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ADVANCED FIRST AID AND EMERGENCY RESPONSE FOR EXTERNAL AND
INTERNAL BLEEDING
Khadirov Bakhodir Salomovich
https://doi.org/10.5281/zenodo.15826361
Abstract. Hemorrhage remains one of the leading preventable causes of death following
trauma, particularly in prehospital and emergency settings. This article provides a
comprehensive overview of first aid management for external and internal bleeding,
incorporating current evidence-based practices, including tourniquet use, hemostatic agents,
trauma-induced coagulopathy recognition, and damage control principles used in modern
trauma systems.
Keywords: Trauma-Induced Coagulopathy (TIC), Tourniquet Science, “STOP THE
BLEED”, “Lethal Triad”
Introduction
Bleeding can rapidly progress to hypovolemic shock, multi-organ failure, and death if not
promptly addressed. While external bleeding is often visible and treatable, internal bleeding is
insidious and harder to detect. With advances in trauma science, first responders and trained
laypersons now play a vital role in hemorrhage control prior to hospital care.
Classification of Bleeding
External Bleeding
Visible blood loss due to damage to skin and underlying vessels.
• Arterial: Bright red, pulsatile spurting; high pressure.
• Venous: Dark red, steady flow; lower pressure.
• Capillary: Oozing, superficial wounds.
Internal Bleeding
Blood loss occurring inside the div, not visible externally, due to:
• Blunt trauma (e.g., spleen/liver rupture, pelvic fractures)
• Penetrating trauma (e.g., gunshot or stab wounds)
• Gastrointestinal bleeding (e.g., ulcers, esophageal varices)
• Aneurysm rupture or ectopic pregnancy
Pathophysiology of Hemorrhage
Hemorrhage causes decreased circulating blood volume, leading to:
• ↓ Oxygen delivery to tissues
• Compensatory vasoconstriction and tachycardia
• Progressive hypovolemic shock
• Activation of coagulation cascade, followed by exhaustion and trauma-induced
coagulopathy (TIC)
The “Lethal Triad” in trauma
:
1. Hypothermia
2. Acidosis
3. Coagulopathy
Early control of bleeding is essential to avoid entering this cycle.
First Aid for External Bleeding
Modern First Response: The “STOP THE BLEED” Campaign
Globally supported by trauma organizations like the American College of Surgeons, the
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Stop the Bleed program trains the public and responders in rapid hemorrhage control using:
•
Direct pressure
•
Tourniquets •
Hemostatic dressings
Step-by-Step Management
1. Ensure safety & use personal protective equipment (PPE)
Gloves, mask, and eye protection reduce infection risk.
2. Apply direct pressure
• Use a clean gauze or cloth and press firmly for at least 5–10 minutes.
• Reinforce without removing soaked material.
3. Elevate the injured limb (if no fracture suspected)
Helps reduce hydrostatic pressure and bleeding.
Use a tourniquet
• Indicated for life-threatening extremity hemorrhage.
• Apply 5–7 cm above the wound.
• Tighten until bleeding stops (not based on patient comfort).
• Note time of application — tissue necrosis risk rises after 2 hours.
Apply hemostatic agents if available
• Hemostatic dressings (e.g., QuikClot™, Celox™): impregnated with agents like kaolin or
chitosan.
• Used in junctional areas (e.g., groin, axilla) where tourniquets are ineffective.
First Aid for Internal Bleeding
Recognition is critical. Signs include:
• Pallor, cold/clammy skin
•
Weak, rapid pulse and hypotension
• Abdominal distension or rigidity
•
Altered mental status
• Hematemesis (vomiting blood), melena (black stool), hematuria
Immediate Actions:
1. Lay patient flat and elevate legs. Improves venous return to the heart (Trendelenburg
position if tolerated).
2. Maintain div temperature. Prevent hypothermia with blankets and warm fluids.
3. Monitor consciousness and breathing. Prepare to initiate basic life support (BLS) if
airway or breathing is compromised.
4. Do not give anything orally. To avoid aspiration or complications if surgery is needed.
5. Rapid EMS activation. Time is critical — definitive care requires hospital-based
imaging, blood transfusion, and possible surgery or interventional radiology (e.g., embolization).
Special Considerations in Modern Practice
Tourniquet Science
• Use of commercial tourniquets (e.g., CAT™, SAM XT™) is now standard.
• Studies show improved survival in battlefield and civilian mass casualty events.
Hemostatic Agents
• Widely used by military and EMS.
• Shown to reduce time to hemostasis and improve survival in junctional and scalp
bleeding.
Junctional Bleeding
• Tourniquets can’t control bleeding in groin, axilla, or neck.
• Junctional tourniquets and wound packing with hemostatic gauze are used.
Trauma-Induced Coagulopathy (TIC)
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• Starts within minutes of severe bleeding.
• Early IV administration of tranexamic acid (TXA) (within 3 hours) reduces mortality:
• 1 g over 10 minutes IV, then 1 g over 8 hours.
• Used in prehospital trauma protocols (e.g., CRASH-2 trial).
When to Refer or Transfer
• Bleeding not controlled after 10 minutes of firm pressure
• Signs of internal bleeding
• Bleeding from the chest, abdomen, or major vessel injury
• Hemorrhage associated with penetrating trauma or multiple injuries.
Conclusion
Effective management of bleeding, whether external or internal, is a cornerstone of
trauma care. With the evolution of trauma systems and emergency medicine, modern bleeding
control incorporates tourniquets, hemostatic dressings, and early pharmacologic interventions
like TXA. First responders and trained laypeople alike must be empowered through education
(e.g., Stop the Bleed) to act decisively and save lives in the critical prehospital window.
References
1.
American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Manual,
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Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: An overview
of epidemiology, clinical presentations, and management. J Trauma. 2006;60(6):S3–S11.
3.
CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive
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4.
Stop the Bleed Campaign. American College of Surgeons. https://www.stopthebleed.org
5.
Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for
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Granville-Chapman J, Jacobs N. Military Tourniquets: A Review of Current Technologies.
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