Symptoms and signs – Not all may be present

• a wound with, or without, an embedded foreign object 
• pain from skin surface wounds  
• bruising or discolouration of the skin 
• loss of normal function in the injured area 
• pale, cold, sweaty skin

 How you can help

1.      Apply direct pressure to the bleeding wound

• Apply firm pressure over the wound. Use a sterile or clean bulky pad and apply it firmly with hand pressure. Apply a bandage to keep the dressing in place. 
• If bleeding is severe, DO NOT waste time looking for suitable padding, but be prepared to use the patient’s hand or your hand to hold the wound together if the patient is unable to do this unaided.

2.      Raise the injured area

• If the wound is on a limb, raise it in a supported position to reduce blood flow to the injured area. 
• If an arm is injured, you could apply an arm sling or elevation sling. 

Try to avoid any direct contact with the patient’s blood or other body fluids. Use disposable gloves if possible. If gloves are not available, place your hands inside a plastic bag.

• If there has been any contact with blood or any other body fluids, wash your hands or any blood splashed on the skin thoroughly with soap and water as soon as possible after the incident.
• If you are concerned about a possible risk of infection, obtain advice from your doctor as soon as possible.

3.      If a foreign body is embedded in the wound

• DO NOT remove it but apply padding on either side of the object and build it up to avoid pressure on the foreign body. 
• Hold the padding firmly in place with a roller bandage or folded triangular bandage applied in a criss-cross method to avoid pressure on the object.

4.      Keep the patient at total rest

• Even if the injury involves the arm or upper part of the body, the patient should rest in a position of greatest comfort for at least 10 minutes to help control the bleeding. 

5.      Seek medical assistance

• If the wound appears to be minor and the patient is able to travel by car, arrange an urgent appointment with a local doctor to assess and treat the injury. 

If the injury is severe or the patient is very unwell – call 111 for an ambulance as soon as possible.

While waiting for an ambulance to arrive, observe the patient closely for any change in condition.

6.      If blood leaks through the pressure pad and bandage

• Apply a second pad over the first. Use a tea towel or similar bulky fabric and apply maximum pressure to the area. 
• For major uncontrolled bleeding quickly remove the blood-soaked pad and bandage and replace with a fresh bulky pad and bandage. The continuing bleeding may be due to the pad slipping out of position when the first bandage was applied.

Wounds that need special care

Amputation

How you can help

Call 111 for an ambulance.

 1.      Control any bleeding

• Use a bulky pad and apply it firmly to the bleeding area. Raise if possible.

2.      Recover the severed part

• If possible, gently place it into a plastic bag. Seal the bag with a little air inside to protect the severed part with a ‘cushion’ of air. 
• Place the inflated bag into a container or bucket of cold water to which several ice cubes have been added. 
• Ensure the severed part is transferred to hospital with the patient.

Crush injury

Background

A crush injury occurs from compression of large muscle groups and soft tissues by a heavy weight. The most serious sites for a crush injury to occur are the head, neck, chest, abdomen and thigh.

How you can help

Call 111 for an ambulance.

 1.      Remove the crushing force

• Remove the crushing force if possible because permanent tissue damage may occur with severe crushing force.
• If the crushing force has been in place for some time, be prepared to give prompt first aid, because removal of the crushing force may cause a sudden collapse or deterioration in the patient’s condition.

2.      Treat the patient’s injuries

• Assess and treat any injuries in order of their importance.  
• Control any bleeding with a sterile pad applied firmly to the injured area. 
• Assist the patient into the position of greatest comfort and use soft padding to provide support for the injured part.
• If a limb is involved, support and immobilise the injured area.
• While waiting for the ambulance to arrive, observe the patient closely for any change in condition.

Nose bleed

Background

A blow to the nose, flying at high altitude, or scuba diving may all cause a bleeding nose.

For a child, always check whether there is a foreign body present – e.g. a bead or coin. If this has occurred, seek prompt medical advice and DO NOT try to remove the object yourself because this may cause further damage.

If bleeding is due to a head injury – e.g. a fractured skull – call 111 for an ambulance urgently.

How you can help

1.      Apply firm pressure, elevation and rest

• The patient needs to hold the head well forward and breathe through the mouth while pinching the entire soft part of the nose for 10 to 20 minutes.
• The patient must be sitting down and at total rest until the bleeding stops.

