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EMS Resources

Trauma Injury: Bleeding & Soft Tissue Injuries

Level 2

Bleeding and Soft Tissue Injury EMT Refresher Course EMSNeeds.com Continuing Education

Overview | Assessment | Treatment | Roles


Bleeding and Soft Tissue Injury EMT Refresher Course

In this Bleeding and Soft Tissue Injury course you will earn 2 CE hours. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

  • Differentiate between arterial, venous, and capillary bleeding.
  • State the emergency medical care for external bleeding.
  • List the signs of internal bleeding.
  • List the steps in the emergency medical care of the patient with signs and symptoms of internal bleeding.
  • State the types of open soft tissue injuries.
  • Describe the emergency medical care for burns.
  • Describe the emergency medical care for an impaled object.
  • Explain the rationale for body substance isolation when dealing with bleeding and soft tissue injuries.[/1]]

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!

EMS Course Levels

Trauma is the leading cause of death in the United States in persons between the ages of 1 and 44. Traumatic injuries and bleeding are some of the most dramatic situations that the First Responder will encounter. The early control of major bleeding has great life saving potential.

Soft tissue injuries are common and dramatic, but rarely life threatening. Soft tissue injuries range from abrasions to serious full thickness burns. It is necessary for the First Responder to become familiar with the emergency medical care of soft tissue injuries with emphasis on controlling bleeding, preventing further injury, and reducing contamination.

Practice BSI when there is bleeding involved.

The First Responder must be aware of the risk of infectious disease from contact with blood or body fluids. The severity of blood loss must be based on the patient's signs andsymptoms and the general impression of the amount of blood loss.The body's normal response to bleeding is blood vessel contractions and clotting. A serious injury may prevent effective clotting from occurring. Uncontrolled bleeding or significant blood loss leads to shock and possibly death. Bleeding may be external or internal.Internal and external bleeding can result in severe blood loss with resultant shock and subsequent death.



  • BSI - Body Substance Isolation.
  • Arterial Bleeding - spurts; oxygen-rich; bright red.
  • Venous Bleeding - steady stream; oxygen-poor; dark red.
  • Capillary Bleeding - oozes; oxygen-poor; dark red; clots easily.
  • Shock (hypoperfusion) - Condition resulting from the inadequate delivery of oxygenated blood to body tissues.
  • Eviscerations -open injuries with protruding organs.[/1]]
Emergency Stop

Assessment of bleeding and soft tissue injuries involves completing:

  1. Scene size-up before initiating emergency medical care.
  2. Initial assessment on all patients.
  3. Physical exam as needed.
  4. On-going assessments.

Identify the type of external bleeding by looking for these signs and symptoms:

  • Arterial - The blood spurts from the wound. It is bright, red, oxygen-rich blood. Arterial bleeding is the most difficult to control because of the pressure at which arteries bleed. As the patient's blood pressure drops, the amount of spurting may also drop.
  • Venous - The blood flows as a steady stream. It is dark, oxygen-poor blood. Bleeding from a vein can be profuse; however, in most cases it is easier to control due to the lower venous
  • Capillary - The blood oozes from a capillary and is dark red in color. The bleeding often clots spontaneously.

Assess if there is any internal bleeding by looking for these signs and symptoms:

  • Injured or damaged internal organs commonly lead to extensive bleeding that is concealed.
  • Painful, swollen, deformed extremities may also lead to serious internal blood loss.
  • Signs and symptoms
    • Discolored, tender swollen or hard tissue
    • Increased respiratory and pulse rates
    • Pale, cool skin
    • Nausea and vomiting
    • Thirst
    • Mental status changes
    • Shock
      • Extreme thirst
      • Restlessness, anxiety
      • Rapid, weak pulse
      • Rapid, shallow respirations
      • Mental status changes
      • Pale, cool, moist skin

Identify specific injury types:

  • Abrasions are on the outermost layer of skin is damaged by shearing forces. These may be painful injuries, even though superficial. There is often very little or no oozing of blood.
  • Lacerations break the skin in varying depths and may occur in isolation or together with other types of soft tissue injuries. These are often caused by forceful impact with sharp object and the bleeding may be severe.
  • Penetration/puncture wound is caused by a sharp pointed object where there may be little or no external bleeding. However, the internal bleeding may be severe. Exit wounds may be present. Examples are gunshot wounds or stab wounds.
  • Burns
    • Burns Classified According to Depth:
      • Superficial burns involve only the outer layer of the skin causing redding of the skin and swelling.
      • Partial thickness involves the outer and middle layer of the skin and the pain is deep and intense with reddening and blisters.
      • Full thickness extends through all layers of the skin and has the same characteristics of partial thickness with the addition of areas of charred skin.
    • Special Burn Considerations:
      • Chemical burns - Remember scene safety to defend yourself with gloves and eye protection. Brush off dry powder and flush with copious amounts of water. Consider eye burns if it is a splash injury.
      • Electrical burns - Take specific scene safety precautions as these are often more severe than external characteristics indicate. Monitor the patient closely for respiratory or cardiac arrest.
      • Infant and child considerations - Remember that there is a greater surface area in relation to the total body size. This results in greater fluid and heat loss. You may need to keep the environment warm when possible. Also consider possibility of child abuse.[/1]]
Scene size-up

