WE have been doing basic bleeding control WRONG!
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- เผยแพร่เมื่อ 20 ก.พ. 2018
- So I want to say something that maybe controversial, we all have been taught wrong in our basic first aid class about bleeding control. We were all taught to stack the bandages on top of each other and not remove them. This was because we didn't want to mess up the clots that were forming, well if the patient is bleeding though multiple bandages are the clots really helping?
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I always thought it was asinine to keep stacking, so my practice has always been to keep the original wound covering in place, and replace the next layer and readjust the pressure. I'm glad to finally hear someone else with the same thoughts about it. The second layer is just mopping up what the first layer isn't, while the first layer is kind of acting as a skin layer until the clotting stops the flow of blood. Thumbs up!
That was my first thought - a kind of hybrid method. Leave the first, replace the second.
My thoughts exactly. Leave the clotting in place. And change out the secondary bandages and adjust your pressure points. Also if it’s bleeding that bad it’s probably time to go with a good quick clot or celox if available.
Earthscum I
This is exactly what I was always taught from Red Cross babysitter's course 22 years ago until present. Only keep the first layer, change everything else and of course PRESSURE!
Absolutely my thoughts, that seems to be the best alternative. Changing the first one could be difficult and painful as well but changing the second one seems to be easy and effictive.
How about leaving the 1st inplace and toss the 2nd. Apply a new second and adjust where you are putting pressure. I have never thought stacking 5 or 6 bandages to be a good idea. But i do believe removing the first could mess with clotted blood in the wound. Also a fan of the 4 X 4 as the first dressing.
100% agree, the clots are forming below the first bandage, the second doesn't have any helpful clots.
@@lobisw true but if ur going to lift bandage maybe it’s very suttl but could still interrupt the cot so might as well toss and re-evaluate
This is the protocol that is in the British First Aid manual. If the first dressing soaks through, apply a second dressing on top. If the second dressing also soaks through, remove both and apply a fresh dressing, ensuring that pressure is applied accurately to the point of bleeding. The manual is the standard text book for all first aid qualifications in the UK. The Oxford Handbook Of Pre-Hospital Care states: "In the event of blood soaking through applied dressings, further applied dressings are unlikely to arrest haemorrhage." It seems that your idea is a good one, as this is what we do this side of the Atlantic.
What does it say about tourniquets?
Touniquets and haemostatics are now part of the basic occupational First Aid certificate course in the UK.
We just love your channel! God bless you
This is where the Swat-T tourniquet (synthetic stretch wrap material)works great, because it can be used to apply the direct pressure needed assist bandages.
Many of my micro trauma kits do not have a full size cat tourniquet I am ordering a bunch of SWAT T s for those kits .. also blood stopper powder hemostatic gauze even an ace bandage
Hello Iv been using your great videos in my EMT class!! Iv has been an inner-city EMT for 35 years as well as an officer. I'm now an instructor and your videos are a god-sent thanks !! happy thanksgiving to you and yours.
What about removing the second 5X9 adding a new one and then changing your pressure point.. that way you're not interferring with any clotting...
That was just what I was thinking, you beat me to it. It just seems like a practical option to me also to reinforce without disturbing the clot and then change location of pressure.
Seriously? That's the way I do. But I also usually don't have trouble stopping a bleed
I’ve had really good results with two layers and a BP cuff (on limbs, obviously). Even, quantifiable pressure and hands free.
The bp cuff is a good idea
Excellent points. We always used to teach in SERE that if direct pressure wasn’t working to try that in conjunction with a constriction band.
Skinny medic that’s a Good idea, I never really thought of it that way. Thanks!
We've always taught in the army to apply a pressure dressing if a field dressing fails
The Immortal.....good to hear from you.
Wolverine Prepper
Good to hear from you too!
Hope all is well buddy.
And with the new (current) elastic combat bandage that is much easier to do.
Yep, but if you don't have an Israeli or the equivalent, you have to make it up as you go along.
