Chapter 10: Bleeding Control

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Overview

Damage to blood vessels, especially arteries, can be immediately life-threatening. Most soft tissue injuries are not addressed during your primary assessment, as they are typically not as serious as issues affecting the airway, respiration, or circulation, but a hemorrhage must be recognized and cared for as quickly as possible.

Soft tissue injuries can be divided into two general categories: open wounds, in which the skin is broken, and closed wounds, in which trauma occurs beneath the skin. Some types of soft tissue injuries, such as crush injuries, may be open, closed, or both, depending on the nature of the specific injury. Others, such as burns, do not fall naturally into either category, so this distinction is more of a guide than a rule.

Infection

Any open wound is at risk of infection and should be protected from harmful pathogens. The best initial defence against infection is cleansing the area thoroughly to remove any bacteria that might already be present. Minor wounds that are not hemorrhaging should be washed with water, preferably running water under gentle pressure (as from a tap or hose). If possible, rinse any minor wound for 5 minutes. Because chemicals such as soap and alcohol can cause damage to sensitive tissues under the skin, water alone is recommended for cleaning wounds.

For wounds that are hemorrhaging or that involve extensive tissue damage, bleeding control and rapid transport are higher priorities than cleaning. These wounds will be cleaned thoroughly in the medical facility as a routine part of the care provided. Do not delay transport to clean a major wound.

When caring for any open wound, you can reduce the risk of infection by using sterile technique. Avoid touching open wounds, and use clean gloves if touching the wound is unavoidable. Take care to keep dirt and debris out of the wound, and avoid letting non-sterile material come into contact with it. When cleaning the area around a wound, always wipe away from the wound, not towards it.

Signs of Infection. When a wound becomes infected, the surrounding area becomes swollen and red, and the area may feel warm or throb with pain. Some infected wounds have a pus discharge. An infection begins in the wound itself but may spread into the surrounding tissues if untreated.

An Infected Wound

In some cases, the infection can enter the patient’s circulatory system and move throughout the body, resulting in a life-threatening condition called systemic infection. Red streaks on the skin moving away from the wound and towards the heart are one sign that an infection is progressing to the systemic level. Systemic infection can also cause a patient to present with flu-like symptoms (e.g., fever, nausea, and general malaise). Systemic infections are usually treated with antibiotics, so a patient with these signs and symptoms should be examined by a physician as soon as possible.

Tetanus. Tetanus is a serious infection caused by the microorganism Clostridium tetani. The spores of this bacterium are commonly found in soil, dust, and the feces of certain animals. Tetanus can cause severe medical problems and can be fatal.

Tetanus spores are introduced into the body through a wound caused by a contaminated object. The spores then grow into bacteria inside the body. Because the organism multiplies in an environment that is low in oxygen, puncture wounds and other deep wounds are at the greatest risk for tetanus infection.

Tetanus produces a powerful toxin that affects the body’s central nervous system and specific muscles. Because it can often cause the jaw and neck muscles to contract, tetanus is sometimes referred to as lockjaw. As a tetanus infection progresses, it can affect other muscles as well. Once the tetanus infection enters the nervous system, its effects are irreversible, so any patient suspected of having a tetanus infection should see a physician as soon as possible.

The best way to prevent tetanus is to be immunized against it. This involves an initial vaccination and periodic booster shots, which help to maintain the antibodies that protect against tetanus. Booster shots are recommended every 5 to 10 years. They are also recommended if a wound has been contaminated by dirt, or whenever a potentially contaminated object, such as a nail in a barn, causes a puncture wound.

Infected wounds of the face, neck, and head should receive immediate medical care since the tetanus toxin can travel rapidly to the brain.

Signs include: difficulty swallowing, irritability, headache, fever, and muscle spasms near the infected area.

Gangrene. Like tetanus, gangrene is caused by bacteria that thrive in the absence of oxygen. It may also be caused by a loss of blood supply to the affected tissue. Gangrene causes a sudden onset of pain and swelling, with local tissue discoloration and a brownish, foul-smelling watery discharge that is highly infectious. A patient may also have a low-grade fever and present with signs of shock.

While rare, gangrene may lead to necrotizing fasciitis, which is a rapidly progressive and very painful infection sometimes referred to as flesh eating disease.

The most definitive characteristic is the presence of crackling (crepitus) beneath the skin due to tiny air bubbles.

Any patient with gangrene should be seen by a medical professional and may require urgent transportation to do so. Monitor the patient for signs of shock during transport.

Dressings and Bandages

Dressings. Once an open wound has been cleaned, it must be protected against the intrusion of additional pathogens. This is done by covering the wound with a dressing. A dressing can also help to absorb blood and other fluids.

Bandages. A bandage is a piece of material (usually cloth or elastic) used to hold a dressing in place. Bandages can also be used to support an injured body part. Wrapping a bandage snugly can create pressure on a wound, helping to control bleeding. This is referred to as a pressure bandage.

Dressings and Bandages Types. A wide variety of dressings and bandages are commercially available Sometimes, a dressing and a bandage will be combined into a single product. When possible, choose the option that is best suited to the wound, taking into account the size, type, and location of the injury. See the table below for common types of dressings and bandages.

