Overview: Bleeding, Wounds & Burns
Bleeding is the most preventable cause of death in trauma. This lesson covers hemorrhage control—the most critical wilderness first aid skill—and wound management to prevent infection and promote healing. It also covers burns: on our trips, exhaust-pipe contact, campfire and stove mishaps, and sun exposure make burns one of the most common soft-tissue injuries you will actually treat.
Critical: Exsanguinating hemorrhage (X in XABCDE) is treated BEFORE airway. Control massive bleeding immediately.
Hemorrhage is the Priority
- Massive arterial bleeding can kill in under five minutes — faster than most airway problems develop
- Shock from bleeding kills faster than airway obstruction in many trauma cases
- Hemorrhage control is the skill that saves the most lives in wilderness trauma
Key Points
Direct pressure and time controls most bleeding
Obviously life-threatening extremity bleeding gets a tourniquet immediately — don't wait for pressure to fail
Hemostatic agents (QuikClot, Combat Gauze) enhance clotting in wounds
Wound irrigation is the most important step in wound care
Don't close bite wounds or punctures — infection risk too high
Cool burns with cool (not ice-cold) running water for 10-20 minutes — never ice
Any airway/inhalation involvement with a burn (singed nasal hair, hoarseness, sooty sputum) = EMERGENT evacuation
Hemorrhage Control
Types of Bleeding
- Arterial (Bright Red, Pulsatile): Oxygen-rich blood from arteries. Bright red color, pulsatile flow (spurts with heartbeat). LIFE-THREATENING — urgent control needed.
- Venous (Dark Red, Steady): Deoxygenated blood from veins. Darker red color, steady flow. Still serious but usually controlled more easily than arterial.
- Capillary (Oozing): Slow ooze from small vessels in skin. Usually stops on its own with direct pressure.
Direct Pressure: The Gold Standard
- Technique: Apply firm continuous pressure with gloved hands and clean cloth/gauze directly on wound
- Duration: Minimum 10 minutes of continuous pressure without peeking. Seriously — don't lift to check if bleeding stopped.
- If bleeding continues: Add more dressing layers on top (do NOT remove first layer, as this disrupts clotting). Keep pressure on.
- Re-bleeding: If bleeding resumes after pressure released, reapply direct pressure for another 10 minutes
- Escalation sequence: Direct pressure → wound packing → tourniquet. (Elevating the limb is no longer taught as a bleeding-control step.)
Do NOT peek: Lifting the dressing disrupts clot formation. Keep pressure on for the full 10 minutes.
Pressure Dressing
- After bleeding controlled, apply elastic bandage (ACE wrap or similar) over gauze pads
- Maintains constant pressure to keep clot intact
- Allows continued activity with some protection
- Monitor for signs of too-tight bandage: cold fingers/toes, numbness, tingling, color changes
Tourniquet Application
When to use: For obviously life-threatening extremity hemorrhage (bright red/pulsatile bleeding, blood pooling rapidly, patient becoming shocky), apply a tourniquet IMMEDIATELY — do not wait for direct pressure to fail. Direct pressure is for bleeding that is not clearly life-threatening, or to buy time while the tourniquet is being readied.
- Indication: Obviously life-threatening bleeding from an arm or leg (tourniquet FIRST), or extremity bleeding that direct pressure fails to control
- Location: Apply 2-3 inches ABOVE the wound, NOT on the joint
- Tightness: Tighten until bleeding stops completely AND the pulse below the tourniquet (distal pulse) is gone
- If bleeding continues: Apply a second tourniquet just above/beside the first
- Document time: Write application time directly on patient's skin (forehead works) or tourniquet
- DO NOT remove in field: Once applied, leave it. Risk of massive re-bleeding if loosened.
- Types: Commercial tourniquets (CAT, SOFTT-W) are more effective than improvised
Improvised Tourniquet
- Use minimum 2-inch wide material (belt, rolled cloth)
- Windlass technique: wrap around limb above wound, place stick through loop, twist to tighten
- Less effective than commercial but can work in emergency
- Document time clearly
Don't hesitate: Tourniquets are safe in place for at least 2 hours. Fear of tissue damage should never delay application — a patient can bleed to death while you wait for pressure to work. Use tourniquets when indicated.
Wound Packing: Junctional Hemorrhage
When to use: Wounds in areas where tourniquets cannot be applied (groin/inguinal crease, axilla)
- Technique: Tightly pack clean gauze into the wound
- Maintain pressure: Don't just stuff gauze and leave — maintain constant pressure
- Hemostatic gauze preferred: Gauze impregnated with kaolin or chitosan enhances clotting
- Duration: At least 3 minutes of sustained pressure with hemostatic gauze; plain gauze needs about 10 minutes of sustained pressure
- Dressing: Once bleeding controlled, leave packing in place with pressure dressing over it
- NEVER pack: Chest or abdominal wounds — packing does not reach the bleeding and delays care. Neck wounds get sustained direct pressure only, never packing.
