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Bleeding Control and Shock Management

Category: Procedures Sources: raw/nremt/psychomotor-skills.md, raw/supplemental/patient-assessment-sequence.md Last updated: 2026-04-03

Overview

Bleeding control and shock management addresses both the source of blood loss and the systemic consequences of that loss. Hemorrhage is the most preventable cause of traumatic death. The EMT-B approach is sequential: stop the bleeding, treat the body's response, and transport. Early aggressive bleeding control saves lives.

Key Points

Bleeding Control

  • BSI/PPE first: Blood is a contact hazard. Gloves are the minimum; eye protection if there is any risk of splatter.
  • Direct pressure: The first and most effective intervention for most external bleeding. Apply firm, continuous pressure with a dressing. Do not lift the dressing to check — this disrupts clot formation. Add more dressing on top if blood soaks through.
  • Tourniquet indications:
  • Extremity bleeding not controlled by direct pressure
  • Bleeding from an amputation
  • Massive extremity hemorrhage where direct pressure is not feasible
  • Apply 2–3 inches proximal to the wound; tighten until bleeding stops; note time of application
  • Once applied, do not remove in the field
  • Wound packing (if in local protocol): Deep wounds (junctional hemorrhage at groin, axilla, neck) that cannot receive a tourniquet may require hemostatic gauze packing and direct pressure.
  • Pressure dressings: After initial bleeding control with direct pressure, secure a pressure dressing to maintain compression hands-free.

Shock Management

Shock (hypoperfusion) means inadequate tissue oxygenation due to insufficient circulation. EMT-B recognition and treatment:

  • Signs of shock:
  • Tachycardia (early compensated shock)
  • Hypotension (late, decompensated — SBP <90 mmHg)
  • Pale, cool, diaphoretic skin
  • Rapid, weak pulse
  • Altered mental status (restlessness, anxiety, confusion)
  • Delayed capillary refill (>2 seconds)
  • Treatment — the "STOP" framework:
  • Stop the bleeding (direct pressure, tourniquet)
  • Treat with position: supine with legs elevated 8–12 inches (modified Trendelenburg) unless head injury, respiratory distress, or spinal precautions apply
  • Oxygen: high-flow O2 via NRB at 10–15 LPM (see oxygen-administration)
  • Prevent heat loss: blanket to maintain body temperature (hypothermia worsens coagulopathy)
  • Transport: Shock is a priority condition — load and go. Definitive treatment (surgery, blood products) is in-hospital. The EMT-B's job is to control bleeding and transport rapidly.

Assessment Relevance

Major bleeding is identified during primary-assessment (Circulation component — major bleeding control is immediate). Signs of shock are confirmed during primary-assessment (skin signs, pulse quality, LOC) and secondary-assessment vital signs (BP, HR, skin).

Shock signs on initial assessment demand: 1. Control the source (direct pressure or tourniquet) 2. High-flow O2 3. Position (supine, legs elevated if no contraindication) 4. Warmth 5. Priority transport

Vital sign trending during reassessment: worsening HR + falling BP = deteriorating shock; update medical control and expedite transport.

Procedures

External Bleeding Control

  1. BSI/PPE.
  2. Expose the wound — cut clothing away if needed.
  3. Apply direct pressure with a gloved hand and sterile dressing.
  4. Maintain continuous pressure; add additional dressings if blood soaks through.
  5. If bleeding is not controlled after direct pressure:
  6. Extremity wound: apply tourniquet 2–3 inches proximal; tighten until bleeding stops; record time.
  7. Secure pressure dressing to maintain compression.
  8. Reassess — is bleeding controlled?

Shock Treatment

  1. Ensure bleeding is controlled.
  2. Position patient supine; elevate legs 8–12 inches (if no contraindications).
  3. Apply O2 via NRB at 10–15 LPM.
  4. Keep patient warm with blanket.
  5. Reassess vitals every 5 minutes (priority patient).
  6. Transport priority — notify receiving hospital.

NM Protocol Notes

  • NM EMT-B scope includes tourniquet application, direct pressure, and pressure dressings.
  • NM protocols may authorize hemostatic dressings (e.g., QuikClot, Combat Gauze) at BLS level — confirm current protocol.
  • In NM rural settings, transport times to trauma centers can exceed 30–60 minutes. Aggressive early bleeding control and shock treatment is critical; do not delay transport for procedures that can be done en route.
  • San Juan Regional Medical Center (Farmington) is the Level III trauma center for the region; major trauma may require air transport to UNM Hospital (Albuquerque).

NREMT Relevance

Bleeding control / shock management is a standalone NREMT psychomotor skill station. Examiners assess: - BSI/PPE verbalized before patient contact - Appropriate choice between direct pressure and tourniquet - Tourniquet application technique (correct position, tightened until bleeding stops) - Shock treatment: position, O2, warmth - Reassessment of bleeding control effectiveness

Critical failures: not recognizing shock signs, not applying tourniquet when direct pressure is clearly insufficient, failing BSI/PPE.

  • primary-assessment — major bleeding identified and initially controlled here; shock signs recognized
  • secondary-assessment — vital signs confirm shock severity; ongoing BP and HR monitoring
  • reassessment — vital sign trending every 5 minutes in shock patient
  • oxygen-administration — high-flow O2 is part of shock management
  • oxygen — pharmacology reference for O2 in shock
  • scene-size-up — mechanism of injury informs expected bleeding pattern and injury severity

Sources

  • raw/nremt/psychomotor-skills.md — Bleeding Control / Shock Management
  • raw/supplemental/patient-assessment-sequence.md — Circulation section, Transport Decision