As the nights grow darker and Halloween approaches, tales of vampire bites might seem like pure fiction. Yet for pre-hospital clinicians, catastrophic haemorrhage is an all-too-real horror, and every minute counts. Whether caused by a fanged fiend or a high-speed crash, rapid recognition and control of bleeding can mean the difference between life and death.
Background
Major haemorrhage is defined as the loss of 1 volume of blood in 24 hours, but this is difficult to apply in practice, so alternative definitions can be used. In adults, this includes loss of blood at a rate of more than 150 millilitres per minute, or loss of blood resulting in a heart rate of more than 110 beats per minute and/or systolic blood pressure of less than 90 mmHg. Haemorrhage is thought to be responsible for 30-40% of mortality in trauma, with up to half of these occurring in a pre-hospital setting; hence, in 2006, the primary survey framework was revised to include “C” for catastrophic haemorrhage, even before airway assessment. This shift was influenced by military experience, where early bleeding control was shown to improve survival rates. Awareness of the general pre-hospital principles of major haemorrhage management can be life-saving.
Assessment
Major trauma assessments follow the C-ABCDE framework, with the first C standing for catastrophic haemorrhage. When identifying bleeding, a well-known phrase to consider is “on the floor and four more”:
- “on the floor” refers to external bleeding, which can be visualised
- may be arterial (brighter red, spurting) or venous (darker red, oozing)
- “four more” refers to areas of the body where there can be significant internal bleeding
- the chest cavity, abdominal cavity, pelvis, and long bones (for example, the femur)
Internal bleeding is trickier to spot but just as important to consider. Patients may show signs of hypovolaemic shock, including pallor, cold, clammy skin, confusion, tachycardia, and hypotension. This is a life-threatening condition caused by a large drop in blood volume. Other signs and symptoms may be present depending on where the patient is bleeding, for example, in an intra-abdominal bleed, they may have abdominal pain, bruising and rigidity. Early recognition of bleeding is essential to ensure that life-threatening injuries are identified and addressed.
Management
The principles of managing a major haemorrhage include controlling the bleeding, resuscitation, and rapid transfer to a major trauma centre.
Haemorrhage Control
For external bleeding, the first step in management is to apply direct pressure to the wound. Wound packing with haemostatic dressings should be used if direct pressure alone fails, and these are particularly helpful in junctional areas, such as the neck or axilla. These help to promote clot formation.
In major limb injuries, a tourniquet should be applied if direct pressure is not enough to control the bleeding. This should be applied approximately 5cm proximal to the injury, and the time should be noted. Ideally, only trained professionals should apply tourniquets due to the risks of complications, including ischaemia, skin necrosis, nerve injury, and compartment syndrome.
Mechanical haemorrhage control is difficult when there is suspected internal bleeding. A pelvic binder should be used if bleeding is suspected from a pelvic fracture. Pelvic binders are splints used to stabilise the pelvis and should be applied at the level of the greater trochanters.
Resuscitation
The method of resuscitation in major trauma is known as “damage control resuscitation”. Gaining wide-bore intravenous or intraosseous access is essential in life-threatening bleeding. The CRASH-2 trial in 2013 showed that early (within 3 hours) administration of tranexamic acid significantly reduced the risk of death due to bleeding.
Losses should be replaced “like for like”, i.e. blood should be replaced with blood, and excessive crystalloid fluids should be avoided. Excessive crystalloid administration is associated with trauma-induced coagulopathy, due to dilution of the patient’s own clotting factors. A key principle in damage control resuscitation is that one unit of fresh frozen plasma should be transfused to match every unit of red blood cells.
Permissive hypotension is another strategy used to reduce mortality from haemorrhagic shock. This involves aiming for a lower than normal blood pressure (systolic 80-90 mmHg or where there is a palpable radial pulse) in patients with major haemorrhage, with the exception of those with a concurrent traumatic brain injury. This helps to reduce excessive fluid administration while still maintaining perfusion.
Transfer
All patients with signs of major haemorrhage should be transferred to a major trauma centre as soon as possible, as, ultimately, the definitive management is often surgical.
Conclusion
While vampire bites may be confined to fiction, the rapid loss of blood is a real and deadly challenge faced by clinicians every day. Catastrophic haemorrhage is a life-threatening event, particularly in pre-hospital settings. Early recognition, effective haemorrhage control, and timely transfer are critical to reduce mortality.
References
Guy’s & St Thomas’ NHS Foundation Trust [Internet]. Major Haemorrhage.
National Institute for Health and Care Excellence. Major trauma: assessment and initial management
Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting.
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Written by: Dr Maria Kent (FY2, MTB Pre-Hospital Medicine Lead)
Reviewed by: Dr Callum Carruthers (GP with a special interest in Emergency Medicine, and responder with BASICS Scotland)
