Major bleeding and haemorrhage: a case-based approach

The presentation

Imagine an adult who has cut a deep gash across their forearm on broken glass. Bright red blood is flowing steadily and soaking through a tea towel pressed over it. They look pale and are starting to feel dizzy and clammy. This is a picture of major external bleeding — blood loss that will not stop on its own and that can become life-threatening if it continues. Now picture a different person who has a small graze that oozes a little and stops within a minute or two of gentle pressure. The skill in an emergency is telling these two stories apart quickly: minor bleeding needs only simple cleaning and a plaster, while major bleeding needs firm, sustained action and, often, an ambulance.

First aid: pressure and elevation

For serious bleeding, the single most important thing you can do is press hard on the wound. Use a clean cloth, dressing or even your gloved hand, and push down firmly and continuously over the bleeding point — do not keep lifting off to look. If blood soaks through, add more padding on top rather than removing what is already there, and keep pressing. Where possible, raise the injured limb above the level of the heart, as this helps slow the flow. Help the person sit or lie down to reduce the risk of fainting. Keep pressure on until the bleeding stops or the ambulance crew take over. Firm, unbroken pressure controls the large majority of external bleeding.

When to call 999

Call 999 straight away if bleeding is heavy and does not slow after a few minutes of firm pressure, if blood is spurting or pumping out, if the wound is deep, large or gaping, or if there is a serious injury such as a stab wound, a road accident or a fall from height. Also call 999 if the person becomes pale, cold, clammy, drowsy, confused or short of breath, as these can be signs of dangerous blood loss and shock. Do not wait to see if things settle. While you wait, keep pressing on the wound, keep the person warm and lying down, and reassure them. If a limb has been severed, keep firm pressure on the stump and preserve the severed part for the crew.

Hidden and internal bleeding

Not all serious bleeding is visible. Bleeding inside the body — after a heavy blow, a fall or a car crash — can be just as dangerous even when little or no blood is seen outside. Warning signs include worsening pain, swelling or bruising over the abdomen or a limb, feeling faint, a racing heart, pale clammy skin, or vomiting or coughing up blood, or passing black tarry stools. People taking blood-thinning medicines bruise and bleed more easily and can bleed heavily from what looks like a minor knock, so any significant bleed or head injury in someone on these medicines should be taken seriously. If internal bleeding is suspected, call 999, keep the person still and warm, and do not give food or drink in case they need surgery.

The safe pathway

The practical rule is simple. Small cuts and grazes that stop with a couple of minutes of pressure can be cleaned under running water, dried and covered with a plaster or dressing at home; check tetanus cover and watch for signs of infection over the following days. Bleeding that is heavy, will not stop, spurts, follows a serious injury, or comes with faintness, drowsiness or clammy pale skin is an emergency — call 999 and keep pressing. A wound that is deep, gaping, dirty, over a joint, or from a bite or a rusty or dirty object may need medical assessment, stitching or antibiotics even if the bleeding has stopped, so contact NHS 111 or an urgent treatment centre.