• Chemical burns: protect yourself first (gloves, and keep it off your own skin). Brush off any dry chemical, then flush with lots of water for at least 20 minutes. Take off contaminated clothing and jewelry as you go.

Cool the burn

• Cool running water, 10-20 minutes: use cool, not ice-cold, water as soon as you can. It's the most effective burn treatment you have, because it limits how deep the burn goes.
• Still worth doing up to ~3 hours after injury: if it takes a while to reach water, cool the burn when you get there.
• No ice or ice water: ice constricts blood flow and makes the injury deeper.
• Solution: clean drinking water is ideal, but on the river, cool clear water beats no cooling.

Assessing the burn: depth and extent

Superficial

• Red, dry, and painful, with no blisters. Classic sunburn.
• Heals on its own. Comfort care only.

Partial-thickness

• Blisters, a moist or weeping surface, and very painful
• The typical scald, stove flare, or brief flame contact

Full-thickness

• Leathery, waxy, or charred. The center may be painless because the nerve endings are destroyed, even when the edges hurt.
• Always an evacuation, whatever the size

Dressing the burn

• After cooling, cover loosely: a clean, non-stick dressing over the burn. Clean plastic wrap laid on top (not wrapped all the way around) works well, and the clinic can look at the burn without pulling the dressing off.
• Leave blisters intact: a blister is a sterile dressing the body made itself. Don't pop it.
• No home remedies: no butter, toothpaste, oils, or ointments on the burn. They trap heat and cause infection.
• Sunburn exception: plain aloe or moisturizer is fine, for superficial sunburn only
• Pain control: burns hurt. Give an OTC pain reliever like ibuprofen.
• Tetanus: burns are tetanus-prone wounds. Check vaccination status just as you would for a dirty wound (see Tetanus and animal bites in the Wound Care tab).

Burn evacuation criteria

• Any full-thickness burn, even a small one
• Partial-thickness burns larger than a few palm-areas (~5% of body surface)
• Burns to the face, hands, feet, genitals, or across joints. These are high-function areas that scar badly.
• Circumferential burns (all the way around a limb or the chest). Burned skin tightens as it swells and can cut off circulation or restrict breathing.
• Electrical burns. The damage inside can be far worse than the skin looks.
• Very young or very old patients

Exhaust pipes and road rash: the crossovers

• Exhaust-pipe burns are deeper than they look: a second against metal at several hundred degrees makes a small burn that's often deep, partial- or full-thickness. Small doesn't mean minor. Be honest about the depth and look again at 24-48 hours.
• Road rash is an abrasion: manage it with aggressive cleaning and irrigation, as covered under Abrasion in the Wound Care tab
• Large road rash counts as a burn: when it covers a big area, think of it as a burn for fluid loss, infection risk, and evacuation decisions