Hemorrhage (Severe Bleeding)

First aid for severe bleeding

1. Call 911 or your local emergency number, or ask someone else to.
2. Protect yourself with gloves or a barrier if available.
3. Apply firm, direct pressure on the wound with a clean cloth, gauze or your hand. Press hard and do not lift to check.
4. Pack deep wounds (such as in the groin, armpit or neck) by stuffing gauze or cloth into the wound, then pressing firmly.
5. Use a tourniquet for life-threatening bleeding from an arm or leg that pressure cannot control. Place it 5 to 7 cm (2 to 3 inches) above the wound, not over a joint, and tighten until bleeding stops. Note the time. Do not remove it.
6. Do not remove embedded objects; pad around them.
7. Keep the person lying down and warm, and reassure them.

The American College of Surgeons' Stop the Bleed program offers short courses in these skills.

Types of hemorrhage

External

Visible bleeding from cuts, lacerations, fractures through the skin, nosebleeds and gunshot or stab wounds.

Internal

Bleeding inside the body is often more dangerous because it may not be obvious. See internal bleeding.

Brain bleeding is described further under intracerebral hemorrhage and subarachnoid hemorrhage.

Signs of significant blood loss

The body compensates at first, so early signs can be subtle. As blood loss increases:

• fast pulse and fast breathing
• pale, cool, clammy skin
• thirst, weakness, dizziness on standing
• anxiety, restlessness, then confusion
• low blood pressure and reduced urine
• loss of consciousness

Doctors classify blood loss from Class I (up to 15 percent of blood volume, few signs) to Class IV (over 40 percent, life-threatening). Loss of more than about 30 percent usually causes falling blood pressure and needs transfusion. This state is hemorrhagic shock.

Children and young, fit adults may keep a normal blood pressure until they are close to collapse, and people on beta blockers may not develop a fast pulse.

Risk factors for serious bleeding

• blood thinners: warfarin, apixaban, rivaroxaban, dabigatran, and antiplatelet drugs such as aspirin and clopidogrel
• bleeding disorders such as hemophilia and von Willebrand disease
• low platelets
• liver disease
• heavy alcohol use
• NSAIDs, which increase stomach bleeding

Diagnosis

• examination, pulse, blood pressure and oxygen levels
• blood tests: hemoglobin, platelets, clotting tests, blood type and crossmatch
• imaging: FAST ultrasound and CT scans to find internal bleeding
• endoscopy or colonoscopy for digestive bleeding
• angiography to locate and block bleeding vessels

Treatment

• Stopping the bleeding: pressure, stitches, surgery, endoscopic treatment, or interventional radiology (embolization) to block the vessel.
• Replacing blood: IV fluids and transfusion of red cells, plasma and platelets. Major trauma centers use balanced transfusion protocols.
• Tranexamic acid: a medicine that reduces clot breakdown; it improves survival in major trauma and postpartum hemorrhage when given within 3 hours.
• Reversing blood thinners: with specific reversal agents, vitamin K or clotting factor concentrates.
• Treating the cause: such as ulcer medicines, aneurysm repair, or clotting factor in hemophilia.

Frequently asked questions

What is a hemorrhage?

A hemorrhage is significant bleeding from a damaged blood vessel. It can be external, from a visible wound, or internal, into the brain, abdomen, chest, gut or tissues. Severe hemorrhage can cause shock and is a medical emergency.

What are the signs of internal bleeding?

Signs include pain and swelling, dizziness or fainting, pale clammy skin, a fast pulse, vomiting blood, black or bloody stools, coughing blood, blood in urine, and a sudden severe headache with brain bleeding. Call 911 if you suspect it.

How do you stop severe bleeding?

Call 911, then press firmly and continuously on the wound with a cloth or gauze. Pack deep wounds with gauze and keep pressing. For life-threatening bleeding from an arm or leg, apply a tourniquet above the wound and tighten until bleeding stops.

How much blood loss is dangerous?

Losing more than about 15 percent of your blood volume starts to cause symptoms, and over about 30 percent usually causes shock and needs transfusion. An average adult has about 5 liters of blood, so losing more than 1.5 liters is life-threatening.