3 Hemorrhage Assessment and Control
Learn how to assess traumatic hemorrhage, recognize concealed blood loss, control external bleeding, and understand advanced resuscitation priorities.
Recognizing and
is a time-critical cause of preventable death after trauma. Assessment and control begin together: identify life-threatening external bleeding immediately, look for signs of , and do not assume that little visible blood means little blood loss.
During the initial survey, rapidly expose and inspect the patient while protecting yourself from blood exposure. Look for active bleeding, expanding hematomas, penetrating wounds, and injuries associated with major blood loss. Ask about the mechanism and timing of injury, and repeat the assessment because bleeding and can evolve.
Assess trends rather than relying on a single vital sign. Tachycardia, narrowing pulse pressure, cool or clammy skin, delayed capillary refill, weak peripheral pulses, restlessness, confusion, or decreasing alertness may indicate poor perfusion. Hypotension is a concerning, often late sign; its absence does not rule out serious .
A normal initial hemoglobin or hematocrit also does not exclude acute blood loss. Clinicians use repeat testing alongside examination and overall clinical status.
Searching for concealed blood loss
Blood can collect internally without an obvious external wound. After significant trauma, consider bleeding in the following locations:
Chest: for example, after penetrating injury or major blunt chest trauma.
Abdomen: including from solid-organ or major-vessel injury.
Pelvis and retroperitoneum: particularly when pelvic injury is suspected.
Soft tissues around long-bone fractures: especially around the femur.
A soft or initially unremarkable abdomen does not reliably exclude internal bleeding. A concerning mechanism, worsening perfusion, altered mental status, or deteriorating vital-sign trends should prompt urgent advanced evaluation and transport to definitive care.
Controlling external bleeding
For life-threatening bleeding, activate emergency services or the trauma response and begin control without unnecessary delay. Follow your training and local protocol.
Apply to the wound. Maintain steady pressure rather than repeatedly lifting the dressing to check.
Pack a deep wound that can be packed, such as an appropriate junctional wound. Use gauze, ideally hemostatic gauze if available and you are trained to use it. Fill the wound firmly and maintain pressure. Do not pack the chest or abdominal cavity.
Use a for life-threatening arm or leg bleeding when indicated. Place a commercial proximal to the wound, not over a joint, and tighten until bleeding stops. If bleeding continues, tighten it or apply a second above the first, as training and protocol direct. Note the application time and do not loosen or remove it yourself.
Once bleeding is controlled, a pressure dressing may help maintain control. Recheck the wound and the patient: bleeding can recur, and a or packed wound must not distract from other injuries.
For example, if a patient with a thigh wound continues bleeding despite pressure and becomes pale and confused, apply an appropriate and reassess for control. At the same time, the trauma team evaluates for and additional bleeding, including concealed injuries. Controlling one wound does not rule out another source of blood loss.
Resuscitation priorities
Definitive control of the bleeding source is central; fluids alone cannot stop . In advanced trauma care, combines rapid control with early, protocol-guided blood-product resuscitation when indicated. It aims to support perfusion while limiting dilution of clotting factors, worsening coagulopathy, and hypothermia from excessive crystalloid.
Clinicians may use restricted-volume resuscitation before bleeding is controlled when there is no evidence of brain injury. is generally avoided when traumatic brain injury is suspected because inadequate blood pressure can worsen brain injury.
For eligible patients with significant traumatic bleeding, clinicians may give as early as possible and within three hours of injury, according to protocol. Resuscitation also includes preventing heat loss and monitoring for and low calcium during major transfusion. These are clinician-level interventions requiring monitoring and local protocols.