I’ve learned so much from you. Thanks, Skinny Medic!!!! 👊🏼
Direct pressure from the start is a winner but just as important, why is the patient still bleeding? Increased BP? Blood thinners? We use an ace wrap or coban to secure dressings when possible and let the patient apply pressure if we have to move on.
Thank you for these, man. It's invaluable information.
Excellent thinking! I always learn useful information from your channel!
Great work in explaining the simple truth about what we do and see in reality vs. A "case study" that creates a protocol.
I have a pretty extensive Trama Kit. My first priority on a serious injury is to stop the blood flow, I myself use Bleedstop, then an Isreal Bandage, then a tourniquet, If need be two tourniquet.
The Bleedstop woks well to couragulate the blood and, in the least, slow down the blood flow. You will need to apply direct pressure for about 5 minutes, depending upon the severity of the wound.
The Isreal Bandage will soak up quite a bit of blood, and you can apply direct pressure on the wound like a tourniquet. Then, use a ratcheting tourniquet above the wound to further stop the blood flow.
I agree w/u, the 2nd one is for cleaning up. Thx for the info.
Nicely explained! And nice ring :D
super thanks. good information for treating someone on anti coagulant meds.
As noted by others, the UK first aid training agencies have been advising on applying only two dressings, then restarting again (as you suggest) since ~2002; regional variations on first aid advice do occur.
2021 and here in the UK. We are now taught to remove the first dressing, check the wound for foreign objects that we may have missed in the first place. Re-assess where the wound is bleeding from and put direct pressure on that point.....so you were correct all along.
Very good point!
Similarly, I heard local paramedics say that more and more neurologist and orthopedic surgeons say that it is better to get victims to the ER quicker that spending a lot of time stabilizing. If you spend hours getting someone stabilized in a car, etc. the damage might be worst. What they need is surgery and or medication ASAP.
That's correct. In a serious trauma the vast majority of treatment will be done en route to the E. D. unless an unpreventable element, such as, extraction requires a prolonged scene. In that case you would begin treatment while the extraction is in progress, if possible.
I agree. Good food for thought.
Great tip and thanks for sharing :) and great video.
Right on! Adjusting the way pressure is applied makes more sense than stacking bandages. Couple thoughts: 1) If the wound is deep, pack with gauze before placing a pressure bandage; 2) 6" pallet wrap makes a fine compression dressing for holding pressure on a 5"x9". Firmly apply 3-4 layers of wrap over the pad.
Great info thanks
Great advice.
In my First Aid classes, I always teach to leave the first dressing in place but don't keep "padding".... remove the second if it soaks through, but leave the first in case there is "some" clotting that has started. You are certainly more educated on this area so I will have to consider your option now.
Great point, the whole purpose is to stop the bleed.
1. 4x4s with good pressure. 2. Roller gauze, still rolled up, set over the original 4x4s. This leaves a sizable “bump” over the wound area. I take CoBan and do a good pressure wrap, check for a distal pulse and or cap refil. Basically it’s a “mini Izzy bandage”. I’ve used this on pretty bad wounds that could have easily gone to a tourni ex. We had a woman who was serious about killing herself, sliced along the vein, not across. Wrapped it, started an IV (she’d lost a lot of blood) and kept her around 90 sys and she was good to go for a good 20 min transport. Anyway…very effective.
Your channel is exactly what I needed SUBBED!
Welcome!
Good point, SM! Makes sense. Couldn't be much clotting if it's still bleeding.
I have been an emt in florida for 19 years i have always hated the keep adding bandage idea. I think its s great thought to readjust the pressure point. I have seen the thick pad over a wound with no help as well lol....
P.s. love your vids.....
go waaaaaaaaaaaaaaaaaaay back 20 years and it was apply bandage/clean cloth/something and get the arm wound above the heart. Thus lowering pressure to the wound causing the blood and clots to pool. And stop bleeding. Maintain above heart level until help arrived or you got to the ER.
As an EMT that was trained in the past few years, and now sometimes acts as an instructor, that's not what I was taught nor is it what I teach. What we generally teach is that after you apply that initial 5x9, you do not remove it. However if it bleeds through add more 5x9s as necessary, and if you can no-longer hold antiquate pressure remove the excess 5x9s (but not the initial one) and add fresh ones if needed.
