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Bleeding and Shock


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Bleeding and Shock

To keep the body functioning, and to keep the organs supplied with oxygen, the body must have enough circulating blood volume. Blood consists of red cells (erythrocytes), which convey oxygen throughout the body; white cells (leucocytes), which fight introduced infection; platelets (thrombocytes), which assist in the clotting process; and plasma, the fluid portion of blood. There are between five and seven litres of blood in the average adult body which makes up 7-8% of the body weight.

Blood is moved around the body under pressure by the heart and blood vessels. Without an adequate blood volume and pressure, the human body soon collapses. Bleeding, or haemorrhage, poses a threat by causing both the volume and the pressure of the blood within the body to decrease through blood loss and is caused by the rupture of blood vessels due to the severity of the injury.

Bleeding is one of the commonest causes of death in accidents. There are two types of bleeding: external bleeding which is obvious and apparent; and internal bleeding where the bleeding is not apparent at the outset but may show itself later in the form of bleeding from the nose, ear, lungs or stomach.

External bleeding

External bleeding is usually associated with wounds caused by cutting, perforating or tearing the skin. Serious wounds involve damage to blood vessels. As arteries carry oxygenated blood from the heart, damage to an artery is characterised by bright red blood which can ‘spurt’ with each heartbeat. Damage to veins appears as a darker red and tends to flow. Capillary damage is associated with wounds close to the skin and is a bright red and ‘oozes’.

When tissue in our body is torn or cut by injury a wound is caused. Types of wounds include:

Abrasion is a wound where the skin layers have been scraped off from a fall on a rough surface, pieces of shells, claws of animals, machinery etc. These wounds have torn or irregular edges and they tend to bleed less.

Amputation is the cutting off of part of the body such as a limb or part of a limb.

Incision is the type of wound made by ‘slicing’ with a sharp knife or sharp piece of metal. It is very thin, clean cut and bleeds extensively.

Laceration is a deep wound with associated loss of tissue, the type of wound barbed wire would cause.

Puncture wounds are perforations, and may be due to anything from a corkscrew to a bullet.

Some bleeding such as Varicose veins can often rupture with little or no injury, and should be treated with direct pressure.


Life Threatening Bleeding


call for an ambulance as soon as possible

expose the wound

check the wound for visible foreign bodies

apply a dressing

apply direct pressure over the wound with a sterile or clean pad

lay the casualty down if not already in this position

raise and support the injured part above the level of the heart if possible

apply a firm bandage to hold the pad in place

treat for shock if required

check circulation regularly to ensure bandage is not too tight

if unable to stop the bleeding consider a constrictive bandage

cut or remove all clothing from around upper limb

ensure that the constrictive bandage can be easily seen

select a firm wide bandage (minimum 7.5cm) that is not too elastic

apply bandage firmly to limb and tighten until bleeding stops

secure bandage

write time of application in pen on patient’s skin

reassess every 30 minutes

Constrictive bandages are a measure of last resort, and should only be used in a life threatening situation where all other methods have failed.

Incisions And Lacerations


quickly check the wound for foreign matter

immediately apply pressure to stop any bleeding

bring the sides of the wound together and press firmly

apply a non-adherent dressing and a firm roller bandage

immobilise and elevate the injured limb if injuries permit



check the wound for foreign matter

swab with a diluted antiseptic solution

apply a non-stick dressing or a light, dry dressing if necessary

Puncture Wound


check the wound - DO NOT remove any penetrating object

apply direct pressure around the wound to stop any bleeding

stabilise with a ring pad and non-stick dressing

apply a firm roller bandage

rest and elevate injured limb if injuries permit



apply direct pressure to stop any bleeding

apply a large pad or dressing to the wound

treat for shock

rest and elevate injured limb if possible

collect amputated part - keep dry, do not wash or clean

seal the amputated part in a plastic bag or wrap in waterproof material

place in iced water - do not allow the amputated part to come in direct contact with ice. Freezing will kill tissue

ensure the amputated part travels to the hospital with the casualty


have the casualty pinch the fleshy part of the nose just below the bone

have the casualty lean slightly forward

maintain this posture for at least 10 minutes

20 minutes or more may be needed in hot weather or after exercise

apply cool compress to over the nose, neck and forehead

if bleeding persists, obtain medical aid

advise the casualty not to blow or pick nose for several hours or to swallow blood

So as not to disturb blood clotting on wounds, do not remove the initial dressing. Remove and replace only the bandage and padding if bleeding continues and seeps through the bandage. The initial dressing should be left in place. Avoid disturbing the bandage or pad once the bleeding has been controlled.

With all wounds the casualty should obtain medical advice for prevention of tetanus.

