Acute hemorrhage is defined as the sudden or rapid loss of blood from
the circulatory system within a few minutes or hours as a result
of an opening or openings in the system. Life is threatened if
blood loss reaches 25%-50% of total volume. Concealed bleeding is
difficult to estimate. Williams/Sperryn point out that over a
quart of blood may be lost into the tissues in a closed fracture
of the tibia, yet this is minor compared to be what may be lost
within pleural or peritoneal cavities in chest or abdominal
injuries. The seriousness of hemorrhage lies in both the rate and
the quantity of blood volume reduction, which are related to the
number, type, and location of the opened vessels.
Whenever an artery or vein is opened, the injured vessel
reflexively constricts and, if severed, retracts into the tissue,
thereby reducing the size of the opening and facilitating clot
formation (scalp vessels are an exception). In addition, other
blood vessels temporarily constrict as a part of the general
reaction to injury. This generalized vasoconstriction helps
maintain blood pressure by reducing the capacity of the
The body in general and the cardiovascular system in
particular react to stress of injury to the circulatory system by
shock that is apparent after sudden loss of 15% or more of the
circulating blood volume. At the site of injury, blood tends to
clot and plug the opened vessel. If vasoconstriction and blood
clotting are unsuccessful, the resulting blood volume reduction
causes a fall in blood pressure which, among its other effects,
facilitates clot formation. If hemorrhage persists, the person
dies of lack of oxygen and other nutrients.
Thrombophlebitis and Embolism
Of the many
complication dangers involved in handling an injury victim,
throbophlebitis and the potentiality of embolism are common
concerns. Venous stasis and pressure or other injury to vein
walls predispose the development of thrombophlebitis. The overt
signs and symptoms are cramping pain in the calf; possible
redness, warmth, and swelling along the course of the involved
vein; and pain which may appear only on dorsiflexion of the foot.
The most common sites are in the veins of the pelvis and legs.
The affected limb should never be rubbed or massaged. It
should be placed horizontal and at rest, supported by pillows.
Cotton elastic bandages may be used if available on each
extremity from foot to groin to assist venous circulation.
Be alert to any complaint or other evidence of respiratory
difficulty or chest pain due to a possible embolism. Sudden
dyspnea, violent coughing, hemoptysis, or severe stabbing chest
pain may be the first sign of a dislodged thrombus. Sudden signs
of shock and collapse should be anticipated.
management of external hemorrhage is best accomplished if the
wound is first exposed to view. Clothing or other material over
the injury should be cut, torn, or lifted away carefully so that
additional harm is not inflicted. Unnecessary movement or
exposure of the patient to general cold should be avoided if to
the extent that it may induce or hasten the lowering of body
External Venous Hemorrhage. Venous bleeding can be
profuse during physical competition or vigorous work because of
the increased blood flow to active limbs. However, the bleeding
is often quickly stopped by a pad, firm bandage, and cold pack
applied to the elevated part. Nothing more is usually necessary
for the next 24 hours unless referral for surgical cleansing or
suturing is required.
External Arterial Hemorrhage. Arterial injuries may be
classed as either (1) complete, where the entire vessel wall is
disrupted, or (2) incomplete, where only the outer coats or, at
most, a portion of the circumference is damaged. These injuries
originate from contusions, incised and lacerated wounds, and
puncture wounds. The early manifestations are hemorrhage and
possibly the appearance of a hematoma. In the later stages,
thrombosis, traumatic aneurysms, and secondary hemorrhage are to
Internal Hemorrhage. Internal bleeding is a medical
emergency. Treatment should only be first-aid measures to benefit
the patient until transportation can be made to an appropriate
trauma center or emergency ward. In some cases, such facilities
may be many miles away. Initial actions can be life saving. If
on-the-scene attention is made, the examiner should seek evidence
of "pattern bleeding" in which the pattern of clothing texture is
imprinted on the skin. This indicates severe compression and
suggests possible visceral rupture.
Note the presence of blood in vomitus, sputum, or excretions.
Hemorrhage within the cranium or lungs may be indicated by
bleeding from the nose, mouth, or ears. Evidence of internal
bleeding may also be represented in such signs as restlessness,
apprehension, thirst, falling blood pressure, and increasing
pulse rate. Swelling and discoloration may be seen. Treat for
shock, and prepare the patient for referral for hospitalization
and blood transfusion.
point is any site where a main artery supplying the wounded area
lies near the skin surface and over a bone or firm tissue.