Sizing a Roller Bandage. A roller bandage needs to be sized carefully to ensure that it is the correct width for the body part involved. As a general guide, the following widths are recommended:
• Lower arm, elbow, hand and foot – 75 mm.
• Upper arm, knee and lower leg – 100 mm.
• Large leg or trunk – 150 mm.

Applying a Roller Bandage.

1. Secure one end of the bandage in place. (figure a).
2. Wrap the bandage around the body part until the dressing is completely covered and the bandage extends several centimetres beyond the dressing. (figure b).
3. Tie or tape the bandage in place. If applying roller gauze to an extremity, apply it distally-to-proximally to facilitate venous return. If blood soaks through the bandage, leave the bandage and dressings in place and apply additional dressings and another bandage on top. (figure c). To tie a roller bandage, make a backwards wrap of the roller gauze forming two loose ends which can then be tied around the limb.
4. Leave the fingers or toes uncovered if possible: This can help you assess sensation and circulation to ensure that the bandage’s pressure is appropriate. Check sensation and circulation before and after applying the bandage. If the fingers or toes show signs of impaired circulation or sensation after applying the bandage, loosen the bandage slightly and reassess. Comparing the injured extremity to the corresponding one on the other side of the body can help you determine the patient’s normal levels of sensation and circulation. (figure d).

Tourniquets

A tourniquet is a tight band placed around an extremity to constrict blood vessels and stop blood flow. It is used to treat a hemorrhage when all other interventions are impossible or have been ineffective. Because the tourniquet completely blocks blood flow to the extremity for the entire time that it is in place, it can have serious complications for the patient and should only be used if it is absolutely necessary. A bandage and dressing should be used in addition to a tourniquet whenever possible to assist with blood clotting.

Apply the tourniquet 5 to 10 cm (2 to 4 in.) above the injury and just above any joint in this range (figures a and b). Tighten the tourniquet until the bleeding stops, and secure it in place (figure c). Continue to apply direct pressure to the wound if possible. Document the time that the tourniquet was applied. A patient with a tourniquet applied should always be in the rapid transport category.

Applying a Tourniquet.

Hemostatic Dressings

Hemostatic dressings and such as Celox, QuikClot and Hemcon are designed to promote rapid blood coagulation in the event of a traumatic wound involving an arterial bleed. They are beneficial when tourniquets cannot be used to control the arterial bleeding such as in sites as the neck, shoulder, or groin.

With hemostatic dressings it is important to cover the entire bleeding surface, including the deep areas of the wound. Sometimes tissue will need to be splayed open to place the dressing into a deeper portion. If blood soaks through the first layer, a second layer of hemostatic can be placed. If the wound is deep, then abdominal dressings or gauze can be used on top of the hemostatic to give it bulk. A pressure dressing, either a roller bandage or ACE wrap, is sometimes used to hold the dressing in place.

Direct pressure from a responder should also be continued on top of the dressings. If needed, other adjuncts, such as pressure point activation or placement of a tourniquet, should be considered. Document the type and number of hemostatic dressings in your report, and be sure to tell the receiving physician and nursing staff that hemostatics were used.

External Bleeding

Most open wounds will have some bleeding, but the body’s clotting response will usually stop minor bleeding within 10 minutes, especially if pressure is applied. A hemorrhage, however, will overwhelm the body’s responses and can rapidly cause a patient to go into hemorrhagic shock. For this reason, it is crucial that you learn to differentiate minor bleeding from hemorrhaging. You should check for external hemorrhaging during the rapid body survey in your primary assessment and provide care for it immediately if it is found.

Each type of blood vessel bleeds differently. Bleeding from arteries is often hemorrhagic (rapid, profuse, and life-threatening). This is because arterial blood is under direct pressure from the heart, so it usually spurts from the wound, making it difficult for clots to form. For this reason, arterial bleeding is harder to control than bleeding from veins and capillaries. Arterial blood has a bright red colour due to its high concentration of oxygen.

Veins are damaged more often than arteries because they are closer to the skin’s surface. Venous blood is under less pressure than arterial blood, and flows from the wound at a steady rate without spurting. Due to the lower pressure, venous bleeding is easier to control than arterial bleeding. Only damage to veins deep in the body, such as those inside the trunk or thighs, produces hemorrhages that are hard to control. Because it is oxygen-poor, venous blood is a dark red or maroon colour.

Capillary bleeding is usually slow because the vessels are small and the blood is under low pressure. It is often described as oozing from the wound. Clotting  occurs easily with capillary bleeding. The blood from capillaries is usually dark red in colour.

External bleeding is life-threatening when significant quantities of blood are spurting or flowing freely (hemorrhaging) from a wound.

Care for External Bleeding

Direct Pressure. To control minor to moderate amounts of bleeding, apply pressure with your gloved hand directly on the wound. This is called applying direct pressure. Pressure on the wound compresses the blood vessels, restricting the blood flow, and allows clotting to occur. You can maintain pressure on a wound by applying a dressing and pressure bandage to the injured area. If the patient is responsive, he or she may be able to maintain direct pressure on the dressing while you apply the bandage.

Direct pressure alone may not be enough to control a hemorrhage, or it may be impossible (for example, if a patient’s leg is inaccessible but is hemorrhaging). If so, apply a tourniquet to control the bleeding.

