By Jessica Duke, MD
You are hiking in the backcountry with a friend when you come across someone being mauled by a bear. The two of you are able to scare the bear away and go to check on the moaning victim. You immediately note trauma to his face and brisk bleeding to his right leg. What do you tend to first?
The most critical medical and trauma care is based on the goal of protecting oxygen transport to the body’s tissues. ABC (airway, breathing, circulation) is the traditional systematic approach to the immediate assessment and treatment of patients in many acute medical and trauma situations. However, a patent airway and adequate breathing (collecting oxygen) along with a functioning circulatory system (distributing oxygenated blood) are irrelevant if there is no blood to carry that oxygen. A victim can lose most of their blood volume within minutes with an injury to a major blood vessel. In fact, hemorrhage is the leading cause of preventable death on the battlefield1 and the second leading cause of death after traumatic injury in the civilian sector.2 When the hemorrhage is external, first responders have the ability to effectively intervene to stop the bleeding through the use of tourniquets and hemostatic dressings. Thus, in patients with massive external hemorrhage, controlling the bleeding is the most important initial step.
In attempt to reduce preventable deaths from massive hemorrhage, the United States Military developed the MARCH (massive hemorrhage, airway with cervical spine assessment, respiration, circulation, hypothermia/hyperthermia and hike/helicopter) algorithm to direct initial patient assessment during combat operations. As a result of increased tourniquet and hemostatic dressing use in the battlefield, deaths from extremity hemorrhage significantly decreased.3-5 This experience was successfully translated in the civilian and wilderness sectors as well.6-8 While traumatic injuries with massive hemorrhage are generally rare in the wilderness, they can have fatal consequences if not treated rapidly as blood cannot be replaced and the victim may be required to be active during their extraction. The following approach can be used in the treatment of life-threatening hemorrhage in the wilderness setting:
- For extremity wounds, apply a tourniquet 2-3 inches above the wound over the victim’s clothing. If a manufactured tourniquet is not available, utilize an improvised tourniquet with material that it about 2 inches wide. Do not use rope, wire, or string as they can cut into flesh. Document placement of a tourniquet by placing a “T” and the time on the victim’s forehead. Generally, the tourniquet should not be removed until definitive care is reached.
- For non-extremity wounds, apply a hemostatic dressing tightly and directly to the source of bleeding. The hemostatic agent will cause the wound to develop a clot and stop bleeding. If possible, remove any excess blood that is pooling in or around the wound. Apply firm, direct pressure continually for at least 3 minutes. Reassess the wound to ensure bleeding is controlled. Generally, the dressing should not be removed until definitive care is reached.
Note that in civilian EMS settings, the protocols set up by the EMS Director should be followed.
In our scenario, the victim has sustained an extremity injury with massive external hemorrhage so immediate application of a tourniquet to his right leg is warranted. After gaining control of the bleeding, you can then proceed with assessment of the airway.
- Champion HR, Bellamy RF, Roberts CP, et al. A profile of combat injury. J Trauma. 2003;54(Suppl):13–19.
- Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths—a reassessment. J Trauma. 1995;38:185–193.
- Butler FK. The US military experience with tourniquets and hemostatic dressings in the Afghanistan and Iraq conflicts. Bull Am Coll Surg. 2015;100(Hartford Consensus Supplement):60-65.
- Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(Suppl):431–437.
- Kotwal RS, Butler FK, Edgar EP, et al. Saving lives on the battlefield: Joint Trauma System review of pre-hospital trauma care in combined joint operating area – Afghanistan. J Spec Oper Med. 2013;13:77-80.
- Zietlow J, Zietlow S, Morris D, et al. Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in a civilian trauma center. J Spec Oper Med. 2015;15:48-53.
- Scerbo MH, Mumm JP, Gates K, et al. Safety and Appropriateness of Tourniquets in 105 Civilians. Prehosp Emerg Care. 2016;20:712-722.
- Pons O, Jerome J, McMullen J, et al. The Hartford Consensus on active shooters: implementing the continuum of prehospital trauma response. J Emerg Med. 2015;49:878-885.