Pressure at these points is applied with the fingers, thumb, or
hand. The object of the pressure is to compress the artery
against a firm substance to occlude the flow of blood from the
heart to the wound. Since it is often difficult to maintain
occluding pressure manually on a pressure point, the pressure
point method is used only until a pressure dressing can be
dressing applied with pressure to a hemorrhaging wound enhances
clot formation, compresses open blood vessels, and protects the
injury from further invasion by infectious organisms. Sometimes
more harm is done to the patient by secondary infection than the
Direct pressure on a wound is usually ineffective in
controlling hemorrhage. Pressure is applied for the purpose of
minimizing the size of the vessel opening by compression,
temporarily or for an extended period, thereby lessening the
amount and the velocity of the escaping blood and aiding clot
formation. Firm pressure may be applied to a wound if there is no
broken bone in or near the wound. Hemorrhage does not always stop
immediately. At times, firm pressure on the dressing over the
wound may be required for many minutes until a clot has formed
with sufficient strength to hold with only the help of dressing
ties. If a clot does not form quickly, a tourniquet must be
considered (if feasible).
The dressing should be of absorbent material that spreads
and slows the blood it absorbs. This spreading and slowing action
exposes a relatively large and thin surface of the outflowing
blood to the air and thereby aids clot formation. Accordingly,
one dressing partially filled with the victim's blood is more
effective in controlling hemorrhage than is a series of others
because clot formation is in progress within the bloody dressing.
Clot formation tends to spread back toward and into the wound
until diminished air exposure, coupled with an adequate
circulating speed, brings the bleeding to a halt.
It is the clot that stops the hemorrhage. If the blood
had no ability to clot, the absorbent dressing applied would
merely draw blood out through the wound and do more harm than
good. When blood is about to clot, it begins to turn darker and
becomes progressively darker as the clot takes form. A hard clot
is almost black as its iron content oxidizes. Unnecessary
prolonged pressure must be avoided. The dressing should be
anchored snugly to prevent slipping, but not tightly. The wounded
part, especially if it is an arm or leg, will swell after a time,
tightening the bandage still more and impairing or stopping
circulation within the part to the detriment of the
wound easily becomes contaminated with microorganisms at the
moment of occurrence, thus the prompt application of a sterile
dressing serves to limit the entrance of infectious organisms.
Once a dressing is applied, it should remain in place if at all
possible. Removal permits entrance of additional microorganisms
and may disturb the clot so that hemorrhage recurs. Also, leaving
the original dressing in place helps the surgeon viewing it later
to estimate the amount of blood the patient has lost.
When a wound is dressed, care must be taken to avoid touching
the wound or the surface of the dressing that is to be placed
directly on the wound, breathing onto the dressing or wound,
stirring up dust about the patient area, or allowing other
actions which would permit infectious organisms to enter the
Elevation of a Wounded Limb
especially of the venous type, can frequently be lessened
appreciably by raising the injured limb to a height slightly
above that of the heart. Because elevation tends to drain the
elevated limb by gravity, an initial gush of blood downward from
open veins should be expected when the limb is first elevated.
Elevation helps to lower the blood pressure at the wound site. It
may be used before, during, or after application of a pressure
dressing, depending mainly on the type and severity of the wound.
The patient may be instructed to elevate an less serious wound
while waiting for a dressing and to maintain the height after the
dressing is applied. Serious hemorrhage, especially of the
arterial type, may require simultaneous and continuous
application of elevation, dressing, pressure, and cold. If there
is a broken bone in the wounded limb, elevation must be postponed
until after the limb is splinted.
Use of a Tourniquet
is any constricting band placed around the circumference of one
of the extremities to stop hemorrhage. In an emergency, careful
judgment is required in making the decision to apply or withhold
a true tourniquet. Both arterial and venous blood flow stops at
the tourniquet. Without circulating blood, the part distal to the
tourniquet begins to die. Rarely will a tourniquet be required
unless a limb is severely mangled. When a tourniquet is used
unskillfully, more harm can be done than from not using one.
Professional Judgment. While later surgical amputation
of the limb distal to the point of application of the tourniquet
does not necessarily always follow, the person who decides to
apply a tourniquet must do so with the realization that this
distal portion will probably be sacrificed. Thus, a tourniquet
applied to a patient must represent a choice between saving a
life or saving a limb. It must not represent a choice
between the quick results a tourniquet produces and the sometimes
tiring application of a pressure dressing.
