Acute haemorrhage is rapid blood loss in a volume that threatens oxygen delivery to the organs. It may be visible from a wound, or come from a natural orifice as heavy nosebleed, vomited blood, black or bloody stool, heavy uterine bleeding, or bleeding after childbirth or surgery, and it may be hidden inside the body after trauma, a ruptured cyst or an ectopic pregnancy. Treating it is a race against time, not something to postpone. Severity is not judged by the amount of blood on the floor alone. Watch for signs that the circulation is running short: pallor, cold clammy skin, sweating, a fast pulse, dizziness on sitting or standing, intense thirst, rapid breathing, restlessness and then drowsiness and confusion. In children, older adults and people on heart medication these signs may appear late and then deteriorate quickly. **Do not wait for them before acting: call emergency services on 911 for any heavy bleeding, any bleeding that does not stop with pressure, any of these signs, or after a forceful injury even when no blood is visible.** The first treatment is firm, continuous direct pressure over the bleeding point with clean gauze or cloth for several minutes without lifting it to look, together with elevation of the limb. If severe limb bleeding continues despite pressure, a purpose-made tourniquet may be applied above the wound, tightened until bleeding stops, and the time of application recorded. Do not tie the limb with rope, wire or hose, do not pull out an impaled object, and do not remove blood-soaked gauze; add more on top and keep pressing. For nosebleeds, lean forward and pinch the soft part of the nose continuously for 10 to 15 minutes, and do not tilt the head back. In the emergency department two tracks run at once: stopping the source and replacing what has been lost. One or more intravenous lines are placed, blood is drawn for tests and for blood grouping and cross-matching, fluids and blood products are given according to the situation, a medicine that reduces clot breakdown may be given early in traumatic bleeding, and the effect of blood thinners is reversed or adjusted in patients taking them. Stopping the source may involve suturing or a pressure dressing, therapeutic endoscopy for gastrointestinal bleeding, interventional catheter embolisation of an artery, an operation, or specific drugs and manoeuvres for postpartum haemorrhage. The limits of what can be done outside hospital are explicit. Controlling visible bleeding does not stop internal bleeding; a tourniquet is a temporary life-saving measure and not definitive treatment; and bleeding that has stopped does not mean the danger has passed, because it can restart hours later. There is no home remedy for internal bleeding, and rapid ambulance transfer is the treatment. Never apply soil, coffee, toothpaste or herbal powders to a wound: they do not stop bleeding, they cause infection, and they make later wound cleaning and surgery harder.
Procedure steps
- 1
Call for help and apply direct pressure
Call emergency services on 911 first, then apply firm continuous pressure over the bleeding point with clean gauze or cloth and elevate the limb. Do not keep lifting the gauze to inspect the wound; add another layer on top if it soaks through. Lay the person flat, keep them warm, and give nothing by mouth if they are confused, vomiting or may need an operation.
- 2
Primary survey and securing the circulation
In the emergency department airway, breathing and circulation are assessed in order, vital signs are measured, one or more intravenous lines are placed, and blood is taken for tests, grouping, cross-matching and clotting studies. Fluids and blood products are given according to the loss and the response, and the patient is kept warm because hypothermia worsens clotting.
- 3
Identifying the source of bleeding
The source is sought clinically and then with appropriate tools: rapid ultrasound of the abdomen and chest after trauma, computed tomography when the patient is stable, upper endoscopy for vomited blood or black stool, and pelvic examination with ultrasound for uterine bleeding or suspected ectopic pregnancy. If the patient is unstable, the decision may be to go straight to the operating theatre.
- 4
Stopping the bleeding
The method is chosen by source: pressure dressing, suturing or vessel ligation; endoscopic clipping, injection or cautery for gastrointestinal bleeding; interventional catheter embolisation; urgent surgery; or specific drugs and manoeuvres for postpartum haemorrhage. If a tourniquet has been used it is a temporary measure, released only where surgical control is possible.
- 5
Correcting clotting, monitoring and treating the cause
Clotting abnormalities and low platelets are corrected, the effect of blood thinners is adjusted by the treating physician, and the patient is monitored for hours or admitted, because bleeding can recur. The underlying cause is then treated, whether an ulcer, varices, uterine fibroids, a clotting disorder or a tumour, along with a plan to correct anaemia and prevent recurrence.
Before the procedure
This is an emergency with no preparation, but what you do in the first minutes is part of the treatment. **Call emergency services on 911 immediately**, then press hard and continuously over the bleeding point with clean gauze or cloth, elevate the injured part, lay the person down and keep them warm. Give no food or water if they are confused, vomiting blood, or may need an operation. Do not pull out an impaled object, do not tie the limb with rope or wire, and do not apply household substances to the wound. If the bleeding is uterine or after childbirth, keep the soaked pads so the volume can be estimated, and note the colour of blood in vomit or stool. Tell the treating team about blood thinners or antiplatelet drugs, liver or kidney disease and clotting disorders, when the patient last ate, and any possibility of pregnancy.
After the procedure
Complete the period of observation set by your doctor, because bleeding can restart after it has stopped. Take iron and treat anaemia as prescribed, rest from exertion and heavy lifting in the first days, and drink enough fluids. Do not restart blood thinners or anti-inflammatory painkillers on your own; that decision belongs to the doctor who stopped them. Complete the plan that treats the cause, whether a follow-up endoscopy, gynaecological assessment, ulcer treatment or testing for a clotting disorder. **Return to the emergency department immediately if you develop: recurrent bleeding or a dressing that soaks quickly, dizziness or fainting or a racing pulse, pallor with cold sweaty skin, breathlessness or chest pain, vomited blood or black tarry stool, increasing abdominal pain or distension, or vaginal bleeding soaking a full pad in under an hour.** Tell any doctor you see later that you had an acute haemorrhage and what blood products you received.
Expected duration
Initial control begins within the first minutes; most cases of acute haemorrhage then need several hours of monitoring or hospital admission depending on the source and volume lost.
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