To control external bleeding, follow these general steps:

1. Place the patient in a seated or recumbent position.
2. Place direct pressure on the wound with a gloved hand.
3. Apply a sterile dressing – use hemostatic dressings for arterial bleeds. Place your gloved hand over the dressing and apply firm pressure (left figure).
4. Apply a bandage over the dressing to maintain direct pressure (middle figure) and hold the dressing in place. If blood soaks through, add additional dressings and bandages. Do not remove any blood-soaked dressings or bandages.
5. If bleeding continues, and the wound is on a limb, apply a tourniquet above the injury (right figure). While painful, this is necessary to save the patient’s life.

Bleeding Control. 

Wound Packing. Wound packing is utilized in deep-arterial wounds when maintaining adequate external pressure can be difficult or impossible. It can be utilized in concert with a tourniquet and hemostatic dressing, or as a solo hemorrhage management technique.

When to Wound Pack. If there’s no (or only minimal) bleeding, the wound doesn’t need packing. Wounds of the extremities and junctional areas are amenable to packing. If a tourniquet is initially placed on an extremity wound, it may later be replaced with a pressure dressing or with packing, which may be more comfortable for the patient and provide for a moderate amount of distal circulation. Direct pressure will usually suffice for bleeding neck wounds. Wounds of the neck aren’t generally packed because of the risk for airway compromise. Although the bleeding from a back wound will typically not be profuse and may be controlled with a simple pressure dressing, wounds of the back can be packed successfully. Wounds of the chest, abdomen or pelvis shouldn’t be packed because bleeding from these wounds is generally from a very deep source that can’t be reached from the outside. These patients must be rapidly transported to a surgeon for operative bleeding control.

How to Wound Pack:

Step 1: Stop the bleeding. Now! Immediately apply direct pressure to the wound, using gauze, clean cloth, elbow, knee-whatever it takes to slow or stop the hemorrhage-until you have time to get out your wound packing supplies. Place your gloved fingers-with or without a dressing-into the wound to apply initial pressure to the target area (with your target being the vein, artery or both) and compress the source of bleeding. Keep in mind that the body’s anatomy presents with major vessels running close to bones. So, whenever possible, utilize a bone to apply pressure against. This will also give you an idea of which direction the wound travels and you can insert the gauze accordingly.

Step 2: Pack the wound with gauze. Tightly! Your goal is to completely and tightly pack the wound cavity to stop hemorrhage. Begin packing the gauze into the wound with your finger, while simultaneously maintaining pressure on the wound. It is critical that the gauze be packed as deeply into the wound as possible to put the gauze into direct contact with the bleeding vessel. By doing so, you’re simultaneously putting direct pressure onto the bleeding vessel and allowing the hemostatic agent to do work its magic.

Step 3: Keep packing! The key to successful wound packing is that the wound be very tightly packed, applying as much pressure as possible to the bleeding vessel. This pressure against the vessel is the most important component of hemorrhage control. This explains why plain gauze (without an impregnated hemostatic agent), when tightly packed, is also quite effective.

Step 4: Apply very firm pressure to the packed wound for 3 minutes. This step pushes the packing firmly against the bleeding vessel and aids in clotting.

Step 5: Secure a snug pressure dressing and transport. After applying pressure for 3 minutes, place a snug pressure dressing over the wound. You may consider splinting or immobilizing the area, if possible because movement during transport can dislodge the packing and allow hemorrhage to restart.

Step 6 (Continued Hemorrhage). Should the bleeding continue, hemostatic gauze manufacturers recommend removal of the original packing and repacking with fresh gauze. The rationale for this is that they assume it wasn’t packed properly the first time, or perhaps the packing didn’t quite get to the bleeding vessel.

Another option is to pack more gauze into the wound, if possible. If no further packing is possible, you must decide whether to remove the gauze and start over or simply apply as much direct pressure to the wound as possible and get the patient to a trauma center quickly. This decision should be made during transport; transport shouldn’t be delayed for extensive packing and repacking of the wound.

Epistaxis (nosebleed). Epistaxis is often caused by blunt force trauma to the nose. High blood pressure or change in altitude can also cause epistaxis. If the MOI suggests more severe injuries, ensure that those are identified and cared for first.

To control epistaxis, have the patient lean forward while pinching their nostrils together (see figure). 

Once you have controlled the bleeding, instruct the patient to avoid rubbing, blowing, or picking their nose. If you suspect that the nosebleed is caused by a foreign body lodged in the nostril or nasal passage, attempt to remove it (unless there is a risk of further injury).

If the patient’s history includes hypertension or blood-thinning medication, epistaxis can become life-threatening. If the bleeding cannot be controlled, these patients require rapid transport.

If the patient loses responsiveness, place him or her in the recovery position to allow blood to drain from the nose.

Internal Bleeding

Internal bleeding is the escape of blood from arteries, veins, or capillaries into spaces inside the body. It can result in severe blood loss and can be life-threatening.

Capillary bleeding is just beneath the skin and is usually not serious; it is usually indicated by mild bruising.