Commitment. The decision to apply a tourniquet is
irreversible. Once a tourniquet is applied, it must be left in
place until removed by a surgeon as soon as possible. It must not
be loosened and retightened in the mistaken belief that the
portion of the limb distal to the tourniquet is being kept alive.
The patient whose system is stabilized after the tourniquet has
reduced the capacity of his circulatory system may not be able to
withstand the shock of its sudden enlargement if the tourniquet
General Guidelines. The need of a tourniquet is
minimized when good techniques are used in pressure points,
pressure dressings, elevation, local cold, and rest. Nonetheless,
bleeding from a major artery of the thigh, lower leg, or upper
arm, or hemorrhage from multiple arteries that is seen in
traumatic amputation may prove beyond control by these methods.
There is no set rule as to how long one should continue to try to
control hemorrhage by pressure dressing, elevation, etc. However,
in the emergency treatment situation, the absorbent capacity of
the injured person's first-aid dressing may be used as a
possibility of delayed hemorrhage occurring either externally or
internally as a postinjury complication is not remote.
Reactionary bleeding may occur within a few hours after injury
when blood pressure and circulation return to normal after shock.
This increased pressure may also cause bleeding by displaced
blood clots previously formed. If signs of renewed hemorrhage
from a wound appear after a dressing is snugly in place,
reapplication of manual pressure may be all that is necessary to
assist clot formation. Sufficient pressure must be used to
occlude the opened vessel(s).
Signs of renewed or continued hemorrhage are (1) the
appearance or enlargement of a bloodstain on the outer surface of
the dressing and (2) the appearance or continuance of blood
trickling between the dressing and the skin.
protruding beyond the surface of the skin is presumptive evidence
of arterial damage. The circulation of the part distal to the
injury may be jeopardized because of marked damage to vital
vessels or be merely a result of pressure resulting from a
hematoma. If subcutaneous fat is exposed, the rule of thumb is
that the wound should be sutured. An emergency attendant is
rarely involved in the handling of wound closure materials such
as suture needles or thread. However, it may be necessary to
apply specially prepared adhesive strips for a sutureless wound
closure before transporting the victim.
arises from a rapid extravasation of blood and tissue fluid that
pools into a singular large fluctuant mass. After injury, it may
localize within a tissue space, a compartment, or an organ at any
depth at most any site in the body. More specifically, O'Donoghue
defines hematoma as a collection of pooled blood, within a
relatively restricted area, that has collected in a localized
area (self-made space) and has maintained its identity as blood.
Bleeding within an anatomically closed space such as a joint,
bursa, or viscus is not commonly called a hematoma.
Etiology. Interstitial hematomas are usually the result
of contusion, while intramuscular hematomas are the product of
intrinsic tears. Both contractile and noncontractile elements are
damaged during muscle strain, but the greatest injury is suffered
by the capillary network between skeletal muscle fibers. The
effect is seepage of blood and tissue fluid into interstitial and
extracellular muscle spaces that are already congested by
activity hyperemia. A degree of hematoma is the result, and it
may protrude within the potential space between muscles.
When extrinsic stress is severe, bleeding may also result in
deep and subcutaneous connective tissues to compound the problem.
When intramuscular tension returns after injury, bleeding points
tend to become compressed. Firm clotting occurs within a few
hours, but slight trauma (eg, massage, bump) may cause further
hemorrhage even after 2-3 days. Resolution follows with a degree
of absorption and fibrosis.
Inspection and Palpation. After a hematoma develops,
the body's reaction is to make an inflammatory response enabling
it to cope with the blood pool. This reaction increases local
tenderness and heat (similar to that seen in cellulitis) for 2-3
days until the stage of reactionary inflammation subsides. A
large hematoma is never absorbed, it undergoes organization,
fibrosis, and scar. The extent of a palpable hematoma should be
noted, along with tissue tension and the presence of a bruit. If
the hematoma pulsates, it may be due to transmitted arterial
impulses or the development of an aneurysm. With aneurysm, a
bruit can usually be auscultated. A hematoma itself is not
tender, but adjacent soft tissues are frequently so. As the
hematoma begins to age, the initial pool firms. If palpable, it
will feel from doughy to fluctuant depending on its stage.
Management. First air for typical hemorrhage is
compression, cold pack, elevation, and rest. Although a
distinctly large extremity hematoma may become obliterated in 1-2
days with this treatment, local compression and padding should be
continued for 1 or 2 weeks to assure complete resolution. Certain
enzymes tend to help disbursement of a hematoma, but they are
less effective than evacuation.
