Surgical Critical Care,  Trauma Surgery

The Five Letters on Which Trauma Stands – Part 4

Letter C – Circulation with Hemorrhage Control

Remember: That is not your blood!

After having managed the first two points of the primary survey, you must check for the main cause of hemodynamic instability in trauma patients: bleeding.

The main questions you need to ask yourself during this phase are:

  1. Is the patient bleeding externally? If yes, stop the bleed
  2. Is the patient bleeding internally? If yes, treat appropriately
  3. Is the patient hemodynamically unstable? If yes, resuscitate

Remember the most important sources of bleeding, follow the riddle:

“blood on the floor, and 4 more”

This means that you must evaluate if patients are actively and massively bleeding externally (i.e. “blood on the floor”), and if they have any injury to the 4 major areas of internal hemorrhage (i.e. “4 more”), which are the chest, abdomen and retroperitoneum, pelvis, and long bones.

External Bleeding

The external hemorrhages are usually managed during prehospital care (if there is one). 

The possible treatments are direct compression to the wound, compressive bandages/packing, or tourniquets.

Those are usually effective in stopping the external bleeding (see the stop the bleed campaign).

Please do NOT try to blindly clamp a bleeding vessel, your maneuver may create more harm and you will lose precious time. Use a tourniquet instead.

If you decide or have to go for a tourniquet, ALWAYS check for a distal arterial pulse after the positioning. If you feel it, your tourniquet is loose; tighten it until the pulse disappears. The problem of not tightening enough the tourniquet is that the venous supply will be stopped, but not the arterial one. The blood will continue to flow distally and won’t be able to return, increasing your patient’s bleeding rate from the wound. 

When you apply the tourniquet ALWAYS  write down the date and time! From that moment you have a maximum of 6 h to solve the problem and release it. The less it remains in situ the better. When you decide to untighten it, do not remove the tourniquet unless you’re in a safe environment (an operating room ready for the hemostasis). 

A tourniquet in an awake patient will be painful: use adequate painkillers!

Internal Hemorrhage

The evaluation of internal bleeding can rely on clinical examination!

  • Chest: there are 3 possible sources of bleeding inside the chest: pleural cavity (i.e. lungs and chest wall), heart, and large mediastinal vessels.
    Lungs and chest wall bleeding should have been already encountered during the “B assessment”. However, always check the chest wall for fractures. In about 85% of cases, the only treatment needed is a chest tube.
    Heart and pericardial bleeding may result in cardiac tamponade. Clinical suspicion of cardiac tamponade may be posed if the patient manifests the Beck’s triad (i.e. jugular veins distention, hypotension, and muffled heart sound). This condition mandates immediate release if the patient is unstable. Clinical signs may not be there though, so help yourself with the ultrasound.
    It is basically impossible to clinically diagnose an injury to one of the large mediastinal vessels. For this purpose, a high index of suspicion based on the mechanism of injury and the imaging (i.e. chest x-ray and eventually a CT scan) will help.
  • Abdomen and retroperitoneum: abdominal tenderness must always be excluded. An additional help will come from the ultrasound (i.e. E-FAST). The diagnostic peritoneal lavage is on disuse thanks to the large availability of ultrasounds machines. The ghost spot will be the retroperitoneum, as per the mediastinal vessel a high index of suspicion will help. However, retroperitoneal bleedings usually limit on their own. CT scan is helpful in this setting, provided that the patient is stable enough to undertake it.
  • Pelvis: pelvic fracture is an extremely serious condition that may lead rapidly to catastrophic hemorrhages. A pelvic fracture may cause a blood loss of at least 1.5 L. An evaluation of pelvic stability is of great importance: a gentle pressure on the anterior-superior iliac spine may evoke pain and manifest the instability. Perineal and scrotal ecchymosis, as well as bleeding from the urethra and/or the rectum, may be signs of pelvic fracture.
    When a patient with a suspected pelvic fracture is in shock, a pelvic binder must be immediately used. Remember that, similarly to the tourniquet, a pelvic binder in place is painful. A badly placed pelvic binder is of no use or, worse, harmful. As per the tourniquets, when in place do NOT remove the binder!

Pelvic x-ray is important in this setting to confirm the fracture and, eventually, characterize it (e.g. open book, vertical shear…) and decide the proper surgical treatment/stabilization.

  • Long bones: basically this includes femoral fractures, which may determine a blood loss of approximately 500-750 mL per limb. Fracture reduction and splinting of the limb is the only procedure to do at this point, allowing to reduce blood loss, pain and the risk of compartment syndrome.
Hemodynamic Status

The rapid assessment of the patient’s hemodynamic status may be obtained using some clinical elements:

  • Level of consciousness: if systemic and cerebral perfusion is impaired, the level of consciousness may be altered (remember that we have already checked this during the airway assessment);
  • Skin color and perfusion: look if the patient is pale, and check the capillary refill (it should be <2 sec);
  • Pulse: tachycardia may be the first sign of hemorrhagic shock, even if the systolic blood pressure (SBP) is normal or only slightly reduced. Moreover, if you cannot feel the radial pulse, that means the patient’s SBP is less than 90 mmHg.

