Hemorrhage Control — The Priority
Uncontrolled hemorrhage is the #1 preventable cause of death in trauma. Control external bleeding before everything except airway. The methods in order of escalation:
1. Direct Pressure
Apply firm, continuous pressure with a gloved hand or dressing. Don't lift to check — this disrupts clot formation. Hold for a minimum of 3–5 minutes. For most wounds, this is all you need.
2. Wound Packing (for junctional or deep wounds)
For wounds that can't be tourniqueted (neck, groin, axilla, junctional areas) or deep cavitary wounds: pack wound tightly with gauze (hemostatic gauze preferred — QuikClot, HemCon), then apply direct pressure for 3 minutes. Keep packing until the wound is full.
3. Tourniquet
- Indicated for: life-threatening extremity hemorrhage not controlled by direct pressure, amputation, arterial bleed
- Apply 2–3 inches proximal (above) to the wound — not over a joint
- Tighten until bleeding stops and distal pulse is absent
- Note the time of application — write it on the tourniquet or patient's skin in marker
- Never remove a tourniquet in the field once applied
- Tourniquet pain is expected — do not loosen for comfort
A properly applied tourniquet does NOT cause limb loss when used for reasonable transport times. Studies show safe use up to 2+ hours. The risk of death from uncontrolled hemorrhage is far greater than the risk of tourniquet complications. Apply it, note the time, transport.
Penetrating Chest Trauma / Open Chest Wounds
A sucking chest wound (open pneumothorax) allows air to enter the pleural space through the chest wall instead of through the trachea, collapsing the lung on that side.
- Signs: wound to the chest with sucking/bubbling sound, respiratory distress, decreased breath sounds on the affected side
- Treatment: Apply a vented (3-sided) occlusive dressing — seals the wound on 3 sides, leaving one side open to allow air to escape but not enter
- If commercial vented dressing unavailable: petroleum gauze or plastic wrap taped on 3 sides
- Monitor for tension pneumothorax — if patient deteriorates after sealing (increasing respiratory distress, hypotension, absent breath sounds), burp the dressing or lift one side to release trapped air
Absent breath sounds on one side + hypotension + tracheal deviation (late) + distended neck veins = tension pneumothorax. BLS: burp the dressing or prepare for immediate transport. This is a paramedic skill (needle decompression) — get ALS ASAP.
Spinal Motion Restriction (SMR)
SMR is indicated based on mechanism AND clinical assessment — not mechanism alone. Current evidence-based practice uses selective SMR, not routine backboarding of all trauma patients.
Consider SMR when:
- High-risk mechanism (high-speed MVC, fall >3× patient height, axial loading, diving injury, hanging)
- Midline spinal tenderness or pain on palpation
- Neurological deficit: weakness, numbness, tingling, paralysis
- Altered mental status (can't reliably assess)
- Distracting injury (so severe the patient may not notice spinal pain)
SMR does NOT apply when:
- Low-energy mechanism with no spinal symptoms
- Alert, oriented, sober patient with no spinal tenderness and no neuro findings after detailed assessment
Burns
Rule of Nines — Estimating Body Surface Area (BSA)
- Head and neck: 9%
- Each arm: 9%
- Anterior trunk: 18% | Posterior trunk: 18%
- Each leg: 18%
- Genitalia: 1%
- For irregular burns: patient's palm = ~1% BSA
Burn Classification
- Superficial (1st degree): Epidermis only. Red, dry, painful. Like a sunburn. No treatment beyond cooling.
- Partial thickness (2nd degree): Epidermis + dermis. Red, wet, blisters, very painful. Cover with moist sterile dressing.
- Full thickness (3rd degree): All layers. White, brown, or black. Leathery. Painless (nerve destruction). Dry sterile dressing. IV fluids (ALS).
Burn Treatment
- Stop the burning process — remove clothing and jewelry (if not stuck)
- Cool the burn with room-temperature water for up to 10 minutes — never ice, butter, toothpaste, or home remedies
- Cover with a dry or moist sterile dressing
- Do not break blisters
- Airway burns (singed nasal hairs, hoarse voice, facial burns) — high-flow O₂, early transport, ALS
Fractures
Splint fractures in the position found unless distal circulation is compromised. Check PMS (Pulse, Motor, Sensation) before and after splinting.
- Femur fractures can lose 1–2 liters of blood into the thigh — treat for shock
- Open fractures: Cover with moist sterile dressing. Do not push bone back in.
- Angulated fractures: Splint as found unless no distal pulse — then one attempt to straighten by applying gentle traction in-line
- Joints above and below the fracture must be immobilized in the splint