Referral. In severe cases or when fluctuation is
obviously evident, referral for aspiration may be necessary. If
so, it must be done early as a firm clot cannot be aspirated;
open drainage must be used for evacuation. Aspiration should be
followed by continued compression. If a semifirm clot resists
aspiration, continued compression and padding are applied to
encourage clot liquefaction. This should occur in 2-5 days. Open
surgery is rarely necessary; when it is, the probability of
secondary infection is always a problem. A dozen or more sterile
needle aspirations are safer than one incision.
Uniqueness of Athletic Injury. The well-conditioned
athlete (or hard laborer) not only has increased work capacity
but also has altered typical metabolism at the microscopic level.
Injury interrupts training and work causing a diminished level of
physical fitness. It also produces a different type of lesion
than that seen in general practice. This is due to the effects of
training that increase muscle-fiber bulk and interstitial tissue vascularity.
Because of the increased muscle bulk, vascularity, and
conditioning to demands in the physically active individual,
bleeding is more marked than in the unconditioned individual.
Well-trained muscle offers more efficient physiologic mechanisms
to remove extravasated blood from muscle, and absorption is much
more rapid. Thus, in the management of hematoma or any similar
injury, treatment must be modified when dealing with the
rigorously trained or with the sedentary person.
Shock is a
reaction to injury or disease, a manifestation of the rebellion
of the body against a major insult or injury -an alarm reaction.
It may appear suddenly after trauma or develop insidiously. There
is inadequate circulating blood to fill the vascular system.
There is interference with the basic physiologic process of the
blood stream delivering oxygen and other essential elements to
body tissues and removing waste products.
Besides the predominant characteristic of a reduction in
volume of circulating blood and initial vasoconstriction,
vasodilatation, hypotension, tachycardia, and prostration follow.
The initial circulatory deficiency is rapidly complicated by
widespread oxygen deprivation and by a lessening of function of
all tissues, especially the brain, liver, heart, and kidneys.
Typical Causes in Sports and Manual Labor
blood volume in circulation can result from (1) loss of blood
through internal or external hemorrhage; (2) loss of plasma by
seepage into tissues at the site of injury (eg, burns,
contusions, crash injuries); (3) excessive loss of fluids and
electrolytes from the intestinal tract through severe vomiting or
diarrhea; or (4) an abnormally sudden increase in the volume
capacity of the vascular system because of extensive
vasodilatation. In the latter instance, many blood vessels dilate
at the same time and, although there is no actual loss in the
amount of blood, blood fails to move forward in the dilated
vessels, thus mimicking cardiac output failure.
and symptoms of shock are related to ineffective circulation and
depression of vital body processes. The classical signs of shock
exhibit the body's attempt to compensate. They are:
of blood from active circulation, which may lead to failing heart
output and insufficient oxygen to cells vital for survival. Cold
perspiration, pallor, and possibly slight cyanosis, reflect the
body's attempt to produce peripheral vasoconstriction.
progressively failing hypotension, which may lead to kidney and
liver failure reflected by oliguria, indicative of
breathing (air hunger), tachycardia, and a rapid weak thready
pulse in compensation for cerebral anoxia. Anxiety, excitement
leading to confusion, listlessness, irrelevant phrase repetition,
apathy, and coma are also effects of cerebral anoxia.
which is mainly neurogenic and may be fatal. During this process,
the patient will usually present a staring or vacant expression
in the eyes. The pupils are dilated unless morphine has been
given or taken.
be anticipated in any person subjected to known causes of shock
such as unusual physical and emotional stress, any severe injury,
loss of blood, or loss of other body fluids. It may develop
slowly. In fact, characteristic signs might not appear for
several hours. In incipient or impending shock that has not yet
developed, no sign may manifest but preventive measures should be
taken if shock is considered possible.
Prevention goals are met through the control or relief of
factors tending to reduce aeration and circulation of an adequate
blood volume. Aside from hemorrhage or even in its absence,
circulatory collapse can be hastened or aggravated by such
factors as fear, fatigue, or pain; dehydration resulting from
excessive sweating, vomiting, or diarrhea; movement of injured
parts; or use of morphine.
The patient should be kept horizontal so available circulating
blood does not have to move against gravity. If the patient must
be moved, move the victim gently. Cover the person lightly to
preserve heat in a cold environment, but not so many blankets
that would increase core temperature. Do whatever is possible to
relieve pain. Establish a quiet atmosphere and a calm attitude to
reassure and secure the patient. Check vital signs frequently to
seek signs of irregularities and sudden changes.