The clot is forming on the initial 5x9 you placed, not anything else. So you should be good to add/remove things as needed so long as you don't remove the 5x9 you placed first.
Good practice point
If I recall correctly, I was taught in the Army that if the first or second bandage didn't do it, apply pressure dressings
Not controversial. I completely agree with you here. Great video, fellow Medic!
I worked EMS for years and always thought this seemed stupid...if it's bleeding so much that you need more bandages, there is clearly no clotting to disrupt...I usually went for a FRESH bandage and some form of additional pressure 'upstream', often manually, all while doing my best to calm the patient and get their heart rate down. I found calming to be incredibly effective when possible.
When do you use a petroleum gauze, only on burns or also cuts like what he's describing? Would you put on a bullet hole(dosent bullet burn skin?) that's somewhere where is not gushing blood?
Well said! Multiple pads give the *illusion* of bleeding control, but in fact the person is bleeding out slowly & neatly into the multiple pads.
Thank you for being a skinny medic⛑
Skinny, Good morning CEU. Best
Good point
I belive you. It sounds like the right thing to do. Greetings from Andreas on Off Grid Sweden
I am in Canada, we were taught if it bleeds through 2 to use a tourniquet, leaving the two in place
How about a Israeli bandage or North American rescue 6”? Then we can really get some pressure on the wound and maybe not have to hold it so we can continue on with patient assessment? .02
Agreed and add some combat gauze or a combat sponge or something with a homeostatic agent in it.
Sounds logical
My first thought was Israeli bandage as well.
You could even do 5x9 with an ACE wrap (trick of the trade from working at a "frugal" EMS system). Israeli bandage = $10+ ... NAR trauma dressing = $11+ ... 5x9 + 4" ACE = < $5 (and they are multi-use)
thanks
I have no experience (only what I gather on channels and fb pages like this), but that will probably work way better than just stacking. I remember discussion about wound packing and the summary was that if it fails and blood is still leaking, don't add more gauze, but remove everything and put new hemostats as most likely it was in the wrong place and doing its job in the first place.
What you say makes sense to me. It has always seemed to me that after a point you're just extracting blood by capillary action when you apply more fibers.
I have simply put a gloved hand with lots of pressure on a wound and controlled bleeding with no bandage. Once its controlled I then apply a bandage with continued pressure.
Makes sense.
MR. FLACKO, you are 100% correct. Also, think about capillary action for a second. By adding mas fabric while pressing only creates a WICKING action and will actually DRAW fresh blood outward. Are there any contraindications using coagulants?
........thanks, LPN (Low Paid Nurse)
On smaller wounds up to an inch and maybe a 1/3 inch deep I have always found dryer bandages stop the bleeding faster. I haven't had much experience with fresh wounds much larger, so I don't know if that would transfer over. But what your saying makes sense. I would also think that pressure should be closing the wound as well it at all possible.
I carry blood stopper powder.. pour on the powder put the pad and wrap a tight ace bandage around
Also been thinking that if you have to use a tourniquet, that putting some soft padding like a rag on the opposite side of the artery you want to clamp down might relieve some pressure and cause less chance of amputation while still targeting the artery that is bleeding out.
Makes sense. I wonder if there would be value in leaving the base one on (for clotting) and changing out the #2 and #3 with fresh?
I enjoyed this video
The bleed through to the 2nd and 3rd bandage, how much of it is just absorbtion from the saturation of the 1st bandage? A good percentage I think. Your thought is spot on. The more bandage you apply to a cut the more dissipated the pressure as it will spread out to a wider area causing less pressure on the focal point.
Good vid SM. 👍
That works! Done it before.
I honestly understand your idea and yes there is a point in game plan change. However, I do believe if we can slow the blood flow through multiple layers while applying direct pressure we can help the clotting under the first layer do its job better. If the clotting under the first layer had begun to start to work removing that layer brings us back to square one.
