Hemorrhage Control

What is Hemorrhage Control?

Blood is vital as it helps circulate nutrients, and remove waste from our brain, organs, and tissues. A hemorrhage refers to loss of blood from our body’s circulatory system. Hemorrhagic shock happens when there’s so much blood loss that it impairs the supply of oxygen to our body tissues. It’s important to note that bleeding due to traumatic injury is the primary cause of death in Americans from age one to 46. An initiative called “Stop the Bleed” was started in 2013; it’s an educational program aiming to lessen the illness and loss of life associated with bleeding due to traumatic injury.

By applying knowledge from military medicine to everyday healthcare, we can significantly improve health outcomes for patients who are bleeding. This information is an overview of recent science and lessons learned to enhance care for a patient suffering from a hemorrhage.

What Causes Hemorrhage Control?

In the year 2000, the World Health Organization (WHO) shared that accidents and injuries were responsible for 9% of deaths worldwide and 12% of all health problems. They expect accidents causing severe trauma, injuries that cause significant damage to the body, to be responsible for over 8 million deaths every year by 2020. Hemorrhage, or excessive bleeding, is the reason for about 35% of these deaths, making it the second leading cause of death in trauma cases after injuries to the central nervous system (the brain and spinal cord).

Unfortunately, about half the deaths caused by hemorrhages occur before the person can get proper medical care. The leading cause of these injuries is violence, with traffic collisions coming in second place. In 2015, the National Trauma Institute estimated that in non-military situations, severe bleeding is responsible for more than 35% of deaths happening before hospital arrival and nearly 40% of deaths within the first 24 hours after an injury.

Coagulopathy, a condition where the blood’s ability to clot is impaired, affects 25% of these injured people. It’s caused by hemorrhage, hemodilution (when your blood gets diluted), hypothermia (low body temperature), and acidosis (too much acid in your body’s fluids).

Risk Factors and Frequency for Hemorrhage Control

These kinds of injuries result in a high number of deaths, especially in low and middle-income countries. They mainly affect people between the ages of 15 and 44, with men being affected twice as frequently as women. Back in 2003, injuries ranked as the third most prevalent cause of death in the United States, and the leading cause of death for individuals aged 1 to 46. The impact of these injuries was so great that they represented a significant portion of potential life years lost before age 65, and accounted for nearly 10% of national healthcare spending. Even with medical advancements and improved prehospital care, these figures haven’t seen much improvement. By 2008, the World Health Organization estimated that over 16,000 people were dying daily from these injuries.

• These injuries majorly cause deaths, particularly in low and middle-income countries.
• The age group most affected is between 15 and 44, and men are twice as likely to be affected than women.
• In the United States in 2003, injuries were the third leading cause of death overall and the main cause of death among those aged 1 to 46.
• These injuries contributed to 30% of the potential life years lost before age 65 and nearly 10% of the nation’s healthcare expenses.
• Despite advances in medicine and emergency care, the situation hasn’t improved much.
• The World Health Organization estimated that each day in 2008 over 16,000 people died from these injuries.

Signs and Symptoms of Hemorrhage Control

Bleeding can be divided into three types depending on the source of the blood. First, arterial bleeding, usually as a result of cuts, punctures, or amputations, is identified by the spurting and bright red color of the blood. Second, venous bleeding, which can also occur from these types of injuries, is marked by a steady flow of dark red blood. Lastly, capillary bleeding is the most common type due to an injury to the skin and is characterized by oozing blood from the injured area. Despite being the most painful, capillary bleeding is the easiest to control as it is surface-level.

Indicators of shock in a patient experiencing bleeding include a weak or absent wrist pulse, a low systolic blood pressure (below 90 mm Hg), pale or ashen skin, speedy and weak central pulses, and a slower than usual capillary refill time (more than two seconds). These signs can potentially suggest hypovolemia, or low blood volume, particularly when noticeable trauma is present.

