The management of major haemorrhage is challenging. The first priority is to quickly establish severity & classification. These are some of the issues the DMT wants to quickly address:

• Is the haemorrhage CATASTROPHIC  ??. If yes this is a greater priority than even the AIRWAY. Rapid intervention is needed.
• Is the bleeding COMPRESSIBLE or NON-COMPRESSIBLE ? Can you apply pressure. Clearly if you can not, you can not stop the bleed. This is common with intra-abdominal or intra-thoracic bleeds. Urgent surgical intervention is needed… which is generally above the level of a DMT !! Its important to note, 80% of catastrophic haemorrhages tend to be limb bleeds (they get in the way & as guarding actions). Limb bleeds are almost always compressible bleeds.
• What stage of shock is the casualty in ?? For every stage of shock there is a 500ml loss. Human beings can cope with a surprisingly large volume loss, when you donate a unit of blood, unto 750ml is bled off… and all you need is a cup tea!!.  By the time they are showing cardiovascular signs (cold, clammy, ⬆︎R.R., ⬆︎H.R. ⬇︎B/P (loss of radial pulse) The victim is generally in cat III shock (a 1.5 Litre loss). Its also nearly impossible to gain vascular access with a venous cannula.

So, 80% of catastrophic bleeding are limb bleeds. So it’s useful to prioritise these. Generally the management is straightforward. It is amazing however that this is an area of trauma management that is often poorly taught. The process involves:

• Elevation: Evaluate the affected limb above the level of the heart.
• Direct Pressure: Enough pressure to stop arterial bleeding, > 150mm/Hg, apply a trauma dressing (don’t bandage) and place a B/P Cuff over the dressing & pressurise for at least 3 minutes (human minimal clotting time is 2mins 42 seconds). Indirect pressure DOES NOT WORK.
• Arterial Tourniquet; If the bleeding is clearly unstoppable by other means, this may be your primary action. Arterial Tourniquetion saves lives. Apply 100mm above the bleed. Document the time of application. Muscular breakdown will occur after 4-6 hrs… which is a VERY long time. DO-NOT release the pressure. This is a surgical decision. Seek immediate shore support (from a vascular surgeon).