Exsanguinating Haemorrhage

Haemorrhage is a very common problem in those who are badly injured. Particularly in penetrating trauma (knives and guns), we sadly see the effects of very severe haemorrhage on a daily basis. We have been searching for solutions to the severe haemorrhage problem for some time. 

It is clear that for those who are truly exsanguinating from major blood vessels, there is a risk that they will bleed to death within minutes if the bleeding isn’t stopped by someone, or if the bleeding doesn’t stop by itself. Even with the fastest response by our teams, there are patients who regularly exsanguinate before the team arrives. The key to helping these patients is in prevention, and in the role of bystander intervention. For those who have been stabbed, and who are visibly bleeding, pressure (significant pressure) must be applied to the bleeding site and this can be done by anyone who is present. 

  • Pallor
  • Clammy
  • Altered sensorium
  • Low or falling ETCO2
  • Air hunger
  • Venous collapse
  • Hypotension (low volume or absent pulses)
  • Tachy or bradycardia

These features, colloquially known as the 'hateful eight', have been described in more detail here.

When our medical team arrives at a patient who is bleeding externally, they will do the same thing as bystanders (put as much pressure as possible onto the wound to stop the bleeding). They may also apply tourniquets in appropriate cases or put special dressings into the wound. Pre-hospital REBOA is a technique reserved for those who will not make it to hospital without this dramatic intervention (or their condition will be much worse if they do not receive REBOA). In some rare cases, a resuscitative thoracotomy may be needed.

Other patients will bleed more slowly from smaller blood vessels or where clots have formed around larger ones. It is still important that the bleeding is stopped as soon as possible and therefore an operation or REBOA may still be required, but these procedures may have better results if carried out in hospital, or after investigations such as X-rays and CT scans, so that the bleeding source can be precisely targeted. 

In the pre-hospital phase of care it is vital that medical teams don’t delay care by intervening at the roadside, but that we intervene immediately for those who need treatment quickly. We have found that those who are truly exsanguinating at the roadside demonstrate some key features and our teams find these signs helpful on scene in determining who can be transported to hospital and who needs an intervention such as REBOA immediately. Senior clinicians use their experienced judgement to assess the risk of a patient by looking fort the following signs (amongst others).

Patients  with blunt trauma (road traffic collisions) and those who have internal bleeding can be difficult to diagnose at the roadside. Accurate diagnosis is essential if opportunities to intervene are not missed, and to avoid preventable deaths. Blood transfusion at the roadside was an important  innovation for our teams, introduced in 2012.