Internal hemorrhaging usually occurs in injuries caused by a violent blunt force, such as when a driver is thrown against the steering wheel in a motor vehicle collision. An internal hemorrhage may also occur when a sharp object, such as a knife, penetrates the skin and damages internal structures, or when a fractured bone ruptures an organ or blood vessels. Major fractures, such as those involving the pelvis, femur, or lower ribs, can also puncture organs or arteries and cause significant internal hemorrhaging.

Because internal bleeding is more difficult to recognize than external bleeding, you should always suspect internal bleeding when the MOI indicates the potential for a serious injury.

The signs and symptoms of possible internal bleeding are not always obvious and may take time to appear. They include:

• Bruising in the injured area.
• Soft tissues that are tender, swollen, or firm.
• Anxiety or restlessness.
• Rapid breathing (tachypnea).
• Skin that feels cool or moist or looks pale or bluish.
• Nausea and vomiting.
• Excessive thirst.
• Declining level of responsiveness.
• A rapid, weak pulse.
• A drop in blood pressure.

The body’s inability to adjust to internal hemorrhaging will eventually result in shock. Shock is discussed in Chapter 25: Altered Level of Consciousness Emergencies.

Care for Internal Bleeding

The care for internal bleeding depends on the severity and site of the bleeding. For minor internal bleeding, such as a contusion (bruise) on an arm, apply ice or a chemical cold pack to the injured area to help reduce pain and swelling. Place something such as a gauze pad or towel between the cold source and the skin to avoid freezing the tissues.

If you suspect internal hemorrhaging, you must obtain advanced medical care for the patient immediately. There is little you can do to control internal hemorrhaging effectively: The patient must be transported to the hospital as soon as possible. Monitor the patient for signs and symptoms of shock.

Open Wounds

There are four main types of open wounds:

1. Abrasions
2. Lacerations
3. Avulsions
4. Punctures

Abrasions. An abrasion occurs when skin is rubbed or scraped away. Because the removal of the outer skin layers exposes sensitive nerve endings, an abrasion is often painful. Because abrasions are usually superficial, the capillaries are the only blood vessels affected. Bleeding is typically not severe.

Infection is a serious concern with abrasions, as dirt and other matter can easily become embedded in the skin during the injury. Cleaning the wound and monitoring for signs of infection are important steps.

An abrasion.

Lacerations. A laceration is a cut caused by a sharp object or when a blunt force splits the skin. They can affect the layer of fat and muscle beneath the skin, and because they can damage both nerves and blood vessels, may not be immediately painful. Blunt force lacerations often occurs in areas where bone lies directly under the skin’s surface (e.g., the eyebrow).

Bleeding control is your primary concern with a laceration, though infection is also a risk. If the wound is deep, damage to underlying tissues can cause internal bleeding. Monitor the patient’s condition closely, and watch for signs of shock especially if the laceration is on the torso.

A laceration.

Avulsions. A laceration is a cut in which a portion of the skin and other soft tissues are partially or completely torn away. Because avulsions often involve deeper layers of soft tissue, bleeding is usually significant.

Bleeding and infection control are your primary concerns with a laceration.

An avulsion.

Punctures. A puncture wound results when the skin is pierced with a pointed object such as a nail, splinter, knife, or bullet. Because the skin usually closes around the penetrating object, external bleeding is generally not severe. However, internal hemorrhages can occur if the penetrating object damages major blood vessels or internal organs. An object that remains in the open wound is called an impaled object. An object may also pass completely through a body part, making two open wounds: one at the entry point and one at the exit point.

Although puncture wounds generally do not hemorrhage, they are still potentially dangerous as they have a high risk of infection. To combat the risk of infection, both major and minor puncture wounds should be cleaned thoroughly.

A puncture wound.

An impaled object

Ballistic Injuries. Look for both an entry and an exit point for the bullet. The location of the entry and exit point can give an indication of the internal injuries that may have occurred. You may also find burns on the skin caused by gunpowder, especially if the bullet was fired at close range. Do not try to remove the bullet.

The scene of a firearm injury is often a crime scene. Ensure that the scene is safe and that law enforcement have been contacted.

Impaled Object. Small objects (such as slivers and fish hooks) can be removed without any risk for the patient, but larger impaled objects (such as a shard of glass or metal rebar) should be left in place unless they interfere with the patient’s airway or respiration. Moving an impaled object can damage internal structures and cause or exacerbate bleeding.

Stabilize the object with bulky dressing (left figure), then bandage the dressing in place around the object to limit movement and control bleeding (figure b).

Bandaging an Impaled Object using bulk dressings to support it.

• • • Removing Slivers. A sliver is a thin piece of material that has penetrated the skin. There are three common types of sliver:
      • Wood. Often difficult to see against the patient’s skin. To find a wood sliver, wet the area with a coloured antiseptic solution (iodine) for 30 seconds. Gently wipe away the remaining liquid; the sliver will have likely soaked up some of the liquid making it easier to see.
      • Metal. These are generally easy to see and remove.
      • Glass. These are usually invisible and difficult to remove. Soak in warm, diluted antibacterial detergent for 20 minutes.

To remove a sliver:

1. 1. 1. 1. Determine the angle at which the sliver entered the skin (left figure).
         2. Grasp the sliver with disinfected forceps and draw it out at the same angle (right figure).
         3. Treat the wound as a puncture or laceration.