Hemostatic Agents
- What they do: Gauze impregnated with clotting agents (kaolin, chitosan) enhances body's natural clotting
- Products: QuikClot, Combat Gauze — commonly found in wilderness first aid kits
- Application: Pack tightly into wound with sustained pressure
- Dwell time: Hold pressure for at least 3 minutes
- Removal: Can be rinsed out but often left in place for transport
Epistaxis (Nosebleed)
- Position: Lean FORWARD (not back as old instruction said) to prevent blood draining down throat
- Pressure: Pinch soft part of nose (below bone) firmly
- Duration: 10-15 minutes continuous pressure
- Cold compress: Apply ice/cold compress to bridge of nose and face
- After control: Avoid blowing nose, strenuous activity for hours
- When to evacuate: If continues >20 min with pressure, or heavy recurrent bleeding, evacuate for medical evaluation
Wound Care & Infection Prevention
Wound Assessment
- Mechanism: How was the wound created? (Clean cut, crush, contamination level?)
- Depth: Superficial (epidermis), partial thickness (dermis), full thickness (into subcutaneous)
- Contamination: Clean (surgical), clean-contaminated, contaminated (soil, feces), dirty/infected
- Neurovascular status: Is blood supply intact distal to wound? Sensation normal?
- Time elapsed: How long since injury? Affects infection risk (>8 hrs = higher infection risk) — note it and report to the receiving clinician
Wound Types & Management
Abrasion (Road Rash)
- Shallow scraping of skin surface
- Clean thoroughly: This is the most important step. Remove all dirt/debris. Use brush if available.
- May be painful without anesthesia — local numbing spray can help if available
- Dress with antibiotic ointment and sterile gauze
Laceration (Clean Cut)
- Relatively clean wound edges
- Irrigate and clean thoroughly
- Dress and keep clean
- Gaping wounds will be evaluated for closure at a clinic — evacuate wounds that need closure
Puncture Wound
- Small entrance, deep penetration
- HIGH infection risk: Deep environment favors anaerobic bacteria (tetanus)
- DO NOT close: Closure traps infection deep in wound
- Encourage bleeding/drainage to flush wound
- Soak in warm water if possible to promote drainage
- Tetanus prophylaxis needed if contaminated (soil, animal matter)
Avulsion (Tissue Flap)
- Tissue torn and partially detached
- If tissue is attached, return to normal position if possible
- If tissue is completely removed, save it (may be reattachable) in clean moist container
- Irrigate wound, cover loosely (don't close tightly)
- Urgent evacuation for surgical evaluation
Crush Wound
- Tissue crushed from blunt force
- Contaminated and high infection risk
- DO NOT close: High infection risk
- Clean and dress, monitor for signs of infection
Wound Irrigation: The Most Important Step
Principle: Clean wounds are less likely to get infected
- Volume: At least 500 mL - 1 L for dirty wounds. Keep going until the wound is visibly clean.
- Pressure: Moderate-pressure irrigation works best — a 20-60 mL syringe, or a squeeze bottle with a pinhole in the cap.
- Solution: Clean drinking water is effective. Sterile saline ideal if available.
- What NOT to use: DO NOT irrigate with hydrogen peroxide or iodine in wound bed. These damage tissue and kill healing cells.
- Scrubbing: Gentle cleaning with gauze or brush to remove debris. Avoid vigorous scrubbing that damages tissue.
Key: Clean water irrigation is more effective than any antiseptic solution at preventing infection.
Wounds That Need Closure
Field approach: Wound closure is a clinical decision made at a clinic or hospital — not in the field. Your job: clean the wound thoroughly, dress it, keep it clean, and evacuate wounds that need closure. A gaping wound will be evaluated for closure by a clinician.
Red flags — these wounds must always be seen by a clinician:
- Bite wounds (dog, cat, human) — high infection risk
- Puncture wounds — infection risk from anaerobes
- Heavily contaminated wounds (soil, feces)
- Older wounds (many hours since injury)
- Signs of infection already present
Dressing
- Sterile gauze: Use clean/sterile gauze to cover wound
- Non-adherent: Use non-stick gauze to avoid disturbing healing tissue when changing dressing
- Cover completely: Entire wound should be covered to keep dirt out
- Change frequency: Daily or whenever wet/soiled
- Observation: Check for signs of infection with each dressing change
Infection Signs & Evacuation
- Cellulitis: Redness expanding beyond wound edges, warmth, increasing pain
- Purulent discharge: Pus draining from wound
- Lymphangitis: Red streaks extending from wound (traveling toward heart) — SERIOUS, indicates systemic infection
- Fever: Systemic infection sign
- Swollen lymph nodes: Near wound (armpit for arm wound, groin for leg wound)
Red streaks from wound (lymphangitis) = urgent evacuation. This indicates infection traveling toward heart.