Valid points. What about leaving on the first 5x9 and replace the 2nd as well as adjust pressure? Maybe an Israeli bandage? . I'm curious about this I recently finished a tecc/tccc training and can't learn enough. Great videos as always. "Train more,bleed less"
Makes sense!
Smaller pressure bandage? Like the 4in one from NAR? I’ve used that one time and it worked pretty well.
My training from Cub Scouts through EMT school was first bandage stays, the second one gets replaced if it bleeds through. Also if it's still bleeding more pressure.
In my case they taught us to leave the initial gauze on, but any subsequent gauze that's bled through could be replaced. It sounds like they may have said to apply extra gauze if it bled through, but never really clarified further than that for you.
Agreed
Feeding the algorithm. We appreciate your content.
MD (to be) here: by taking the 5*9 off, you're not taking out the clots (if it is still bleeding there are no clots) you're however taking away the blood which has most of your clotting factors.
Place the 5*9, wrap it real tight with gauze or tape and apply pressure. You want to keep as much blood as possible in the site, so the clotting factors dont get washed away. If you know your anatomy, you could try holding pressure over the artery leading up to the wound. But over all, one 5*9, wrap it, press hard on it. Small nicks and cuts clot immediately because the primary clot (platelets holding together by only moleculed on their membranes) coupled with vaso constriction is enough to close the capillaries since the blood flow is very weak and the space to close off is small.
If you got smaller arterioles or venules that are bleeding like in this situation, the primary clot wont cut it, you need a secondary clot, where fibrin is layed all around the site by platelets grabing and tangling more platelets, red blood cells, white blood cells, proteins and everything that comes into contact. It will take longer and you need to slow the bloodflow down as to allow clotting factors to do their work.
I agree
Please do a video on the STAT tourniquet, what do you think about it?
Good thought! Maybe even leave the first and swap the rest
In the vast majority of cases where one might need to address a serious wound in the field, there is just one such wound, and most of the time, once you've got the bandage on, you can afford a few extra minutes at that point. How about assisting the bandage by applying hand pressure over the bandage. Clotting can be relatively quick if the clot itself isn't disturbed by blood flow. So put the heel of your palm over the wound after you bandage it and apply sufficient pressure manually. It's a rare wound indeed that will still be bleeding after a few minutes of that.
What if instead we apply the bandage and just wrapped it tightly with a roller bandage or an ace wrap (but not too tight) to maintain constant pressure on the wound? would that work?
@Bryan Choo
It would be less effective than direct pressure. The roller bandage will be applying pressure equally, all around where it is wrapped. Any additional pressure beyond the tight wrapping to the wound will be solely due to the thickness of the wound dressing. For some wounds, adding sufficient additional pressure from tight wrapping might well be tantamount to the effect of a tourniquet. Tourniquets should be the last resort choice, the choice when nothing else will do either due to wound severity or urgency of time constraint. There are huge downsides in terms of after effects however from that kind of generalized pressure reducing or eliminating blood flow past that point.
Hand pressure to assist wound clotting avoids the tourniquet problem. Moreover, while a tight wrapping may well do the job, it continues it's tightness well beyond the point from when it is still needed, unlike hand pressure, where a human brain is in the loop.
One thing I could suggest if you don't want to spend minutes pampering a wound but also don't want to wrap too tightly, is to heighten the packing above the wound right at the start. Apply a sterile pad to the wound, then put a gauze roll, 'unrolled', directly atop that positioned to maximally cover the shape of the wound, then gauze wrap (using a second roll) the pile. The unrolled gauze will create that localized pressure. It won't be as much pressure as direct hand pressure, but it will be sufficient for most.
Direct pressure is the standard technique for bleeding wounds and that is what he is talking about in this video.
@@bryanchoo4598 sometimes it works and sometimes it doesnt.
Yeah. Stacking is, imho, kinda silly if it keeps bleeding; if the wound looks that bad, and superior medical assistance isn't close by (say five or ten minutes away, max), I'm going to pack that wound with either celox ribbon (by preference) or granules, THEN apply the 5x9.
Once it bleeds profusely through the second gauze I would fold one in half and tape for added pressure directly over the wound site.
