Trauma Basics - Catastrophic Haemorrhage

24th July 2020

Catastrophic Haemorrhage has become a popular phrase on almost all first Aid courses in the years since military operations in Iraq and Afghanistan where battlefield protocols have been used with huge success to manage similar injuries in civilian environments.

The problem is that the term Catastrophic Haemorrage is widely used but rarely, and inconsistently defined.

• "A life threatening bleed"

• "Arterial bleeding"

• "A squiring / spurting bleed"

• "A non-compressible bleed"

• "Bleeding you can hear" (1)

• ”The loss of a patient’s total body volume in less than 24 hours” (2)

• “A major hemorrhage, from an artery, which is likely to result in death within a period of time that may be as short as minutes, because of the rapid internal or external loss of circulating blood volume.” (3)

• “Blood loss of 50% of circulating blood volume within a 3-hour period or, blood loss exceeding 150 ml/min, or blood loss that necessitates plasma and platelet transfusion." (4)

Whilst many of the definitions provided are true some of the time, they are not true all of the time, which means they are not strictly reliable definitions, which can present a problem if we need to know what we are looking for.

The most common definitions provided involve reference to the following recognition features:

Catastrophic Haemorrhage is arterial / bright red / spurting.

Sometimes. Arterial bleeding can be Catastrophic, but not always. The following video shows a small injury to the foot. The bleeding is clearly arterial (bright red and pulsatile) but is it catastrophic? The volume of blood being lost is not significant; we can lose nearly a pint of blood when we donate and the treatment is a cup of tea and a biscuit. It would take a long time to lose a pint of blood from this injury so it is not immediately life threatening. The arterial bleed is also not under much pressure so It could easily be controlled by direct pressure.

This video of Cedric Gracia was captured as he came off his bike, impaling a brake lever into his groin and puncturing his femoral vein. There is only a brief glimpse of the wound as he pulls the waistband of his shorts down at 1:49. From what we see, the blood does not ‘spurt’ but rather “wells up” to fill his inguinal crease and it does not appear bright red.

In this video of Clint Malarchuck’s infamous neck injury from 1989 to his jugular vein. Being venous it does not spurt and is not bright red, yet is clearly catastrophic.

Catastrophic Haemorrhage is bleeding you can hear.

Sometimes. This is cited in the Royal College of Surgeons of Edinburgh’s Faculty of Pre Hospital Care core text (4). Whilst in a clinical setting (i.e. complete silence), surgeons have reported hearing arterial bleeding. Outside of a clinical setting, bleeding you can hear splatter off the walls is obviously going to be more than a graze.

To suggest that you could hear catastrophic haemorrhage would infer that if you can’t hear it, it is not catastrophic.

Catastrophic Haemorrhage is immediately life threatening

Sometimes. But it can also take a lot longer to kill you. It really depends upon the rate of blood loss. A serious bleeding wound which is not being controlled by ordinary means (direct pressure) will eventually kill you if it is not arrested. To suggest Catastrophic Haemorrhage will kill “within 3 minutes “ infers that anything that takes longer to kill you, is not catastrophic.

Catastrophic Haemorrhage is a life-threatening bleed to a limb.

Thankfully this is appearing less and less in literature as we develop our understanding of junction (neck, groin and armpit) and abdominal injuries.

Amputations cause Catastrophic Haemorrhage

Sometimes. It is possible to bleed to death from an amputation but not necessarily immediately. It is common for a complete amputation to bleed very little or even not at all as blood vessels collapse and recoil into the tissue. This automatic process does not last forever as tissue relaxes bleeding can begin to occur well after the initial injury.

As such tourniquet is immediately applied to an amputation, regardless of whether is initially bleeding or not.

Catastrophic Haemrorrhage is a large volume of blood loss

True….but what does that look like. It is extremely difficult to estimate blood loss based on what you can see. A large volume of blood can be lost internally, soak away into ground surfaces, soaked into clothing, ‘hidden’ under poor lighting or orange street lighting or on wet tarmac.

Conversely, a nosebleed in a white tiled bathroom can look like a massacre.

If the casualty is laying in a large puddle of blood, is it catastrophic? If the puddle is not actively increasing in size – they either have no more blood left or the bleeding is stopped.

Rather than the size of the ‘puddle’ the rate at which that puddle is developing is a more accurate gauge…but only if you can see it.

The image shown here of Jeff Bauman Jr at the Boston Marathon bombings in 2013 shows a large amount of blood on the floor but how much is there? Is it from one casualty or multiple casualties? Are the injuries actively bleeding?

Whether bleeding is catastrophic or not is dictated by both the speed and volume of blood loss. This may be quick or take time to develop. It may be arterial or venous. It may be dramatic or it may be subtle depending upon what clothes the casualty is wearing, the ground surface they are laying on and lighting at the scene.

We teach that Catastrophic Haemorrhage is either:

• immediately life threatening or

• is not controlled by ordinary means

We do not make reference to specific recognition features which may or may not be there (arterial, venous, spurting, audible). We define immediately life threatening as the rate of blood loss – how quickly are they losing blood? How quickly are their clothes becoming saturated? No matter what it looks like, a large volume of blood that is freely and quickly leaving the body is potentially Catastrophic.

We also recognise that what may not initially appear as immediately life threatening , if our normal approach to arresting the bleed (direct pressure and pressure dressings) are not working, we have to escalate to the same Catastrophic Haemorrhage techniques, such as tourniquets and wound packing.

Further reading

Tourniquets

Haemostatic Agents

Open Chest Injury

Next Article: Trauma Basics - Shock!

References

1. Royal College of Surgeons Faculty of Pre Hospital Care (2019) Foundation Material for Immediate Care.

2. Shields DW, Crowley TP. (2014) “Current concepts, which effect outcome following major hemorrhage”.  Journal of Emergencies, Trauma and Shock. 7(1):20-24

3. Harris DG, Noble SIR (2009) “Management of Terminal Hemorrhage in Patients With Advanced Cancer: A Systematic Literature Review“. Journal of Pain and Symptom Management. 38(6):913-927

4. Irita K (2011). "Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events". Korean Journal of Anesthesiology. 60 (3): 151–60