The learner should study the content of this page then take the readiness test. It is highly recommended that the learner be familiar with this content before proceeding to the skill pages.

Bleeding & Hemorrhage - Why is this a problem for patients?[edit | edit source]

Figure from: Spahn, D.R., Bouillon, B., Cerny, V. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 23, 98 (2019).

Hemorrhage is the leading cause of preventable death after trauma, in itself the cause of up to 40% of deaths in traumatically injured patients.[1][2] According to the Center for Disease Control and Prevention (CDC), 62% of people who died from injuries and 75% from gunshot wounds perished outside a hospital.[3] Steward et al. found that 53% of deaths attributed to trauma occurred in the first 12 hours and, of these, 37% were caused by hemorrhage.[4] It only takes minutes for a patient to bleed to death.  Decisions on hemorrhage control must be made within seconds.

In HICs, first-responders (paramedics, police officers, firefighters) are trained in hemorrhage control  techniques[5] [6] but this is not the current reality in Guatemala, which lacks a formalized EMS system.  Emergency prehospital care for the entire country of Guatemala is provided by three separate  firefighting companies. In total, these three companies are made up of about 8500 firefighters, at  least half of whom are volunteers. The firefighters of Guatemala attend to every type of emergency,  from childbirth to shootings to natural disasters. The medical training to attend these emergencies is basic, with only one of the three companies providing the option of a formal EMT course which is  not mandated. Furthermore, many traumas occur in rural areas where there are no trauma centers, blood banking capability is scarce, and hospital transport times vary dramatically and can be extensive. Guatemala has no centralized blood bank system to provide transfusion therapy to patients in need. There are only 3 public blood banks in Guatemala City, which has a population of more than 3 million people.[7] This accentuates the importance of managing hemorrhage in trauma patients.

You can learn more about the importance of hemorrhage control here

Four ways to stop Hemorrhage: Pressure, Packing, Tourniquets, and Foleys[edit | edit source]

We chose to specifically address a suite of hemorrhage control techniques in our simulation, as these skills are often taught by direct observation, without appropriate feedback on the application of appropriate pressure. Successful use of tourniquets, for example, often require higher-than-expected amounts of pressure. Baruch et al[8] noted a "confidence-competence mismatch" when  observing non-medical users applying tourniquets and investigating reasons for failure. They report that a common reason for tourniquet failure in this group of users is retention of too much slack in  the straps and too few turns of the windlass, as a result of inadequate assessment of the amount of  pressure required to successfully deploy the tourniquet. In our model, sensors will measure the pressure applied to assess adequacy of compression. We will also use pump-based active fluid  technology to generate visual feedback of the adequacy of compression. Our system will provide quantitative feedback on pressure, as well as visual feedback based on arresting the 'hemorrhage' of the fluid. The use of a dynamic model that actively simulates bleeding, and provides both visual and  quantitative feedback for the trainee, addresses the shortcomings of a standard training model for hands-on tourniquet application, and may result in fewer tourniquet failures due to inadequate  compression.

Inadequate or incomplete training leads to poor hemorrhage control techniques and, ultimately, ongoing bleeding and preventable death. Practice in hemorrhage control has been shown to be effective, especially for advanced maneuvers which include tourniquet application.[9] Untrained personnel was found to have unacceptably high rates of tourniquet failure when given tourniquets to deploy without any additional training aside from package instructions. These findings confirm that formalized training and hands-on practice is essential.[10]

Click here to learn more about how to stop hemorrhage, and see the how-to videos.

Formal training around the world[edit | edit source]

Overall, there are few formalized programs to train healthcare workers how to stop bleeding.  One such program is called "Stop The Bleed", which is a grassroots campaign that was also started by the American College of Surgeons as a way to teach bystanders how to help stop people from dying as a result of bleeding injuries.[11] Over 1.5 million people in 119 countries have been trained through the Stop The Bleed campaign, but there is still a gap in access in many low and middle-income countries.  