I knew a guy who got a head injury. At the hosp the Dr commented on nice application of dressing but said next time put it over the wound. Dressing in the right place, preasure in the right place? More preasure or TQ
Makes sense to me.
Interesting video. I think most of have used multiple 4x4s on a wound, can't imagine using that many 5x9 or ABD on a wound. I can see your point. As others have said maybe an ABD wrapped with Kling or ACE for compression.
New Market EMS swat-t ?
Agree
Interestion point....intrease the direct in addition ELEVATION ABOVE THE HEART is also benifishal to slow the blood flow
Would it be ok to stack a couple and then wrap it with an ace bandage? I would think that would be the best way to apply even pressure to stop the bleeding. Also would free up your hands to asses/treat other possible wounds.
German here, not familiar with US first aid protocols.
Am I getting this right, the standard first aid courses teach to keep stacking gauze pads with no other alterations?
We do teach stacking bandages here, but by bandages we don't mean gauze pads...
My protocol as a first aid instructor currently is (extremity, arterial bleeding):
(This applies to driving license applicants, and the bi-yearly legally required courses for at-the-workplace first aid):
1) Apply manual pressure
2) If possible, elevate limb (yes, controversial)
3) Call for help, get someone to get a first aid kit out of a nearby car (if noone cooperates and the bleeding is life-threatening, it is legal to break into a car in this case)
3a) The standard issue first aid kid in a German car includes no israeli bandage or tourniquet, but lots of gauze pads and bandages.
4) Apply a sterile gauze pad firmly
5) Wrap bandage around gauze pad once or twice, then add still-wrapped bandage as pressure padding on top of the gauze pad, then wrap the first bandage around that as well (tightly)
6) If bleeding persists, you may stack another pressure padding on top of the first pressure padding, and apply another bandage even more tightly to press both pressure paddings onto the wound area. The reason not to remove the first pressure bandage is to not loose pressure
7) Failing that, apply even more direct pressure (kneel down if necessary)
8) Taught only in specialized courses for firemen/-women, woodworkers, mechanics etc.: You may apply a tourniquet in addition or instead of stacking pressure bandages.
Now that system isn't without fault (it is certainly rather complex if you do not visit the required refresher courses and is not aimed at major trauma scenarios), but that's the only protocol I know which makes you stack anything on a wound. You only stack pressure bandages to increase pressure if a normal bandage wasn't enough. You'd never stack normal bandages. In fact, we make sure the pressure dressing remains wrapped to avoid soaking in blood because we do want to immediately see further bleeding, not hide it inside a soaking, now-soft pressure bandage. It'd be a different matter if we'd pack wounds, but that's only recently been added to EMS protocol here (with all the hysteria around terror attacks and depression-induced shootings), it has never been part of first aid training.
I find it fascinating how things are handled differently around the world. The "elevate the injured limb" thing, for instance, is really out of fashion in the US, while in Germany, people are way too afraid of teaching to use tourniquets. Also, haemostatic agents: Pretty popular with Americans, but extremely controversial over here. As a medic, I am currently not allowed to use QuikClot for instance. Even privately, I should not do it because there are hardly any deaths due to external bleeding in my state, but a very high number of clotting-related deaths (mostly your good old pulmonary embolism, stroke, heart attack and such). We are currently buying chinin-based wound packing material, though, so protocol is becoming more forgiving. Not many medics have been taught packing wounds as of yet. And I mean, it's extremely rare. 99% of life-threatening emergencies require a quickly established IV access, good ECG reading, solid CPR and intubation skills, early defibrillation and/or rapid transport. 1% may require difficult to control external bleeding, so I understand why our protocol only added tourniquets a few years ago. We were way too afraid of losing limbs, but current statistics show no problem with tourniquet use.
Makes sense
The other problem is, if you don't approximate the wound edges, additional pressure can actually cause the wound to stay open. Removing the initial bandages, readjusting making sure the wound edges are approximated as best as you can and then apply direct pressure or a pressure bandage can make a big difference.
i agree
I am not a trained medic, but what you say makes sense.