If bleeding continues after 20 minutes of pressure, continue the pressure and call for an ambulance.

A cold compress can be used. 

2.      Once the bleeding has stopped

• Tell the patient not to blow their nose for a few hours because this may restart the bleeding.

Other wounds

An abrasion (graze)

How you can help

• Gently clean with soapy water or saline. If there are pieces of gravel embedded in the wound, ask the patient to try to remove them while the area is soaking in soapy water.
• Dry the area well by blotting with gauze swabs or a pad of tissues.
• If a protective dressing is necessary, apply a non-adherent sterile dressing and fix it in place with a light roller bandage or tape.

A puncture wound

How you can help

• Clean the wound with warm soapy water and allow it to penetrate the puncture track because tetanus spores may be trapped deep in the wound.
• Allow the wound to dry thoroughly in the air before covering it.
• If a protective dressing is needed, use a porous adhesive dressing and change it daily to keep the wound healthy and dry.

Contact a local doctor for advice about tetanus immunisation.

Internal bleeding

Background

Internal bleeding is often difficult for the first aider to recognise. This type of bleeding can

occur without an obvious wound and can be very serious as it is difficult to stop without surgical intervention.

Internal bleeding occurs when blood vessels within the body are ruptured and blood escapes

out of the circulatory system. It may follow such incidents as a blow to the head, chest, or

abdomen due to a fall or being struck by a vehicle. Internal bleeding should be suspected when blood is seen in vomit, urine, sputum or faeces.

Symptoms and signs – Not all may be present

• rapid and ‘gasping’ breaths
• increasing thirst
• frothy red blood coughed up from the lungs, blood-stained vomit like ‘coffee grounds’, red or rust-coloured urine, or dark faeces like tar
• pale, cold, sweaty skin

How you can help

1. Place the patient at total rest
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• Assist the patient into the position of greatest comfort.
• Cover the patient with a blanket to maintain body heat.
• Place protective fabric underneath the patient if the surface is rough, cold or hot – e.g. a coat if the patient is lying on a road.

Call 111 for an ambulance.

1. While waiting for the ambulance

• Manage any other injuries.
• Ensure that all restrictive clothing has been loosened, especially at the neck and waist.
• Keep any bystanders clear.
• Reassure the patient.
• DO NOT allow the patient to eat, drink or smoke.

For severe bleeding, take these actions immediately:

1. Remove any obvious dirt or debris from the wound. Don't remove large or deeply embedded objects. Don't probe the wound or attempt to clean it yet. Your first job is to stop the bleeding. Wear disposable protective gloves if available.

2. Stop the bleeding. Place a sterile bandage or clean cloth on the wound. Press the bandage firmly with your palm to control bleeding. Maintain pressure by binding the wound tightly with a bandage or a piece of clean cloth. Secure with adhesive tape. Use your hands if nothing else is available.

   Raise the injured part above the level of the heart.

   Special cases:

   • Don't put direct pressure on an eye injury or embedded object.
   • Don't reposition or put pressure on displaced organs. Cover the wound with a clean dressing.
3. Help the injured person lie down, preferably on a rug or blanket to prevent loss of body heat. If possible, elevate the legs.

4. Don't remove the gauze or bandage. If the bleeding seeps through the gauze or other cloth on the wound, add another bandage on top of it. And keep pressing firmly on the area.

   Tourniquets: A tourniquet is effective in controlling life-threatening bleeding from a limb. Apply a tourniquet if you're trained in how to do so. When emergency help arrives, explain how long the tourniquet has been in place.

5. Immobilize the injured body part once the bleeding has stopped.Leave the bandages in place and get the injured person to the emergency room as soon as possible.