Removing a Sliver.

Removing Fish Hooks. Do not remove an impaled fish hook if there is a chance that removing it might injure vital structures (e.g., muscles or nerves around the eye). In these cases, immobilize the fish hook until it can be removed at a medical facility. If the fish hook can be removed without risk to underlying tissues, take it out using one of the following methods, and then treat the resulting puncture wound.

To remove a fish hook:

1. 1. 1. Move the hook in a curve so that the barbed tip exits through the skin.
      2. Clip off the barbed tip and remove the remainder of the hook by pulling it back the way it entered. This avoids forcing the eye of the hook through tissue.

Closed Wounds

A closed wound is generally defined as any wound that occurs without breaking the skin. While infection is less of a concern with closed wounds, they often involve damage to internal structures and the risk of internal bleeding. Like open wounds, closed wounds range from extremely minor to life-threatening.

Abscesses. An abscess (boil) is a significant localized collection of pus within tissues, usually in hair-bearing areas.

If the abscess involves the face, neck, groin, or buttocks, or if it is very painful, the boil should preferably be treated by a physician.

The abscess may drain naturally if left alone. Draining can be hastened by applying hot and warm compresses alternately until the pus begins to discharge. Avoid squeezing the abscess, as this is likely to spread the infection. Clean the area and apply dry dressings once the abscess has begun to reduce in size. The dressings will continue to absorb the remaining fluid from the wound. Change the dressings if they become saturated with fluid. Continue to cleanse the area periodically, watching for signs of infection.

Subungual Hematomas. A subungual hematoma is a collection of blood or fluid between the nail bed and the fingernail. Subungual hematomas result from direct trauma to the fingernail, most commonly after a crush type injury. The pressure of the fluid causes the fingernail to throb, often resulting in intense pain. If the blood is released, the patient will feel some relief.

To care for a subungual hematoma, begin by cleaning the area. Ensure that the patient’s hand is on a firm surface. Heat the end of a paperclip until it is red-hot and use it to create a hole in the nail over the area. Because there are no nerve endings in this area, the procedure should be painless. Clean the area and apply a dressing.

If pressure builds over time, the hole may need to be reopened. If releasing the fluid does not stop the pain, perform a focused exam on the affected digit to check for a possible fracture or other damage to internal structures.

Myocardial Contusions. Myocardial contusion is a bruising of the heart’s muscle tissue. It is usually caused by blunt chest trauma and therefore is frequently suspected in patients involved in a motor vehicle collision or a fall. Cardiac contusion can cause life-threatening arrhythmias and cardiac failure. Because of nonspecific symptoms, myocardial contusion is difficult to identify. Common symptoms include pain in the chest (from the blunt force) and the feeling that the heart is racing. Any patient with serious chest trauma should be rapidly transported to a medical facility for assessment.

Dermatitis. Dermatitis is a general term for an inflammation of the skin. Most cases of dermatitis result either from direct contact with a chemical irritant or from an allergy. Dermatitis is not contagious, but it can spread if left untreated. If you encounter a patient with dermatitis, ask whether he or she has had a reaction to a skin irritant in the past.

Signs and symptoms of dermatitis include:

• Redness, irritation, or swelling.
• Itchiness or pain.
• Possible thickening and cracking of the skin.
• Possible blisters.

To care for dermatitis:

• Avoid further contact with the irritant.
• Protect the skin with a suitably sized dressing.
• Advise the patient to seek additional medical  attention if the irritation persists for more than 3 days.

Burns

A burn is a soft tissue injury caused by heat, chemicals, electricity, or radiation. While all types of burns have similar characteristics, the care that is indicated for a patient can vary based on how the burn occurred. Interventions indicated for a thermal burn may not be indicated for a chemical burn, and so on.

When burns occur, they affect the epidermis (outer layer of skin) first. If a burn progresses, it can also damage the dermis and other underlying tissues (including muscle and bone). Burns that break the skin can cause infection, fluid loss, and loss of temperature control.

The severity of a burn depends on the following factors:

• Intensity of the source (e.g., the temperature of steam or concentration of a chemical)
• Length of exposure to the source
• Location of the burn
• Extent of the burn
• Patient’s age
• Patient’s underlying medical conditions

In general, patients under the age of 5 and over the age of 60 have thinner skin and burn more severely. Patients with acute trauma (e.g., fractures) or chronic medical problems (e.g., heart or kidney conditions, diabetes) tend to have more complications resulting from burns; burns are often more severe in these patients, and they are more vulnerable to dehydration as a result of burn injuries (increasing the risk of shock).

Severity of Burns. In addition to being broken down by their causes (heat, chemicals, electricity, or radiation), burns are classified by their depths. The deeper the burn, the more types of tissue are affected, and the more severe the burn is.