Our Solution[edit | edit source]

We are designing a transposable, low-cost simulator and assessment tool for hemorrhage control techniques that will markedly improve the efficacy of care in one of the most effective interventions in initial trauma management. We are creating a novel training model for teaching bleeding control techniques that will have broad implications in reducing prehospital morbidity and mortality from traumatic hemorrhage.  

The CrashSavers Simulator will allow paramedics in Guatemala and other countries to become confident and competent in performing hemorrhage control techniques (wound  pressure, wound packing, tourniquet application, foley catheter inflation) as part of the initial trauma triage performed in the pre-hospital environment.

Paramedics will learn four related psychomotor skills as a suite of hemorrhage control techniques:  

(1) application of external pressure to a bleeding superficial wound

(2) application of packing into a deep wound

(3) appropriate application of a tourniquet to a bleeding extremity, and

(4) appropriate insertion and deployment of a foley catheter to a profusely bleeding wound or a  wound in an anatomic junction (base of neck, axilla, groin)

Our simulation technology includes (1) a physical model of an extremity, complete with low-cost sensor technology and tubing with pumps to simulate blood flow and (2) a smartphone application that includes didactic material and video instruction to learn techniques and a virtual simulator to  practice these techniques prior to physical model-based practice.

See more information here

Self-assessment[edit | edit source]

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  • Self-assessment: Here.
  • Work in progress

References[edit | edit source]

  1. Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute management of  trauma hemorrhage: a systematic review of randomized controlled trials. Crit Care.  2011;15(2):R92. doi:10.1186/cc10096
  2. Rhee P, Joseph B, Pandit V, et al. . Increasing trauma deaths in the United States. Ann Surg.  2014;260(1):13-21.
  3. CDC. Quickstats: Percentage of Injury Deaths for Which Death was Pronounced Outside the Hospital. Morb Mortal Wkly Rep 2008;57:1130.
  4. Stewart RM, Myers JG, Dent DL, et al. Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention. J Trauma 2003;54:66-70 discussion −1.
  5. American College of Surgeons—about us.
  6. Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK,  Fallat M, Taillac P, White L, Salomone JP, Seifarth W, Betzner MJ, Johannigman J, McSwain N  Jr. An evidence-based prehospital guideline for external hemorrhage control: American  College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014 Apr-Jun;18(2):163- 73. doi: 10.3109/10903127.2014.896962. PMID: 24641269.
  8. Baruch EN, Kragh JF Jr, Berg AL, Aden JK Rd, Benov A, Shina A, Shlaifer A, Ahimor A,  Glassberg E, Yitzhak A. Confidence-Competence Mismatch and Reasons for Failure of Non Medical Tourniquet Users. Prehosp Emerg Care. 2017 Jan-Feb;21(1):39-45. doi:  10.1080/10903127.2016.1209261. Epub 2016 Aug 5. PMID: 27494564.
  9. Baruch EN, Benov A, Shina A, Berg AL, Shlaifer A, Glassberg E, Aden JK 3rd, Bader T, Kragh JF  Jr, Yitzhak A. Does practice make perfect? Prospectively comparing effects of 2 amounts of  practice on tourniquet use performance. Am J Emerg Med. 2016 Dec;34(12):2356-2361. doi:  10.1016/j.ajem.2016.08.048. Epub 2016 Aug 27. PMID: 27614373.
  10. Dennis A, Bajani F, Schlanser V, Tatebe LC, Impens A, Ivkovic K, Li A, Pickett T, Butler C,  Kaminsky M, Messer T, Starr F, Mis J, Bokhari F. Missing expectations: Windlass tourniquet  use without formal training yields poor results. J Trauma Acute Care Surg. 2019  Nov;87(5):1096-1103. doi: 10.1097/TA.0000000000002431. PMID: 31274827.
Page data
Part of Crash Savers Trauma
Type Medical knowledge page
Keywords emt
SDG Sustainable Development Goals SDG03 Good health and well-being
Authors CrashSavers
Published 2021
License CC-BY-SA-4.0
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