Bleeding, Shock, Soft-Tissue Wounds, Burns and Eye Injuries

Hemorrhage Identification, Hemostasis, and Shock Management

Rapid identification and control of external bleeding are essential steps in the primary assessment. Arterial bleeding may be bright red and pulsatile, but appearance varies; assess the amount and rate of blood loss, and control life-threatening bleeding immediately regardless of the vessel involved. Venous bleeding typically flows steadily and may appear dark red, but color and flow pattern are not reliable enough to determine whether bleeding is life-threatening. Capillary bleeding is typically red, oozes slowly from superficial vessels, and often stops on its own. For general external bleeding, apply firm direct pressure using a clean dressing to promote clotting.

For life-threatening extremity hemorrhage, apply a commercial tourniquet promptly when indicated by local protocol; do not delay its use to attempt direct pressure first when immediate tourniquet application is warranted. Place the device 2 to 3 inches proximal to the injury site, taking care to avoid placement directly over a joint. If severe bleeding persists after the initial device is secured, place a second tourniquet immediately proximal to the first. Once applied, an EMT must never loosen or remove an extremity tourniquet unless specifically directed by medical control. Document the tourniquet application time on the device or patient when feasible, record it in the patient care report, and communicate it during handoff.

In anatomical areas where a tourniquet cannot be placed, such as severe junctional bleeding in the groin or axilla, commercial hemostatic dressings are indicated. For example, just as a plumber firmly packs material into a high-pressure junction to seal a leak, an EMT must pack an appropriate hemostatic dressing firmly into the depths of a junctional wound. Maintain continuous direct manual pressure over the packed wound for the duration specified by the product instructions and local protocol to allow active clotting agents to function.

Severe blood loss precipitates systemic hypoperfusion, or shock. In compensated shock, the body actively works to preserve perfusion, presenting with tachycardia, tachypnea, pale and cool clammy skin, while maintaining a normal systolic blood pressure. Hypotension is a late sign of shock that indicates transition into decompensation. Pediatric patients utilize intense vasoconstriction to sustain blood pressure during shock, masking volume loss until sudden cardiovascular collapse occurs. Neurogenic shock from spinal cord injury may cause vasodilation, warm skin, and relative bradycardia, but these findings are not always present; continue to assess an injured patient for hemorrhagic shock. Basic life support care across all shock etiologies requires maintaining the airway, supporting breathing, administering oxygen when indicated by assessment and local protocol, preventing heat loss, splinting closed fractures to stabilize bone ends and reduce internal hemorrhage, and transporting promptly.