   Call 911 or your local emergency number if the bleeding is the result of major trauma or injury. Also call for emergency help if you suspect internal bleeding. Signs of internal bleeding include:

   • Bleeding from a body opening, such as the ear, mouth, nose or anus
   • Vomiting or coughing up blood
   • Bruising
   • A tender or swollen stomach
   • Cold, clammy skin
   • Thirst
   • Fractures
   • Shock, indicated by a rapid, weak pulse, pallor, sweating, rapid breathing and decreased alertness
   • Make sure that there is no immediate danger of further injury. Do not move the injured person if you do not have to. However, if there is immediate danger of other injury (from traffic, falling objects, etc.), try to form a barrier, keeping the injured person and others safe, such as by directing traffic around an accident site. If you absolutely must move the injured person yourself, immobilize the wound site as best you can.If you suspect the person has injuries that are causing internal bleeding, let medical help know when you call. There might be internal bleeding if you notice the person coughing up blood, vomiting, or bleeding from the ears, eyes, nose, or mouth.^[1]
   • Make sure that there is no immediate danger of further injury. Do not move the injured person if you do not have to. However, if there is immediate danger of other injury (from traffic, falling objects, etc.), try to form a barrier, keeping the injured person and others safe, such as by directing traffic around an accident site. If you absolutely must move the injured person yourself, immobilize the wound site as best you can.
   • 
     3
     Wash your hands if possible. If you can, you'll want to sanitize your hands by washing them with soap and water. Put on surgical gloves as well, if they're available. This will not only protect you from the risk of getting diseases, but also prevent the injured person from becoming infected.

     • Always be careful when handling someone else's blood. Since blood can carry disease-causing pathogens, take steps to wash your hands and protect yourself.^[2]
     • Never re-use plastic or surgical gloves, since doing so can spread infection.
     • If you do not have disposable gloves, try using something like plastic wrap to put a barrier between your hands and the wound.^[3]
   • 4
     Clear the wound site. If there is obvious dirt or debris in the wound, remove it if possible.^[4] However, do not try to remove large objects, or ones deeply embedded in the wound, since this can make bleeding worse. If you must leave an object in the wound, avoid pressing on it, as this may push it deeper into the wound.
   • 
     5
     Apply pressure. Use a sterile or clean cloth, bandage, or gauze and apply firm pressure directly on the site of the bleeding. Use your hands only if you have nothing else.^[5][6] Do not put pressure on an eye wound, or if there is an object embedded in the wound.

     • Keep applying pressure without removing the cloth to check on the bleeding. If you take the bandage off, you could disturb clots that are forming to stop the bleeding.^[7]
   • 
     6
     Secure the bandage. You can fix the bandage in place with tape, gauze strips or whatever you have on hand, like a necktie or strip of cloth. Take care not to tie the strips too tightly, or you could cut off circulation.
   • 
     7
     Elevate the wound. If a bone does not appear to be broken, raise the wound site so that it is above the heart.^[8][9] For instance, if a leg is injured, raise it on a chair or place a pillow under it. Elevating the wound can keep blood from rushing to it and intensifying the bleeding.
   • Apply pressure to a pressure point if the bleeding does not stop.^[10][11] A pressure point is a location where you can squeeze an artery against a bone, which can slow the flow of blood. There are two major pressure points on the body; choose the one nearest the site of the wound.

     • If the bleeding is near a leg, press and hold against the femoral artery in the groin, where the leg bends at the hip.
     • If the bleeding is near an arm, press and hold against the brachial artery, along the inside of the upper arm.
   • 2
     Help the injured person lie down, if the injury permits. Cover the injured person with a blanket or similar material to keep in body heat. Resting the injured person can help prevent him or her from going into shock.^[12]
   • 3
     Apply more dressing to the wound, if necessary. Don't remove the cloth covering the wound even if it soaks through with blood, as this can make the bleeding worse. You can place another layer of cloth or bandage over the soaked one. The important thing is to keep applying pressure.^[13][14]
   • 4
     Use a tourniquet only if you have proper training. If bleeding does not stop, even after prolonged pressure, you may need to make a tourniquet. Because there are severe dangers from incorrectly placing or applying a tourniquet, you should only use one if you've been trained to do so.^[15][16][17]

     • An easy-to-use combat tourniquet is now available for civilian purchase. If you can get one, buy a Combat Application Tourniquet (CAT) and learn how to use it.^[18]
     • When paramedics or other help arrives, let them know how long the tourniquet has been in place.
   • 5
     Keep calm. Dealing with severe bleeding can be shocking and stressful. While you wait for medical help to arrive, calm yourself by focusing on the steps necessary to stop the bleeding. Calm the injured person by talking to him or her, and giving assurance that help is on the way.