The American College of Surgeons developed a classification system to determine the severity of shock based on blood loss. The classification ranges from Class I to Class IV, with Class I having the least and Class IV having the most blood loss. Class I is less than 15% blood loss with mostly normal vital signs, while Class IV is greater than 40% blood loss leading to mental change, low blood pressure, rapid heart rate, and fast breathing. This system has recently been complemented with the use of base deficit (BD) measurements to provide a more reliable assessment.

• Class I: 0 to -2
• Class II: -2 to -6
• Class III: -6 to -10
• Class IV: -10 or less

Testing for Hemorrhage Control

If you’ve lost a lot of blood, your doctor can learn a lot about your condition through a physical exam, but they can gather further information using several lab tests. There’s something called the ‘lethal triad’ in medicine, which involves coagulopathy (a condition that affects how your blood clots), hypothermia (when your body temperature drops too low), and acidosis (an excessive amount of acid in your body fluids). Coagulopathy can be a serious risk factor for death due to extreme blood loss.

Your doctor can use specific tests, like thromboelastography (TEG) and rotational thromboelastometry (ROTEM), to understand how quickly your blood clots. These tests can help them create a customized treatment plan for you. These tests are believed to be superior to traditional tests that measure blood clotting.

Other familiar tests, like prothrombin time (PT), international standardized ratio (INR), activated partial thromboplastin time (PTT), fibrinogen, and platelet count, can also be used to detect coagulopathy. Additional tests, such as serum lactate and base deficit, can help monitor the amount of tissue that’s not getting enough blood supply. However, one-time measurements of your hematocrit (the part of your blood made up of red blood cells) are not usually recommended for keeping tabs on acute (sudden) blood loss.

Treatment Options for Hemorrhage Control

When it comes to stopping bleeding, it really depends on where the bleed is. Bleeding can either be compressible (can be stopped by applying pressure) or non-compressible. For compressible areas, when there’s obvious bleeding, the first step is to apply pressure using your fingers. If that doesn’t work, a tourniquet (a device used to stop blood flow) should be used. However, different organizations have different recommendations on where exactly to place the tourniquet on the body. Generally, though, once it’s safe to do so, the tourniquet should be placed just a few inches above the wound itself. If the bleeding doesn’t stop, a second tourniquet can be applied next to the first. The good news is a study found that 92% of injured service members and civilians survived after a tourniquet was used, and only a tiny number suffered from any nerve damage as a result.

Non-compressible bleeding often come from more central areas of the body, such as the chest, abdomen and where limbs meet the body. Junctional wounds, which occur where limb meets body, account for 21% of recent combat deaths. Over time, there have been a lot of new devices created to help stop these kinds of bleeds, but some may need improvement, particularly when a patient needs to be moved. One act that could potentially stop or slow bleeding from bigger arteries, such as the aorta, is to apply strong pressure using a knee close to the navel while these devices are being applied.

In the 2000s, wound dressings and powders designed to help stop bleeding came onto the scene. Some were made to adhere to bleeding tissues and seal vessels, while others worked by quickly absorbing water to help form a blood clot. Some of these products showed promise but were too costly, needed too much testing, or caused other complications. The committee on tactical combat casualty care (CoTCCC) in 2015 recommended a particular gauze impregnated with kaolin and aluminium silicate to be used for dressing wounds. For deep penetrating wounds, a syringe that can deliver expandable sponges into the wound has been proven highly effective.

The CoTCCC recommends that tourniquets and dressings should be replaced once it’s safe to do so, as long as the patient isn’t in shock, the wound can be closely monitored, and the tourniquet isn’t being used to control bleeding from an amputation. But tourniquets shouldn’t be removed if left on for more than six hours, unless the patient is being closely monitored and lab tests can be performed.

When dealing with non-compressible bleeding from areas like the abdomen, it often requires surgery to stop the bleeding. For example, if a patient has a pelvis fracture, it can be temporarily stabilised using a device like a pelvic binder until they can be operated on. Sometimes, the aorta in the chest may need to be clamped to stop the bleeding. There is also a procedure called resuscitative endovascular balloon occlusion of the aorta (REBOA), which uses a balloon to stop the blood flow and control the bleeding, and is similar to the aortic clamp procedure in terms of effectiveness and potential complications.