Generally, three depth classifications of burns are used:

1. Superficial (First Degree) Burn. A superficial burn involves only the top layer of skin. The burnt skin is red and dry, the burn is usually painful, and the affected area may swell. Superficial burns generally heal in 5 to 6 days without permanent scarring.
2. Partial-thickness (Second Degree) Burn. A partial-thickness burn involves both the epidermis and the dermis. These burns appear red and have blisters that may open and weep clear fluid, making the skin appear wet. The skin may also appear blotchy in the area around the burn. These burns are usually very painful. Minor partial-thickness burns may heal in a few weeks without in-hospital burn care, but more severe partial-thickness burns can be life-threatening. Scarring can occur from partial thickness burns.
3. Full-thickness (Third Degree) Burn. A full-thickness burn destroys the epidermis, the dermis, and any or all of the underlying structures— fat, muscles, bones, and nerves. They may look brown or charred, and the tissues underneath sometimes appear white. They can be either extremely painful or relatively painless, depending on how much damage is caused to the nerve endings in the skin. Full-thickness burns are often surrounded by painful partial-thickness and superficial burns. Full-thickness burns can be life threatening: Because the burns are open wounds, the body loses fluid (reducing blood volume), so hypovolemic shock is a serious risk. Full-thickness burns are also large open wounds, so they make the body highly vulnerable to infection. Severe scarring may occur, and skin grafts are usually required.

Identifying Critical Burns. A critical burn is a burn that is likely to be life threatening, disfiguring, or disabling and requires immediate, advanced burn care. A patient with a critical burn requires rapid transport. Determining whether a burn is critical is not simply a question of determining its depth or cause: A superficial burn that covers large areas of the body or damages certain body parts can be critical.

The following are examples of critical burns:

• A full-thickness burn of any size
• A partial-thickness burn that covers more than 10% of the body
• Any partial- or full-thickness burns on a child or an older adult
• Inhalation injuries causing respiratory difficulty
• Burns around the mouth or nose, or signs of smoke inhalation
• Significant burns on the head, neck, hands, feet, or genitals
• Burns resulting from chemicals, explosions, or electricity
• Burns that cause a great deal of pain
• Burns that result in unresponsiveness

Estimating the Extent of Burns. When communicating with medical personnel about a burned patient, you may be asked how much of the body is burned. The Rule of Nines is a common method for estimating the percentage of the body affected by burns (figure and table below). It is most useful when assessing large burns that cover multiple areas of the body.

In an adult, the head equals 9% of the body’s total surface. The anterior and posterior sides of each arm are considered 4.5% each, for a total of 9% per arm. Each leg equals 18%, as does the anterior and posterior side of the trunk. The groin equals 1%. If the front of the trunk (18%) and one entire arm (9%) are burned, you would estimate that 27% of the body’s surface area had been burned.

The Rule of Nines is modified when assessing an infant (figure below). For an infant, the head equals 18% of the total body surface. As for adults, the anterior and posterior sides of each arm are considered 4.5% each, for a total of 9% per arm. Each lower extremity equals 14%, and each side of the trunk (anterior and posterior) equals 18%. For an infant with burns to one leg (14%) and the front of one arm (4.5%), you would estimate that 18.5% of the body’s surface area had been burned.

In simpler cases, or if the Rule of Nines is not practical, communicate how the burn occurred, the body parts involved, and the severity of the burn. For example, “The patient was injured when an overheated car radiator exploded. The patient has partial-thickness burns on his or her face, neck, chest, and arms.”

The Rule of Palms is another method used to estimate the percentage of a patient’s body that has been burned. It is generally used when burns are less extensive. The palm of the patient’s hand is roughly equivalent to 1% of his or her body’s surface area, so if the burns cover an area equal to about 4 of the patient’s palms, the burns cover approximately 4% of the patient’s body.

Care for Burns

Pay special attention to the patient’s airway during the primary assessment to ensure that it has not been affected by inhalation injuries. Regardless of the burn type, you should perform these three basic care steps:

1. Prevent additional damage to tissue. Burns can continue to worsen over time if steps are not taken to mitigate their effects. A patient who has been burned by boiling water, for example, will continue to experience tissue damage until the area is cooled. A caustic chemical can continue to burn a patient until it is flushed from his or her skin. When caring for a burn, your first priority is to minimize additional damage. If a patient’s eyes have been flash burned, rinse them with saline or water. Have the patient close his or her eyes, and cover them with moist, sterile dressings.
2. Cover the burned area with dry dressings. Cover the burned area to protect against pathogens and help reduce pain, leaving any blisters intact to further reduce the risk of infection. Use dry, non-stick, sterile dressings and loosely bandage them in place. The bandage should not put pressure on the burned area. If the burn covers a large area of the body, cover it with clean, dry sheets (or other large pieces of clean, dry cloth). Unlike most burns, small burns (covering less than 10% of the body) may be covered with a moist dressing if this reduces pain for the patient. Do not put ointments or other oils (e.g., butter, cooking oil, commercial salves) on a burn. Instead of relieving pain, these substances tend to seal in heat and cause infections by contaminating open skin areas.
3. Take steps to manage shock. Additional steps may be necessary depending on how the burn was caused. Pain and fluid loss from full-thickness and large partial-thickness burns can cause shock. Monitor the patient closely and provide care for shock. Patients with burns tend to lose body heat easily, so it is important to manage the temperature of the environment as much as possible to help the patient maintain a normal body temperature.

Thermal Burns. Thermal burns are caused by exposure to heat. This may be direct (e.g., touching steam or a hot stove) or radiant (e.g., being exposed to the heat from a forest fire).

