Since I get LOTS of questions regarding bleeding, I thought this would be a nice instructional video to post regarding treatment of excessive bleeding.
The post is mildly political at the beginning and does contain some profanity (bleeped out), but at the end it is a great discussion of controlling bleeding— particularly use of tourniquets.
Thanks ZDogg, MD for the great information and keep up the good fight.
I get asked often as a medical expert and host of this blog how fast someone can bleed out from a variety of injuries. When I say fast, I think many people are doubtful. I’ve said many times that all bleeding can lead to death if not controlled, whether venous or arterial.
Recently, Bo Johnson, a friend of mine who is an ER nurse and avid outdoors man had a very close call with nearly bleeding to death. This story does have a happy ending (thank heavens.)
Bo was riding his bike to his children’s school while carrying a razor scooter in one hand. The scooter became caught in his bike and when he fell, his neck landed on the edge of the scooter, severing his right internal jugular as well as a large muscle. What follows is video of the bleeding before surgery that Bo graciously gave me permission to post here. WARNING: The following video is a graphic representation of active bleeding.
Photo Courtesy of Bo Johnson
Keep in mind, this is a large vein, and not an artery. However, the bleeding is still quite brisk and if uncontrolled would be deadly. If it had been arterial, the blood would be a brighter red in color and would spurt from the wound, and would be more difficult to control.
Bo spent two hours in surgery to repair the injury. The jugular vein could not be repaired so was tied off. The jugular vein on the other side of the neck will hopefully compensate. He spent one night in the hospital and should be back to work helping to heal others in about a month.
All who know Bo are so thankful that he is going to be okay after this freak accident. I personally publicly thank him for allowing me to share his story, video, and photo with you so you can see just how significant bleeding can be.
Speedy recovery, my friend.
Sandy Asks:
I am writing a scene where my heroine gets shot in the scuffle with the bad guy. If she’s shot in the brachial artery in her left arm, is it conceivable that she’d pass out and bleed a lot? Her firefighter hero is there and immediately rips off his shirt and balls it up to stop/slow the bleeding. He then uses a strip of fabric from another shirt to tie around that and then carries her to a waiting police car to get her to the hospital—in this case, an ER clinic.
How much danger is there of bleeding out? Is the pressure wrap enough? Can she survive? What would be the treatment? Surgery, I assume, and blood transfusions. Would she remain unconscious and for how long?
Jordyn Says:
Yes, it is conceivable that she would pass out and bleed a lot. The brachial artery will bleed briskly and quickly and without direct intervention she could bleed to death in a matter of minutes (3-6 min). I think both methods to control the bleeding need to happen quickly. The firefighter can direct a bystander to apply direct pressure while he fashions the tourniquet as he will have more experience. The tourniquet should be applied above the level of bleeding. After those two measures, I would have the firefighter continue direct pressure at the sight with a compression dressing. This will be better than continuing to hold direct pressure.
To your specific questions:
Without intervention, this character is in great danger of bleeding out. With immediate intervention, she should be all right.
I would do both the tourniquet and the pressure dressing.
Initial treatment by EMS would be to establish IV access very quickly and start supporting the fluid loss with IV fluids. A set of vital signs. Possibly oxygen if her heart rate is really elevated, her oxygen level is low, or she’s exhibiting any kind of distress.
Since she is being transported by a police car, these would then become the initial steps performed in the ER.
Upon arrival to the ER, labs will be drawn to check her blood counts. If low, then blood transfusion would be warranted. Repairing a severed artery will require surgery.
Whether or not the character goes unconscious depends on a lot of factors. A person can just pass out from looking at blood and the stress of being shot in addition to blood loss. If a person passes out from blood loss, they should regain consciousness as soon as their blood pressure is normalized either with IV fluids and/or blood transfusions.
You mention an “ER clinic”. I’m not quite sure what you mean by this, but a free standing ER, urgent care, or an “emergency” room outside a major hospital can have limitations in the type of care they can deliver. So, if it’s such a situation, the patient would need to be transferred to a larger hospital (for surgery, admission, etc).
Best of luck with this story!
Anonymous Asks:
I have a character in my story who is stabbed three times with a three inch, narrow blade trench knife in the abdomen. I’m trying to avoid the guts or arteries and make it as non-lethal a spot as possible. He is a doctor and also a spy. I would like him to live and make a complete recovery.
He is two hours away from a hospital and has a friend to help him get there. Here are my questions:
1. Would it be feasible for him to live that long while he gets to the hospital for treatment?
2. Would he want to leave the knife in during travel time so he doesn’t bleed to death?
3. Or do I need to rework the scene so he’s closer to the hospital? If two hours is too long, what’s the maximum time he could have in travel before it’s too late?
