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A catastrophic bleed is a bleed that will rapidly become life threatening to the casualty and must be aggressively addressed. A massive external haemorrhage should be the responder’s initial focus when arriving at a casualty; your priority is to stop the bleeding. This is due to the fact that once a large amount of blood is lost (approximately three litres) it can be too late to address the issue and measures such as intravenous fluids or a blood transfusion may be ineffective.

When arriving at the scene responders should look for obvious severe external bleeding. Note: this is not just any bleeding but rapid bleeding in large volumes. This will likely be obvious and evident in spurting arterial bleeds, blood-soaked clothing, or blood pooling on the floor. However, it is possible that a severe bleed could be obscured by heavy or waterproof clothing, and it may be absorbed into soft ground making it initially appear less severe. Responders should use appropriate PPE when controlling any haemorrhaging, including at least gloves.

Other symptoms of a major bleed include anxiety or confusion, deteriorating conscious level or unconsciousness, loss of radial pulse or pulse rate > 110, respiratory rate > 20 breaths per minute, capillary refill time > 3 seconds.

Controlling a Massive Haemorrhage

Prior guidance recommended the use of elevation and indirect pressure to address bleeding. However, research has shown that this is often ineffective, especially for life-threatening bleeding and it was removed from the European Resuscitation Guidelines in the 2015 update.

Options for addressing bleeding includes direct pressure, wound packing, haemostatic agents, and applying a tourniquet. The specific action will depend on the severity and location of the bleed. For example, a tourniquet may be appropriate for a limb bleed but will be useless elsewhere.

If there is an object embedded in the wound do not apply pressure to the object but when applying pressure, apply it to either side of the object. Build up padding around the object before applying a dressing to avoid putting pressure on the object.

With deep wounds the bleeding point may be deep inside, and direct pressure may need to be applied by inserting the fingers or thumb. However, if the wound appears to be coming from all over the wound and pressure cannot be applied in this way then wound packing may be required. Which is the process of packing a long bandage or gauze in the wound to fill up the cavity and then applying direct pressure to the packed dressing. Gauze is available that contains a haemostatic agent that may be used to pack a wound which can assist in controlling bleeding, but these are inappropriate for non-compressible injuries such as injuries to the chest and the abdomen. For a penetrating chest wound a chest seal may be appropriate.

Prior to addressing the bleed, fully expose the wound so that it can be assessed and clearly monitored; consider cutting clothing using rescue shears.

Managing a Severe Head, Neck, or Torso Bleed

Apply a field dressing to the wound and the apply direct pressure. Pressure must be firm and applied directly over the wound. If bleeding does not stop apply direct pressure and apply a second dressing over the top of the first dressing.

Managing a Severe Limb Bleed

In the case of a limb bleed it may be possible to control the bleed with a tourniquet. A tourniquet may be used if bleeding cannot be controlled through direct pressure. These should be placed on the limb as low as possible proximal to the wound, usually two to four centimetres above the wound.

For tourniquets with a windlass, such as the C-A-T Tourniquet: The tourniquet should be pulled tight by hand and the strap retained before turning the windlass. Once enough pressure has been applied to control the bleed, secure the windlass under the retainer. Then record the time of application.

Some tourniquets do not have a windlass. These may use an elasticated design which increases pressure with each wrap of the material (such as the FullStop) or may use a ratcheting mechanism (such as the RapidStop). In either case, the intention is the same – to ensure there is enough pressure on the limb to stop a catastrophic bleed. Once applied, record the time of application.

Leaving a tourniquet in place for an extended period of time (greater than six hours) may cause long-term damage and in the most severe cases may result in the loss of the limb. However, in the case of a catastrophic bleed, failure to control the bleed may result in the loss of life and so applying a tourniquet may be a requirement to save the life.

Applying a tourniquet for under 2 hours is unlikely to cause lasting damage and therefore we should aim to remove the tourniquet within 2 hours where possible. In extended extractions between 2 and 4 hours some numbness and tissue damage may occur, but this will largely if not fully recover.

Bleed Control Kits

A bleed control kit is a small pack that contains just the items that are required to address a catastrophic bleed so that they are readily available when required. These generally contain:

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