Internal bleeding

Internal bleeding is classified as either visible, in that the bleeding can be seen, or concealed, where no direct evidence of bleeding is obvious. Internal bleeding is always to be considered as a very serious matter, and urgent medical aid is necessary.

In most instances, obtaining an adequate history of the incident or illness will give the first aid provider the necessary clue as to whether internal bleeding may be present. Remember that current signs and symptoms, or the lack of them, do not necessarily indicate the casualty’s condition. Certain critical signs and symptoms may not appear until well after the incident due to the stealth of the bleed, and may only be detected by the fact that the casualty’s observations worsen despite there being no obvious cause.

Visible internal bleeding

Visible internal bleeding is referred to this way because the results can be seen:

Bleeding in the Lungs - frothy, bright red blood coughed up by the casualty

Anal or Vaginal Bleeding - usually red blood mixed with mucus

Bleeding in the Stomach - dark ‘coffee grounds’, or red blood, in vomitus

Bowel or Intestinal Bleeding - dark, loose, foul smelling stools

Bleeding in the Urinary Tract - dark or red coloured urine

Bleeding from the Ears - bright, sticky blood or blood mixed with clear fluid

Bruising - the tissues look dark due to the blood under the skin. Caused by blows from blunt instruments or by crushing.

Concealed internal bleeding

In these cases, the first aid provider is heavily reliant on history, signs and symptoms. Judgement and experience play a part, but it may come down to a first aider’s ‘gut feeling’. If you are unsure, assume the worst and treat for internal bleeding.

The detection of internal bleeding relies upon good observations and an appreciation of the physical forces that have affected the casualty. Remember to look at the important observations that may indicate internal bleeding, which include:

Skin appearance

Conscious state




pale, cool, clammy skin


rapid, weak pulse

rapid, shallow breathing

‘guarding’ of the abdomen, with foetal position if lying down

pain or discomfort

nausea and/or vomiting

visible swelling of the abdomen

gradually lapsing into shock


call ‘000’ for an ambulance

position the casualty supine, with legs elevated and bent at the knees (only if conscious)

if unconscious, side position with support under the legs to elevate them


treat any injuries

give nothing by mouth


Shock is a life-threatening condition, and should not be confused with the flood of adrenaline that accompanies dangerous or fearful situations. This reaction to danger or fear is called the ‘fight-or-flight’ reaction, and is often confused with, and referred to as, ‘shock’. This condition should be treated as top priority, second only to attending to safety, an obstructed airway, absence of breathing, cardiac arrest or severe life threatening bleeding.

Causes of shock

Loss of blood - Shock is most often caused due to loss of blood, which may occur at once or may be delayed. The blood loss could be either seen externally or internally within a particular system or organ. The greater the loss of blood, the greater the chance of developing shock. A slow, steady loss of blood can also produce shock.

Abdominal emergencies - Burst appendix, perforated intestine or stomach, intestinal obstruction, pancreatitis.

Loss of body fluids - May be due to extensive burns, dehydration, severe vomiting or diarrhoea.

Heart attack - Failure of the heart to function due to an obstructed blood supply to the heart itself can produce shock.

Sepsis or toxicity - Discharge of toxins produced by bacteria in the blood stream can produce shock.

Spinal injury - Due to the injury and the reaction of the nervous system.

Crush injuries - Injuries following explosions, building collapses etc.

Shock is a deteriorating condition, and one that does not allow a casualty to recover without active medical intervention. A delay of even a few minutes may mean death, so attend to the casualty as quickly as possible.

As a first aid provider attending a casualty, you should ask yourself the following:

Does the injury appear serious?

If I don’t do anything to help, is the casualty likely to become worse?

If the casualty’s condition worsens, is death a possibility?

If the answer to any of these questions is ‘YES!’, then you should treat for shock.


pale, cool, clammy skin


rapid, shallow breathing

rapid, weak pulse

nausea and/or vomiting

evidence of loss of body fluids, or high temperature if sepsis present

collapse and unconsciousness

progressive ‘shutdown’ of body’s vital functions

A good indicator for shock is when a casualty displays two or more of the observations listed in the shocked patient list below.

Healthy Patient

Skin Condition - Pink, warm, dry

Conscious State - Alert and aware of time and place

Pulse -

Adult - 60 to 100 per minute

Child - 90 to 130 per minute

Infant - 120 to 160

Respiration -

Adult - 12 to 20 per minute

Child - 16 to 25 per minute

Infant - 20 to 30

Shocked Patient

Skin Condition - Pale, cold, wet

Conscious State - Altered, confused, aggressive

Pulse - Rapid (above upper limits)

Respiration - Rapid (above upper limits)



control any bleeding

call ‘000’ for an ambulance

if conscious, position supine, with legs elevated

if unconscious, stable side position with support under the legs to elevate them


maintain body temperature, but do not overheat

treat any other injuries

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