Jordyn Says:
This is an example of all things are possible, but not necessarily probable. Of course, people survive devastating injuries every day. Miracles do happen. This is the category I would put your character in to.
The largest problem with him surviving these injures in the length of the knife and how many stab wounds he has. Three inches is long when it comes to knife wounds— particularly if the full length is buried into the abdominal area. We have to operate on a worst case scenario until the patient proves otherwise. Looking at the picture to the right, you can see all that is located in the abdomen and how likely it is that something devastating to this patient would be punctured or nicked.
If you want to keep the scenario as is, then I would have all the punctures be to the lower abdomen and to either side. This could puncture the intestines and bladder. These would need to be surgically repaired, but should be survivable (if the bleeding is minimal) for a couple of hours.
You’d definitely want to avoid the left upper and right upper abdomen which house the spleen and the liver. If these are punctured, your character would likely bleed out within two hours. Also, more midline to the abdomen is the descending aorta (a very large blood vessel), which also would lead to rapid hemorrhage and low survivability.
Leaving the knife in is up to you as an author. I could see his friend doing either thing. In a panic, he removes the knife. Or, maybe he has some medical knowledge where he thinks leaving it in place might be a good idea. I would pick whatever increases the tension for your scene.
Two hours is reasonable if you pick the injuries I describe above. I would caution you, though, to give the reader an image that there is little bleeding and the pain is somewhat tolerable. Rapid bleeding, a hard distended belly, accompanied by signs of shock (rapid heart rate, rapid breathing, sweating, paleness, clammy skin) would be poor prognostic indicators for surviving two hours.
Hope this helps and good luck with your novel!
How fast a person can bleed to death is a very common question among authors and I’ve done several posts on the topic. About a month ago, I got a comment asking a variation of the question.
It’s as follows:
Although I’ve worked in an animal clinic for years, I wasn’t sure how much of what I’d seen there translated to the human side. I’m currently editing someone’s manuscript and the injuries in a couple of scenes struck me wrong enough to do some digging before revision. A couple of things I’m still looking for is how long a person remains conscious with arterial or venous bleeding (in one scene, this is from a femoral injury) and whether/how much accelerated heart rate from exertion speeds bleeding?
Jordyn Says:
It’s hard in medicine to give actual time frames. The best demonstration I ever saw of how fast it took to bleed out was from a physician that drilled a hole into a two liter bottle of pop and then squeezed it mimicking a heartbeat. He said the size of the hole could be equated with an injury to the popliteal artery (which is behind your knee) and that bottle was empty in about two minutes.
Devastating injuries to larger arteries (your aorta for instance) can cause the patient to bleed out (hemorrhage or exsanguinate) in 1-2 minutes. It’s fast. For instance, if you rupture your descending aorta in a hospital and they know exactly what is wrong with you, and even have a couple of IV’s in place, your chances of survival are still not awesome.
Some general rules:
Arterial bleeding is faster than venous bleeding. This is because the pumping action of the heart causes more brisk blood loss. That being said, all bleeding can lead to death if not controlled. It’s probably safe to assume that bleeding from an artery without any intervention could lead to unconsciousness in one to three minutes and death in under five minutes.
Uncontrolled venous bleeding might take upwards of twenty minutes or days. Again, if not controlled in any way. Again, this could be variable. The author has a lot of leeway.
Does a fast heart rate accelerate bleeding? Yes. The faster your heart beats, the more blood spills, particularly from an arterial bleed. This is a double edged sword because your body will compensate by increasing your heartbeat during blood loss to compensate for all those red blood cells on the pavement and not in your body carrying oxygen.
Here are other posts on the topic of blood loss:
Author Beware: Arteries vs. Veins.
Author Beware: Arterial Bleeding vs. Venous Bleeding.
Killing my Arteries: Truth or Die by James Patterson. Can IV drugs be given in an artery?
Pregnant Woman Bleeding to Death.
Pregnant Woman Bleeding after Delivery.
What other questions do you have about characters bleeding to death?
As a medical nerd, I’m always a little fascinated by new medical devices and what they can do. I was alerted to this device by Mike H. via Facebook (Thanks, Mike!) and found it worthy to post upon to keep all your medical treatment scenes in those novels up to date.
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| The Blaze |
It is true that not all bleeding can be controlled by direct pressure. It is also true that bleeding is the leading cause of death when it comes to bullet wounds (unless you have suffered a direct hit to either your heart, brain, and/or spinal cord which is likely the end of your life here on earth.) Uncontrolled bleeding from limbs is one thing that harkened back the use of the tourniquet. First by the military and now by civilian EMS agencies. They found the concern over tissue damage didn’t pan out in the research.