At this point, if not yet in place, at least 2 large-bore IV lines (at least 18 G) should be inserted. The lines must be large and short for the following four reasons: 

  • Poiseuille’s law: larger the cannula, higher the flow, faster the administration of fluids;
  • Using smaller lines (20 G or less), there is a higher rate of hemolysis during the blood transfusions;
  • With smaller lines (20 G or less) the flow may not be enough to administer IV contrast during imaging exams (i.e. contrast-enhanced CT scan);
  • It is more stable, with a lower risk of kinking or malfunctioning.

If it is not possible to find a good peripheral vascular access, an intraosseous access must be obtained. Once the line is in place, blood must be collected for blood gas, lactate level, blood cell count, routine biochemistry, blood type and crossmatch, and, in women, pregnancy test.

As you should have noticed, according to Poiseuille’s law, a “regular” central line (small caliper and long tube) is NOT a resuscitative line! On the other hand, the use of a sheath introducer (short and large) could be an alternative if the intraosseous line will fail. 

1. Syringe with local anesthetic
2. Scalpel
3. Sterile gel for US guidance
4. Introducer needle on syringe with saline to detect backflow of blood upon vein penetration
5. Guide wire
6. Dilator
7. Indwelling catheter
8. Additional fasteners, and corresponding surgical thread

Ideally, the way you should follow is:

  • Peripheral line;
  • Intraosseous access;
  • Central line or sheath introducer;
  • Venous cut-down.

For each access, you have two attempts, then you must switch to the next type of access. As you can imagine, the time needed to insert a vascular access increases as you try a more advanced one. You start with the quickest and end with the most complex.

A urinary catheter should be inserted to monitor urine output, which reflects renal, and consequently, systemic perfusion in the long time. An acceptable urinary output is 0.5-1 mL/kg/h. Care must be taken if the patient has a pelvic fracture and/or blood from the urethra, meaning a high risk of urethral injury. In these conditions, a normal urinary catheter may worsen the urethral injury (one gentle try is acceptable, but nothing more). Therefore, think if you really need it now, and if the answer is yes, a suprapubic catheter may be preferable.

A rapid infusion of warmed (37-40°C) crystalloids must begin immediately in shocked patients. Remember that this bolus must not exceed 500-1000 mL. If the patient does not respond appropriately to this volume, administration of blood products should start as soon as possible.

After this first bolus you have to understand if your patient is a “responder” or a “non-responder”. The first type is the one with no ongoing hemorrhage that you can study, the second one has massive ongoing bleeding somewhere that you have to find and treat as soon as possible (“put a finger on the bleeding hole”). Be extremely careful about the responders, because among them you’ll find the “transient responders”: patients that get better after your first line treatments but than splashes while they are in CT (be always with your patients until you’re sure about their physiology). During your stay with the patient start thinking about his/her hemodynamically/physiologically state, because your long term decisions will be based on it.

When facing a massively bleeding patient prepare fluid (no more than 1 L, as we said before) and get ready with blood products! If you have enough information from the prehospital team, before the patient arrives, ask immediately for blood and activate the massive transfusion protocol, provided that your hospital has one. 

As a wise Soweto’s anesthetist once said: “they lose blood, they need blood!”

The concept of reducing the liquids to the minimum stands in not dilute the patient. This will lead to coagulopathy and more bleeding. What you want to avoid is the patient entering in the lethal triad (i.e. coagulopathy, acidosis, and hypothermia). Once it is initiated, the patient’s recovery will be extremely difficult! Thus, you have to start treating them as soon as the patient enters your ED!

Very interesting information should also come from the patient ABG (arterial blood gas). You should seek for pH, lactates, and BE (base excess). A metabolic acidosis is what you’ll find in a bleeding patient: vasoconstriction and hypovolemia will cause a switch to an anabolic metabolism leading to a production of lactates creating the acidotic status. Remember you may have a “stable patient” if you only look at the vitals, but if he/she has a very deranged ABG (e.g. pH 7.23, Lactate 12, BE -15), the overall physiology of our patient is NOT STABLE at all! Don’t be so foolish to underestimate a patient like this! 

On purpose we are not speaking about the coagulopathy and the specific treatments, otherwise this post would last as the book “War and peace”. Take home these few concepts and integrate them into your mindset. 


  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
  2. Peitzman AB, et al. The Trauma Manual: trauma and acute care surgery; 4th Ed. Philadelphia, PA: Lippincott; 2013.
  3. European resuscitation Council and European Society for Trauma and Emergency Surgery. European Trauma Course: the team approach.
How to Cite This Post

Marrano E, Bellio G. The Five Letters on Which Trauma Stands – Circulation. Surgical Pizza. Published on June 18, 2020. Accessed on January 15, 2023. Available at [].


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