After the bleeding has stoped do we remove the gauze irrigate and clean wound and reapply new gauze and wrap it with cling, ace bandage, compression bandage, or self-adherent bandages.
about 4 years ago I had a nasty cut, about 3" (the ones that requires stitches) in my arm and I only got my t-shirt and press firmly about 2 hours and the bleeding stoped, from then I always carry a IFAK near !!!
What about switching the bandage style overall. Like switching or adding an ETB?
i agree with changing location of pressure ive always questions when dealing with bleeds like that why cant we treat it like a tourniquet required injury and apply pressure above the wound while still applying secondary pressure directly to the wound
Thank you man at least one person who learned it like I did. You have a nasty wound on your arm. Go and squeeze the upper arm in order to tighten the arteria brachialis and slow the blood flow, then apply your pressure bandage and you should almost always be good to go in like a minute
Blood in the veins is moving from the limb towards the heart. So for this idea to work on a venous bleed, you would need to apply pressure distal to the wound to prevent blood flow.
@@objectiverunamok8918 you would not have such massively bleeding wounds if only the veins are affected except for some extreme cases of anticoagulations. And because the bloodflow in the veins is regulated passively by the arteries next to them, proximal pressure is highly effective anyways.
i would put 1 or 2 5x9 then wrap it with thick medical tape for pressure.
Can you use something to show how much pressure is applied to a wound when using one, two and three pads? A scale?
???
Who would tell you to just stack bandages on top of one another and everything will be okay? Apply pressure to the arteria brachialis, apply one bandage with good pressure and you're good to go in a minute or so. Increasing the direct pressure on the wound will not necessarily help any further instead stop the blood flow by increasing the pressure on your upper arm (should be enough using your hands no tourniquet)...
I agree. When using the emergency roll of TP and duct tape at the job site you get a good wad, hold pressure then after a song or smoke pitch it out the window, put second wad on wound and tape in place. If it runs out the duct tape or you can't get it to stick due to river of blood you have to tell your boss, which might be worse then going to the doctor. Just saying ;)
Just like how you pull combat gauze out of a wound if it becomes blood soaked.
Why not leave the first to maintain any clotting and adjusting pressure and reapplying gauze layer #2 from there?
Here's how I see it. For us non-professionals, we worry about the amount of blood and the length of time we continue to bleed. I once cut my index finger near the top ( I was in the bathroom cleaning a khukri knife) and it bled all over the sink while I tried to open gauze pads to put on the cut and deal with the blood by running water and using paper towels. I managed to wrap it and I just held it until I got to a clinic.
The nurse was the one who took care of me. She basically had me soak/rinse my hand in a basin of hydrogen peroxide and put on the foam and bandaged it. The doctor without even saying "Hello" to me, looked at my finger for 2 seconds and told her to do exactly what she was thinking. After she dressed my finger, she then gave me supplies and instructions on how to redress it myself. I thought oh great, a "do it yourself" kit.
If I had a blood clotting agent and the supplies at home I could have done it myself..... but even thought it stopped bleeding on the ride to the clinic, I thought I might require stitches or some medication. Apparently I handled it better than I thought and if I was more knowledgeable I could have taken care of it, but "better to be safe" is what guides most of us.
I have never heard of stacking 5x9's at all in a heavy bleed. The 5x9 is not there as a patch such as on a flat tire. It is a semi sterile surface that is absorbent. The pressure is to stop the bleeding while the 5x9 provides a more sterile cover than your bare hand and to reduce blood running all over. If the pressure is not handling the bleeding and the bleeding is excessive it is time to move to something else. You could put a 4" thick folded towel and it will just absorb blood and stop no bleeding at all. It's all about pressure, cleanliness and reduction of infection via the 5x9 instead of the 5x9 being a non-permeable membrane.
I have NEVER been taught to keep applying more & more dressings.
1 trauma pad with direct pressure.
If it doesn't work, get someone to apply direct pressure while you go for the brachial/femoral artery and use indirect pressure.
If blood still soaking through at that point, you should be already booking it to the hospital!