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Hemorrhage Control Algorithm
Step-by-Step Bleeding Control Protocol for Trauma Patients
Work through the hemorrhage control sequence, from direct pressure and pressure points through tourniquets, hemostatic agents, and definitive surgical control.
Step 1: Direct Pressure
First-line hemorrhage control for external bleeding
Technique
- Apply firm, direct pressure to bleeding site
- Use gauze or clean cloth if available
- Maintain pressure for 10-15 minutes minimum
- Do not remove blood-soaked dressings - add more on top
Indications
- External bleeding from wounds
- Compressible bleeding sites
- As initial intervention for all external hemorrhage
Contraindications
- Suspected foreign object in wound
- Obvious fracture at pressure site
- Severe crush injury with tissue loss
Step 2: Pressure Points & Elevation
Adjunctive measures to enhance bleeding control
Technique
- Apply pressure to arterial pressure points proximal to bleeding
- Elevate injured extremity above heart level if possible
- Common pressure points: brachial, femoral, carotid
- Maintain direct pressure while using pressure points
Indications
- Extremity bleeding not controlled by direct pressure alone
- Multiple bleeding sites on same extremity
- Need to maintain control while preparing advanced interventions
Contraindications
- Suspected spinal injury (avoid elevation)
- Multiple trauma with potential internal bleeding
- Fractures that would be displaced by elevation
Step 3: Tourniquet Application
Life-saving intervention for severe extremity hemorrhage
Technique
- Place tourniquet 2-3 inches proximal to wound
- Tighten until bleeding stops completely
- Note time of application clearly
- Do not loosen once applied in field
Indications
- Severe extremity bleeding not controlled by direct pressure
- Traumatic amputation
- Multiple casualties requiring rapid hemorrhage control
- Combat or tactical medicine situations
Contraindications
- Bleeding from head, neck, or torso
- Partial amputations with intact vessels
- Suspected compartment syndrome
Step 4: Hemostatic Agents
Advanced hemostatic products for persistent bleeding
Technique
- Pack hemostatic gauze directly into bleeding wound
- Apply firm pressure over packed gauze for 3 minutes
- Common agents: QuikClot, Celox, HemCon
- Follow with pressure dressing
Indications
- Deep wounds not amenable to tourniquet
- Junctional bleeding (neck, axilla, groin)
- Persistent bleeding despite direct pressure
- Penetrating trauma to torso
Contraindications
- Allergic reaction to hemostatic agent
- Large vessel injury requiring surgical control
- Contaminated wounds (relative contraindication)
Step 5: Definitive Surgical Control
Immediate surgical intervention for life-threatening hemorrhage
Technique
- Rapid transport to operating room
- Damage control surgery principles
- Consider resuscitative thoracotomy if indicated
- Early massive transfusion protocol activation
Indications
- Internal bleeding not controlled by external measures
- Penetrating trauma to chest, abdomen, or pelvis
- Hemodynamic instability despite resuscitation
- Class III or IV hemorrhagic shock
Contraindications
- Futile care situations
- Prolonged cardiac arrest
- Unsurvivable injuries
Hemorrhagic Shock Classification
| Class | Blood Loss | Volume (70kg) | Pulse | BP | Respirations | Urine Output | Mental Status |
|---|---|---|---|---|---|---|---|
| I | < 15% | < 750 mL | < 100 | Normal | 14-20 | > 30 mL/hr | Slightly anxious |
| II | 15-30% | 750-1500 mL | 100-120 | Normal | 20-30 | 20-30 mL/hr | Mildly anxious |
| III | 30-40% | 1500-2000 mL | 120-140 | Decreased | 30-40 | 5-15 mL/hr | Anxious, confused |
| IV | > 40% | > 2000 mL | > 140 | Decreased | > 35 | Negligible | Confused, lethargic |
Critical Points to Remember
- • Time is critical - rapid control of hemorrhage saves lives
- • Don't remove impaled objects - stabilize in place
- • Tourniquet time should be documented and communicated
- • Consider early activation of massive transfusion protocol
- • Hypothermia and coagulopathy worsen bleeding - prevent both