1. Bleeding

2. Bleeding (hemorrhage) is the escape of blood from capillaries, veins, and arteries.
Arteries are large blood vessels that carry oxygenated blood away from the heart
Veins are blood vessels that carry non-oxygenated blood to the heart.
Capillaries are very small blood vessels that carry blood to all parts of the body.
Bleeding can occur:
External (outside the body)
Internal (inside the body)
or both.
Uncontrolled bleeding (massive bleeding), whether external or internal, is life threatening.
Blood is made up of liquid (plasma) and solid components (white and red blood cells and platelets).
Function of Blood:
Transports oxygen, nutrients and wastes.
Protects against disease.
Maintains constant body temperature.

3. There are three types of bleeding:
Arterial bleeding: is bright red, the blood "spurts" from the wound. Arterial bleeding is life threatening and difficult to control.
Venous bleeding :is dark red (reddish purple), the blood flows in a steady stream.
Capillary bleeding: is slow; the blood "oozes" from the (wound) cut.

4. External Bleeding
- Capillaries bleeding is usually not serious and can easily be controlled. - Veins and arteries bleeding are more serious and can be life threatening. - There are four methods to control bleeding: direct pressure, elevation, indirect pressure, and the use of a tourniquet.

5. Direct Pressure
- Direct pressure is the first and most effective method to control bleeding.
- In many cases, bleeding can be controlled by applying pressure directly (Fig. 1) to the wound.
Place a sterile dressing or clean cloth on the wound, tie a knot or adhere tape directly over the wound, only tight enough to control bleeding.
If bleeding is not controlled, apply another dressing over the first or apply direct pressure with your hand or fingers over the wound.
Figure 1: Direct Pressure

6. Elevation should be used together with direct pressure.
- Raising (elevation) of an injured arm or leg (extremity) above the level of the heart will help control bleeding.
Elevation should be used together with direct pressure.
Do not elevate an extremity if you suspect a broken bone (fracture) until it has been properly splinted and you are certain that elevation will not cause further injury.
Use a stable object to maintain elevation.
Placing an extremity on an unstable object may cause further injury

7. Indirect Pressure:
In cases of severe bleeding when direct pressure and elevation are not controlling the bleeding, indirect pressure must be used.
Bleeding from an artery can be controlled by applying pressure to the appropriate pressure point.
Pressure points, are areas of the body where the blood flow can be controlled by pressing the artery against an underlying bone (Fig. 2) .
Pressure is applied with the fingers, thumb, or heel of the hand.

8. Figure 2. Pressure Points for Control of Bleeding

9. Pressure points should be used with caution
Pressure points should be used with caution. Indirect pressure can cause damage to the extremity due to inadequate blood flow.
Do not apply pressure to the neck (carotid) pressure points, it can cause cardiac arrest.
Indirect pressure is used in addition to direct pressure and elevation.
The brachial artery is used to control severe bleeding of the lower part of the upper arm and elbow. It is located above the elbow on the inside of the arm in the groove between the muscles.
The femoral artery is used to control severe bleeding of the thigh and lower leg. It is located on the front, center part of the crease in the groin.

10. Tourniquet:
A tourniquet should be used only as a last resort to control severe bleeding after all other methods have failed and is used only on the extremities.
Tourniquets cause tissue damage and loss of extremities when used by untrained individuals.
Tourniquets are rarely required and should only be used when an arm or leg has been partially or completely severed and when bleeding is uncontrollable.
The standard tourniquet is normally a piece of cloth folded until it is 3 or more inches wide and 6 or 7 layers thick.
A tourniquet can be a strap, belt, towel, or other similar item. A folded triangular bandage makes a great tourniquet.
Never use wire, cord, or any material that will cut the skin.

11. Application of tourniquet: (Fig. 3)
1. While maintaining the proper pressure point, place the tourniquet between the heart and the wound, leaving at least 2 inches of uninjured skin between the tourniquet and wound.
2. Place a pad (roll) over the artery.
3. Wrap the tourniquet around the extremity twice, and tie a half-knot on the upper surface.
4. Place a short stick or similar object on the half-knot, and tie a square knot.
5. Twist the stick to tighten, until bleeding is controlled.
6. Secure the stick in place.
7. Never cover a tourniquet.

12. 8. Identify the time in which tourniquet was applied.
9. Never loosen or remove a tourniquet once it has been applied. The loosening of a tourniquet may dislodge clots and result in enough blood loss to cause shock and death.
Figure 3. Applying a Tourniquet

13. Internal Bleeding:
Internal bleeding, although not usually visible, can result in serious blood loss.
A victim with internal bleeding can develop shock before you realize the extent of their injuries.
Bleeding from the mouth, ears, nose, rectum, or other body opening (orifice) is considered serious and normally indicates internal bleeding.
Causes of internal hemorrhage:
Deep chest or abdominal wound
Any cut into muscle or fracturing of bone
Bleeding ulcers
Signs of internal bleeding include:
1. Anxiety and restlessness.
2. Excessive thirst (polydipsia).
3. Nausea and vomiting.
4. Cool, moist, and pale skin (cold and clammy).
5. Rapid breathing (tachypnea).
6. Rapid, weak pulse (tachycardia).
7. Bruising or discoloration at site of injury (contusion).

14. If you suspect internal bleeding, do the following:
1. Apply ice or cold pack (contusion), with cloth to prevent damage to the skin, to reduce pain and (edema) swelling.
2. Severe internal bleeding:
a. Call local emergency or medical personnel.
b. Monitor circulation, airway , and breathing (CABs).
c. Treat for shock.
d. Place casualty in most comfortable position.
e. Maintain normal body temperature.
f. Reassure casualty

15. Epistaxis
Epistaxis (nose bleeding): means hemorrhage from the nose, due to mainly spontaneous rupture of minute vessels.
Causes:
Local causes:
- Trauma
Blow on the nose
Foreign body
- Infection: acute / chronic rhinitis
- Violent sneezing
- neoplasm in the nasal cavity, nasopharynx, or sinuses
General and systemic causes:
Blood diseases
Hypertension
Acute infectious fever
High altitudes 15

16. First aid treatment - Apply pressure by pinching the nostrils for 5-10 minutes. - Keep the patient in a setting position - Apply ice over the nose - Keep the patient quite Hospital emergency care - Simple packing of the nose - Use of adrenaline nasal pack - In hypertension cases: sedation and reduce blood pressure - Check for blood coagulative disorders.