When caring for a thermal burn, it is essential to cool the affected areas immediately. Even after the source of heat has been removed, soft tissue will continue to burn for several minutes, causing further damage.

Hot grease poses a high risk of critical burns because it is slow to cool and difficult to remove from the skin. Burns that involve hot liquid or flames contacting clothing will also be serious since the clothing keeps the heat in contact with the skin. Some synthetic fabrics can melt and stick to the skin when exposed to heat and may take longer to cool than the body’s soft tissues. Although the severity of thermal burns may seem low at first, they can continue to worsen over time if they are not cooled thoroughly.

Cool thermal burns with cool or cold potable water. Flush or immerse the area using whatever clean sources of water are available (e.g., a tub, shower, or garden hose).  If possible, immerse the burn in water (instead of using running water) to reduce the risk of tissue damage. Ensure that any water used stays cool: You may need to add more cool water to maintain an appropriate temperature.

You can apply soaked cloth compresses to areas that cannot be immersed or are too painful to immerse. Continue adding water regularly to keep these compresses cool until the burn site has been cooled completely. Allow adequate time for the burned area to cool, usually at least 10 minutes. If pain continues after 10 minutes, additional cooling may help to relieve it.

If a partial- or full-thickness burn covers more than 10% of the body, cool only a small area at a time. Cooling a large area increases the risk of cold stress and hypothermia. Do not use ice or ice water because they can cause critical body-heat loss. Care should be taken to monitor for hypothermia when cooling large burns. This is particularly important in children, who have a higher susceptibility to hypothermia. If the patient starts to shiver, stop cooling his or her burns immediately and monitor for additional signs of hypothermia and shock.

If possible, remove any jewellery early in the cooling process. When the burn is cool, remove any remaining clothing from the affected area by carefully peeling or cutting the material away. Do not remove any clothing that sticks to the burn.

Inhalation Burns. The presence of soot, thermal burns around the mouth or nose, singed hair, and/or singed eyebrows may signal that a patient’s air passages or lungs have been burned (figure below). Burns that result from a fire in an enclosed, confined space are likely to involve inhalation injuries of the airway and lungs. Usually, only the upper airway is vulnerable to inhalation injuries.

If possible, move the patient to a well-ventilated area. If you suspect a burned airway or burned lungs, place the patient in the rapid transport category. Airway management, assisted ventilations, and supplemental oxygen may be indicated.

Chemical Burns. Chemical burns are caused by exposure to caustic chemicals. These substances are more common in industrial settings but also occur in the home. Cleaning solutions (such as household bleach), oven or drain cleaners, toilet bowl cleaners, paint strippers, and lawn or garden treatments are common sources of caustic chemicals. Typically, burns result from chemicals that are strong acids or alkalis (bases).

The severity of a chemical burn depends on the strength of the chemical and the duration of the chemical’s contact with the body. The chemical will continue to burn as long as it is on the skin. You must remove the chemical from the skin as quickly as possible and then place the patient in the rapid transport category.

Before providing care for a chemical burn, ensure that you have taken the proper steps to protect yourself from any possible hazardous chemicals by donning the appropriate personal protective equipment. Ask the patient whether he or she touched any tools, equipment, etc. after being contaminated by the chemical (as this could contaminate others as well). You should also ask whether anyone else may have been exposed in the same incident.

Flush the burn continuously with large amounts of cool, running water. If the chemical is in the form of a powder or granules, brush the chemical from the skin before flushing the area. Continue flushing for at least 20 minutes. Have the patient remove contaminated clothing, including clothing that became wet during flushing.

Chemical Burns to the Eyes. Chemical burns to the eyes can be extremely traumatic. Flush the affected eye for at least 20 minutes. Take care to avoid contaminating any unaffected areas of the patient: Flush the affected eye from the nose outward, and angle the patient’s head to avoid washing the chemical into the other eye or onto unaffected skin.

Electrical Burns. The human body is an effective conductor of electricity. When a person makes contact with an electrical source, the electricity is conducted through his or her body. Some body parts, such as the skin, resist the electrical current. Resistance produces heat, which can cause electrical burns along the path of the current. The severity of an electrical burn depends on the circumstances of the contact with the source, the current’s path through the body, and the duration of the contact with the electrical current. Ensure that any electrical current is turned off before approaching a patient with suspected electrical burns. Some areas have specific lock-out procedures for de-energizing electrical systems.

Although electrical burns may look superficial, the underlying tissues may be severely damaged. Some electrical injuries will be marked by characteristic entry and exit burns that indicate where the current has entered and left the body (figure below). Look for two burn sites during the secondary assessment.

If a patient has been electrocuted (especially by a lightning strike), you should suspect life-threatening conditions such as respiratory or cardiac arrest. Because of the powerful forces involved, you should also suspect spinal injuries and other fractures.

Radiation Burns. Radiation from the sun and other sources can cause radiation burns, which are similar to thermal burns. The most common radiation burn is a sunburn, which is caused by exposure to the natural ultraviolet radiation of the sun. These burns are usually mild, but they can be painful. Occasionally, radiation burns may be partial-thickness and blister. Care for a sunburn as you would a thermal burn: Cool the burn and protect the area from further damage by avoiding exposure to sunlight.