Williams/Sperryn warn that the worst treatment
given is overheating as this increases peripheral vascularity
depriving deeper essential circulation. Elevated body temperature
places stress on the cardiovascular system. As the superficial
vessels dilate in an attempt to cool the blood within them, the
system may become too large for the amount of blood it contains.
In addition, there is an increased loss of electrolytes,
particularly sodium and chloride. In a warm or hot atmosphere,
padding used beneath the patient should not be made of wool. The
patient should be shaded from the sun.
Temperature, pulse, and blood pressure should be checked every
15 minutes. A critical point for effective kidney function is
reached when systolic blood pressure drops below 80 mm Hg. This
can be a fatal complication. The only effective treatment of
severe shock is transfusion of whole blood. Until this can be
arranged, assure that the patient's airway is open. Other
measures are explained below.
patient supine if conscious or in the three-quarter coma position
if unconscious. The victim's limbs should be raised to a level
about 6-inches above the head to let gravity assist venous
drainage. Pillows can be placed beneath the patient's feet (with
flexion at the knees) and buttocks. The good method is to raise
the foot end of a spineboard, cot, or litter. This creates
pooling of blood in the abdominal area without pressure on the
Placing the head of a sitting victim down is not good
procedure because respiration is hindered from the weight of the
viscera producing an elevated diaphragm. The semiprone coma
position may be used when the patient is unconscious; when there
is a wound of the head, face, neck (except fracture or
dislocation), or chest; or when vomiting is likely. When the
patient is in this position, drainage from the respiratory tract
clothing around the neck, chest, waist, and at any other areas in
which clothing tends to bind. Loosen but do not remove shoes.
Keep the patient
comfortable. The patient should not be allowed to become either
cold or overheated. A drop in skin temperature gives rise to
constriction of the superficial blood vessels, thereby reducing
the volume of the vascular system. In a cool or cold atmosphere,
the patient's body and limbs should be covered with blankets. Wet
clothing should be removed and blanket coverings tucked close to
the patient's skin. Clothing may be left on and exposed to the
atmosphere, provided a breeze does not evaporate perspiration in
the clothing so rapidly as to chill the patient. The victim
should also be protected against atmospheric temperature changes
such as those brought on with nightfall.
Relieve thirst in
the conscious patient who is not vomiting and has no wound in the
abdominal cavity or alimentary canal. Warm sweet drinks may be
offered. Never offer an alcoholic beverage because it will dilate
the vessels, and never force fluids by mouth.
Oxygen must be
started immediately at 6 liters/minute if cyanosis of lips,
nailbeds, or earlobes is noticed. Reassure the patient if
conscious that his or her best interests are being
Treatment should be discontinued gradually when vital signs
return to normal and stabilize. One valuable test of returned
circulatory control is the ability of the patient to maintain
stable vital signs as the patient changes position gradually
upright. No sudden or abrupt movements should be allowed.
states O'Donoghue, is the effect of any type of trauma causing
bruised skin and subcutaneous tissue that results in capillary
rupture and an infiltrative type of bleeding followed by edema
and an inflammatory reaction. Soft-tissue damage is usually more
painful and can be more serious than bone injury.
Bone heals with calcium. Soft tissue heals with fibrous scar
tissue and is different from the original tissue by lacking its
elasticity, pliability, plasticity, flexibility, and viability.
Soft tissue also takes longer to heal than osseous tissue. Bone
may actually be stronger after the healing process has taken
effect, whereas soft tissue is usually weaker and less adaptable
BIBLIOGRAPHY OF MAJOR REFERENCES
Eisenberg MS: The Paramedic Manual. Philadelphia, W.B.
Craig TT (ed): Athletic Injuries and First Aid: Comments in
Medicine. Chicago, American Medical
Dolan JP, Holladay LJ: First-Aid Management, ed 4.
Interstate Printers & Publishers, 1974.
Hirata I Jr: The Doctor and the Athlete, ed 2.
O'Donoghue DH: Treatment of Injuries to Athletes, ed 4.
Philadelphia, W.B. Saunders, 1984, pp 94-103,
Schafer RC: Chiropractic Management of Sports and
Injuries, ed 1. Baltimore, Williams &
Synder D: Chiropractic on the Field. Journal of Clinical
Special Edition: Athletic Injuries,
Williams JGP, Sperryn PN (eds): Sports Medicine, ed 2.
Williams & Wilkins, 1976.
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