For those other folks who get shot in the chest and/or abdomen, it’s always a race to the hospital where definitive control of bleeding can happen– which usually necessitates a trip to the OR– which takes time. You may have heard the term “Golden Hour” which is generally the preferred window to get the patient to definitive treatment before they die.
Rapid control of bleeding could actually extend this hour in my opinion.
Enter the X-STAT. For lack of a better term, the X-STAT is a tampon shaped (sorry, guys) device that is filled with dime-sized medical grade sponges that are coated with a hemostatic (stops bleeding) agent. It is inserted into the wound and the plunger places these sponges deep into the wound where they expand (like the firework snakes) and stem bleeding without direct pressure. The expansion of the sponges prevents them from being forced out of the wound.
Genius.
Thus far it seems to be listed as an investigational device and its use is limited but if it does what it says it does I think this could mean a big difference for trauma patients.
You can read more about the X-STAT here.
What do you think of the X-STAT? Would you use it in a novel? You can bet I’ll find a way to.
As you know, I’m critically watching some of the new Fall TV shows for medical accuracy. I’ve already posted about the CBS drama Hostages. You can find that here.
This week, I’m going to knock it down but then offer it a helping hand back up. Episode 5 is going to be the brief knock down.
If you haven’t watched all the episodes you have been thusly warned that there will be spoilers in this post.
If you’re not familiar with the show, the President needs an operation and his surgeon, played by Toni Collette, and her family have been taken hostage to force her hand to assassinate him or her family will be killed.
In episode five, the family plots to escape. They end up getting split up. The husband at home. The children on a bus to Canada and Ellen (Toni’s character) almost getting on the bus until she sees video of her husband being shot in the gut.
And, of course, even though he’s a cheating slime ball she goes home to save his life.
Issue One: One of the ways a person who has been shot and is bleeding dies is of exsanguination– meaning all their blood leaks out. The reason significant blood loss kills you is that your body is no longer delivering oxygen and you go into shock/circulatory collapse. What you really need is BLOOD to save your life. Without it– nothing the medical team can do will pull you out from the drain you’re swiftly traveling down. When our trusty surgeon arrives home she finds her husband unconscious and not breathing . . . no pulse.
She starts CPR– yea!! Then asks Mr. Hostage taker to get her medical bag from which she happens to have a hospital grade defebrillator.
Issue Two: There are only a few shockable rhythms. I’ve blogged about the use of electricity here. A likely rhythm for the patient to be in strictly from blood loss is what we call PEA or pulseless electrical activity. There is actually two parts of good heart activity. The electrical component and mechanical component. You need both working appropriately to propel your blood forward and keep you alive. You can actually have normal electrical activity and yet the heart is not mechanically beating– thus the term pulseless electrical activity.
In the case of this character’s husband– his heart likely has normal electrical activity but since he’s lost so much blood– it doesn’t have blood filling the chambers and so doesn’t have anything to pump out. Hence the lack of a pulse.
I’m guessing this husband’s injuries would lead to this set-up. Normal electrical activity with no pulse. So he doesn’t need electricity. He needs BLOOD.
Issue Three: I don’t know any physician anywhere that has a hospital grade defibrillator for their private use. Or would know how to work it . . . quickly. Now, this isn’t a backhanded slap to my physician co-workers. They know how to do their job very well. This just isn’t necessarily in their skill set. Nurses usually set-up the defribillator. The physician orders the desired amount of electricity.
I’ve taught advanced resusitation courses for two decades and I can tell you, across the board, every type of physician struggles to get it programmed. These classes are not a requirement for EVERY physician to take either.
So– wrong treatment with too much ease of use.
What would have been more believable would have been for her to have an AED (automatic external defibrillator) in the home. These are designed for lay people to use and some people do actually have them for home use. They basically diagnose the shockable rhythms and provide electricity if indicated. It’s what many first responders are carrying to even high school settings. They are very user friendly.
Check out my post on Thursday where I’ll continue my discussion of this particular episode.
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| I-stock Photo |
Carotid – 2-20 min
Any major artery (and the ones listed are major) that is completely severed will likely lead to the patient’s death in less than five minutes. I saw a demonstration once where a physician simulated this happening.
He took a 2 Liter bottle (an empty pop bottle) and filled it with water. He drilled a hole into it (to simulate arterial severing) and then squeezed it at a regular rate to simulate the heart pumping. That bottle was empty in a matter of three minutes. Yes, we timed it.He said the diameter of the hole he drilled equated to the popliteal artery which is behind your knee.
However, the injury may not be a complete separation which is why you have the varying time lengths. Of course, if the person gets some type of medical treatment (like a pressure dressing that stems the bleeding) they may last a lot longer as well.
I know this answer isn’t a clear cut answer but in medicine . . . they usually aren’t.
Redwood's Medical Edge 