People who work in special settings, such as certain medical, industrial, or research sites, may be exposed to other types of radiation. These facilities will have systems for responding to this type of incident, so you will be working with internal response teams. Treat radiation burns as you would thermal burns and place the patient in the rapid transport category.

Major Soft Tissue Trauma

Amputations. An amputation occurs when a body part is completely or partially severed from the rest of the body. This can cause damage to many types of soft tissue simultaneously, as well as to bones and other tissues.

Although damage to the tissues is severe, bleeding is often less than would be expected from such a major injury. Initial bleeding is often heavy, but blood vessels usually constrict and retract from the site of the amputation, slowing bleeding and making it easier to control with direct pressure.

An amputated body part can often be surgically reattached if it is cared for properly. To increase the chance of successful reattachment, rinse the body part quickly with saline, then wrap the body part in sterile gauze and place it inside a plastic bag. Place this bag inside a larger bag and cool it with ice or chemical cold packs. Label the bag clearly with the patient’s name, the date, and the time. Patients with amputations are usually in the rapid transport category.

Crush Injuries. Crush injuries occur when the body is subjected to intense blunt force. If a patient is trapped under a heavy object or between two objects, then it is likely that crush injuries have occurred. These injuries can be internal or external and affect a variety of tissues. Internal hemorrhaging and the buildup of toxins in the body are likely.

If necessary, request specially qualified personnel to assist with extricating the patient. Because of the extensive damage that typically results, patients with crush injuries almost always require rapid transport.

Crush Syndrome. Crushing forces can impair or eliminate circulation in the affected tissues. If a patient has been subjected to crushing forces for a longer period of time (typically more than 1 hour), the hypoxic tissues begin to function anaerobically (without oxygen), producing a buildup of toxins (e.g., lactic acid). When the crushing object is removed, these toxins are carried through the body, affecting multiple body systems and causing a condition referred to as crush syndrome. Impaired heart function and renal (kidney) failure often result. As with any patient suffering crush injuries, a patient with crush syndrome should receive interventions for life-threatening conditions and be placed in the rapid transport category.

Care: For crushes less than 15 minutes, release the compressive force or object as quickly as you can, control any bleeding, and treat for shock. For crushes longer than 15 minutes DO NOT release the compressive force or object before the arrival of pre-hospital care. If help is not immediately available, consider removal of the crushing object, but apply a tourniquet above the injury site prior to lifting the object. This will help to prevent the sudden release of toxins into the circulatory system.

Compartment Syndrome. Compartment syndrome occurs when pressure within the muscle compartment builds up to dangerous levels and blocks circulation to the cells. Within the muscle compartment, swelling and/or bleeding creates pressure on capillaries and nerves. The capillaries collapse when the pressure in the compartment becomes greater than the blood pressure within the capillaries, and this disrupts blood flow to muscle and nerve cells in the area. Without a steady supply of oxygen and nutrients, nerve and muscle cells begin to die within hours. Unless the pressure is relieved quickly, compartment syndrome can cause permanent disability or death.

Compartment syndrome can be caused by a traumatic injury, such as a fracture of one of the long bones in the body. It can also have other causes, such as a badly bruised muscle, complications after surgery, a crush injury, or anabolic steroid use. Compartment syndrome can affect muscle groups in the arms, hands, legs, feet, and buttocks because they are covered by fibrous membranes that do not readily expand.

The classic sign of compartment syndrome is pain, especially when the muscle is stretched. Other signs and symptoms of compartment syndrome may include:

• Pain that is intensely out of proportion with  the injury, especially if no bones are broken.
  A tingling or burning sensation in the muscle.
• A feeling of tightness or fullness in the muscle.
• A numbness or paralysis in the area. This means that cell death has begun, and efforts to lower the pressure in the compartment may not be successful in restoring function to the muscle.

Acute compartment syndrome is a medical emergency. Place the patient in the rapid transport category.

Blast Injuries. Blast injuries occur when heat and pressure waves generated by an explosion strike and pass through the body’s surfaces. These waves can also throw debris (shrapnel) against a patient, or throw the patient’s body against other objects (causing injuries similar to those sustained in a fall from a height). Blasts release large amounts of energy in the form of pressure and heat. Injuries can include thermal burns (including inhalation burns), loss of hearing, pneumothorax, internal bleeding, and organ damage. Pressure waves are especially likely to damage hollow structures in the body, such as the lungs, sinuses, and GI tract.

The extent of blast injuries may be difficult to identify because sometimes there are no visible external injuries, and indicators of internal injuries may not be apparent. Any patient with suspected blast injuries should be placed in the rapid transport category.

High-Pressure Injection (HPI) Injuries. High-pressure injection (HPI) injuries occur when a substance is injected into the body under high pressure. This usually occurs in workplace settings and involves a tool such as a grease gun or pressure washer. The injected substance may be paint, oil, water, grease, or even air.

The only visible sign of injury may be a small puncture wound on the hand, which may be overlooked, but the damage to internal tissues can be significant. If the mechanism of injury suggests an HPI (for example, if the patient was injured while using a paint gun), you should suspect additional internal injuries. Immediate surgical interventions are often necessary.