Circulation & Hemorrhage Control

Uncontrolled hemorrhage is the leading cause of preventable death in trauma. In the <C>ABC approach, catastrophic (exsanguinating) hemorrhage must be controlled before even addressing the airway.

The Lethal Triad of Trauma

When a patient bleeds significantly, they enter a physiological death spiral known as the Lethal Triad:

1. Hypothermia: Blood carries heat. Losing blood means losing core temperature.
2. Acidosis: Poor perfusion leads to lactic acid buildup.
3. Coagulopathy: Cold, acidic blood loses its ability to clot.

<goldenrule> Keep trauma patients warm! A cold trauma patient will bleed to death because their clotting cascade shuts down. Blankets are a life-saving intervention. </goldenrule>

Types of Bleeding

• Arterial: Bright red, spurting, pulsatile. Immediate life threat.
• Venous: Dark red, steady flow. Can still be life-threatening if a major vein is severed.
• Capillary: Oozing, easily controlled.

Stepwise Hemorrhage Control

Follow the tactical approach to bleeding control:

1. Direct Pressure

Apply firm, sustained, continuous direct pressure over the bleeding site using a sterile dressing. Do not peak to check the wound every 10 seconds—pressure must be sustained for at least 3-5 minutes.

2. Tourniquets

If direct pressure fails for an extremity wound, or if the bleeding is catastrophic and arterial from the start, apply a commercial tourniquet (e.g., CAT).

• Placement: "High and Tight" (over the clothing) during care under fire/immediate danger. Once in a secure area, place 2-3 inches above the wound on bare skin.
• Tightening: Twist the windlass until the bleeding STOPS and distal pulses are ABSENT.
• Documentation: Always write the time of application on the tourniquet and the patient's forehead.

<redflag> A properly applied tourniquet is extremely painful. If the patient is not complaining about the pain of the tourniquet, it is either not tight enough, or they are in profound shock. </redflag>

3. Wound Packing

For junctional areas (groin, axilla, neck) where a tourniquet cannot be placed:

1. Identify the bleeding source deep in the wound.
2. Tightly pack hemostatic gauze (or standard gauze) directly against the bleeding artery.
3. Apply very firm direct pressure over the packed wound for 3 minutes (if hemostatic) or 10 minutes (if standard gauze).

Recognizing Shock

Shock is inadequate tissue perfusion. Recognize the stages:

1. Compensated Shock: Tachycardia, normal BP, delayed CRT, anxiety, pale/cool skin. The body is fighting to maintain blood pressure.
2. Decompensated Shock: Hypotension (falling BP), altered mental status, absent peripheral pulses. The compensatory mechanisms have failed. Death is imminent.

<goldenrule> Hypotension in trauma is a late and ominous sign. By the time the blood pressure drops, the patient has already lost 30-40% of their blood volume. Treat for shock early based on mechanism and tachycardia! </goldenrule>