Bleeding Control

  • Apply finger tip pressure (use flat part of fingers) directly on the point of bleeding.
  • If no injury to the muscle or bone exists, elevation of a bleeding extremity may be used secondary to and in conjunction with direct pressure. Large gaping wounds may require sterile gauze and direct hand pressure if finger tip pressure fails to control bleeding. If bleeding does not stop, remove dressing and assess for bleeding point to apply direct pressure. If more than one site of bleeding is discovered, apply additional pressure. Pressure points may be used in upper and lower extremities.

Comfort, calm, and reassure the patient while awaiting additional EMS resources.

  • Use body substance isolation.
  • Maintain airway/artificial ventilation.
  • Manage any external bleeding.
  • Reassure the patient.
  • Keep the patient calm and in position of comfort.
  • Keep the patient warm.

Treat for shock.

  • :Shock: (hypoperfusion) is a condition resulting from the inadequate delivery of oxygenated blood to body tissues. It can be a result of failure of the heart to provide oxygenated blood, abnormal dilation of the vessels, or blood volume loss.
  • Keep patient warm and attempt to maintain normal body temperature.
  • Do not give food or drink if the patient is in shock.
  • Provide care for specific injuries.

Dressing and Bandaging

  • The function of dressing and bandaging is to stop the bleeding and protect the wound from further damage while preventing further contamination and infection.
  • The universal dressing is often a 4 X 4 inch, occlusive, adhesive-type gauze pad. Bandages hold the dressing in place may be self-adherent, gauge rolls, triangular, adhesive tape, or a combination of these.
  • Manage open soft tissue injuries.
  • Expose the wound to control the bleeding and prevent further contamination.
  • Apply sterile dressing to the wound and bandage securely in place.

Special Considerations

  • Chest injuries - Apply an occlusive dressing to open wounds and seal on three sides. Lay the patient in a position of comfort if no spinal injury is suspected.
  • Impaled objects - Do not remove the impaled object unless it is through the cheek or it might interfere with airway management or chest compressions. Manually secure the object. Expose the wound area. Control bleeding. Utilize a bulky dressing to help stabilize the object.
  • Eviscerations are open injuries with protruding organs. Do not attempt to replace protruding organs. Instead, cover with thick moist dressing.
  • Amputations involves the extremities and other body parts. Massive bleeding may be present or bleeding may be limited. Locate and preserve the amputated part. Place the part in a plastic bag. Place the plastic bag containing the part in a larger bag or container with ice and water. Do not use ice alone. Do not use dry ice.


  • Stop the burning process initially with water or saline.
  • Remove smoldering clothing and jewelry. Be aware that some clothing may have melted
    to the skin. If resistance is met when removing the clothing, leave it in place.
  • Prevent further contamination.
  • Cover the burned area with a dry sterile dressing.
  • Do not use any type of ointment, lotion, or antiseptic.
  • Do not break blisters.[/1]]

Blood circulation









Roles and Responsibilities
  1. Complete a scene size-up before initiating emergency medical care.
  2. Complete an initial assessment on all patients.
  3. Complete a physical exam as needed.
  4. Complete on-going assessments.
  5. Comfort, calm, and reassure the patient while awaiting additional EMS resources.
  6. Maintain airway/artificial ventilation.
  7. Prevent further blood loss.
  8. Keep patient warm and attempt to maintain normal body temperature.
  9. Do not give food or drink if the patient is in shock.
  10. Provide care for specific injuries.

Be aware of the implications of not using body substance isolation precautions. Use proper gloves, gown, and eye protection. Wash your hands before and after contact with those needing help. For more information, take the Bloodborne Pathogens course.

External bleeding is assessed during the initial patient assessment after securing the scene and ensuring personal safety. After airway and breathing control of arterial or venous bleeding will be done upon immediate identification. Soft tissue injuries, unless life threatening, will be treated after the initial assessment. Failure to treat soft tissue injuries could lead to severe bleeding, further damage to the injury, or further contamination. [/1]]

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