There are medications available that can also help to stop bleeding by enhancing the body’s ability to form blood clots. One medication, called Tranexamic acid (TXA), has been found to help those injured in trauma by reducing their need for blood transfusions and decreasing their chances of dying. Other medications are currently being studied as potential treatments for severe bleeding.

What else can Hemorrhage Control be?

When a patient comes in with bleeding from anywhere in the body, the doctor may consider several conditions as likely causes. These can include:

• Injuries from blunt or sharp objects
• Disorders that affect blood clotting
• Problems with the platelets in the blood
• Use of medications that thin the blood or prevent blood clots
• Cancer
• Liver disease
• Lack of certain vitamins

Now, if a patient is experiencing bleeding from the digestive tract, the potential causes that may come to mind for the doctor could be:

• Injuries from blunt or sharp objects to the head, neck, chest, stomach, or pelvic area
• Tears in the lining of the digestive tract
• Vein abnormalities known as varices
• Ulcers
• Inflammation of the esophagus, stomach, or duodenum
• Separation of the layers within the aorta wall, a condition known as aortic dissection
• Growths in the digestive tract, including cancer
• Abnormal blood vessels known as angiodysplasias
• Pockets in the wall of the digestive tract, known as diverticula
• Hemorrhoids

What to expect with Hemorrhage Control

Death rates varied among different digestive conditions with 13% for Mallory-Weiss tear (a condition that involves tearing of the lining near the junction of the stomach and esophagus), climbing to 34% for gastritis & duodenitis (inflammation of the stomach or small intestine lining), 38–41% for duodenal ulcer, gastric ulcer, and oesophagitis (swelling and inflammation of the tube that connects your throat to your stomach), 52% for varices (abnormally enlarged veins), and up to 95% for upper digestive tract cancer.

The death rate was also higher for those that started bleeding while already in the hospital (54%) compared to those whose bleeds started at the time they were admitted to the hospital (36%).

In cases of severe bleeding caused by injuries, the chances of survival depend on a few factors. These include whether the area of bleeding can be compressed, how quickly medical treatment is received, and whether a tourniquet (a device used to control bleeding by tightly squeezing the blood vessels) is used.

Possible Complications When Diagnosed with Hemorrhage Control

Uncontrolled bleeding can be harmful and may even result in death. It can also cause several other problems such as:

• Ischemia from hemorrhagic shock: This essentially means that due to excessive blood loss, some parts of the body may not get enough blood supply, in turn, leading to tissue damage.
• Coagulopathies: This refers to disorders that can affect your body’s ability to stop bleeding. They can cause abnormal bleeding and clotting.
• Multiorgan failure: At times, critical body organs might stop functioning due to uncontrollable bleeding.
• Sepsis: This is a life-threatening condition which happens if an infection spreads throughout your body.

Preventing Hemorrhage Control

In 2013, following the successful Surviving Sepsis Campaign (a movement dedicated to reducing death from severe infections), the “Stop the Bleeding” campaign was initiated in Europe. The goal of this campaign is to decrease the percentage of patients who die within the first 24 hours of arriving at a hospital due to excessive bleeding by at least 20% within five years. This is crucial considering the fact that every year, more than 5 million people lose their lives due to injuries, and one-third of those injured arrive at the hospital already suffering from coagulopathy, which is a condition that impairs the blood’s ability to clot.

The main strategy of the campaign is to empower doctors with guidelines to quickly identify and treat hemorrhage (severe bleeding) and coagulopathy. The strategy is summarized in the acronym STOP, which stands for Search, Treat, Observe, and Prevent. This help healthcare providers to identify bleeding, provide necessary treatment, watch the patient’s progress, and take measures to prevent future episodes.

In 2015, a similar campaign called “Stop the Bleed” was introduced in the United States by the White House. This campaign not only shares the same goals as its European counterpart but also includes the training of laypersons, everyday citizens who aren’t healthcare professionals, in basic medical procedures. The US Department of Homeland Security is in charge of the “Stop the Bleed” campaign’s website.