Tetanus & Animal Bites
- Tetanus risk: Any wound contaminated with soil, feces, or animal matter. Check patient's vaccination status.
- Booster needed if: >5 years since last tetanus (if dirty wound), >10 years (if clean wound)
- Animal bites: Wash immediately and aggressively. High infection risk (Pasteurella bacteria). Rabies risk assessment required. Report to public health.
- DO NOT close animal bites: Even "minor" bites should not be closed due to infection risk
Internal Bleeding
Recognition of Internal Bleeding
Challenge: Internal bleeding is not visible but can cause massive blood loss
- Abdominal signs:
- Rigid/board-like abdomen (sign of peritoneal irritation)
- Distension (swelling)
- Bruising over abdomen
- Grey-Turner sign: bruising on flanks (sides)
- Cullen's sign: bruising around umbilicus (belly button)
- Note: Grey-Turner and Cullen's signs are DELAYED findings (hours), so absence early doesn't rule out bleeding
- Other signs:
- Blood in stool (dark/tarry = upper GI bleeding, bright red = lower GI)
- Blood in urine
- Vomiting blood (hematemesis)
- Shock without external bleeding: Think internal bleeding. Signs: pale, cool, diaphoretic skin; rapid pulse; weak pulses; confusion
Field Treatment of Internal Bleeding
- Position: Supine (flat). Do not elevate the legs — routine leg elevation is no longer taught.
- Keep warm: Prevent hypothermia which worsens shock
- Nothing by mouth: Patient may need surgery; NPO (nothing by mouth) reduces aspiration risk
- Urgent evacuation: No field treatment will stop internal bleeding. Get to hospital.
- Monitor: Watch for deterioration; repeat vitals every 5 minutes if unstable
Specific Internal Bleeding Scenarios
Aortic Rupture/Aneurysm
- Signs: Severe tearing pain in back or abdomen, shock, elderly patient
- Prognosis: Extremely high mortality even with surgery
- Treatment: Immediate evacuation (helicopter if available)
Pelvic Fracture
- Pelvis has large blood vessels; fracture can cause massive internal bleeding
- Your actions: Suspect from mechanism (high fall, crush, high-energy impact). Do NOT press on or "stress" the pelvis. Keep the patient still. Evacuate EMERGENTLY.
- For reference: EMS providers may apply a pelvic binder to stabilize the pelvis and reduce bleeding
Burns
Burns are a fact of life on motorcycle and river trips: a bare calf against an exhaust header, a flaring camp stove, a spilled pot of boiling water, or a full day of sun on the water. Most are manageable in the field — the skill is cooling them properly, dressing them simply, and recognizing the ones that must be evacuated.
Stop the Burning
- Remove from the source: Extinguish flames (stop-drop-roll if clothing is on fire), pull the patient away from the exhaust pipe, stove, or fire. Get sunburned patients into shade.
- Remove jewelry and loose clothing EARLY: Rings, watches, and bracelets come off before swelling starts — a ring on a burned finger becomes a tourniquet. Remove boots/socks and non-adherent clothing around the burn.
- NEVER peel off melted or stuck fabric: Synthetic riding gear and fleece melt into the burn. Cool over it and cut around it — leave adhered material in place for the clinician.
Cool the Burn
- Cool running water, 10-20 minutes: Cool (not ice-cold) water as soon as possible. This is the single most effective burn treatment — it limits how deep the burn goes.
- Still worth doing up to ~3 hours after injury: If it takes time to reach water, cool the burn anyway when you can.
- NO ice or ice water: Ice constricts blood flow and deepens the injury.
- Solution: Clean drinking water is ideal, but on the river, cool clear water for cooling beats no cooling.
Backcountry caution: Cooling a large burn area can chill the whole patient. Cool the burn, but keep the rest of the patient warm and dry — watch for hypothermia.
Assessing the Burn: Depth & Extent
Superficial
- Red, dry, painful — no blisters. Classic sunburn.
- Heals on its own; comfort care only
Partial-Thickness
- Blisters, moist/weeping surface, VERY painful
- Typical scald, stove flare, or brief flame contact
Full-Thickness
- Leathery, waxy, or charred; may be painless in the center (nerve endings destroyed) even when the edges hurt
- Always an evacuation, regardless of size
Depth declares itself over 24-48 hours: A burn often looks shallower on day one than it really is. Reassess — and when in doubt, assume deeper. Extent: the patient's palm plus fingers ≈ 1% of their body surface area (the palm method).
Dressing the Burn
- After cooling, cover loosely: Clean, non-stick dressing over the burn. Clean plastic wrap laid on (NOT wrapped circumferentially) works well and lets clinicians inspect without pulling the dressing off.
- Leave blisters intact: The blister is a sterile biological dressing. Don't pop it.
- NO home remedies: No butter, toothpaste, oils, or ointments on the burn — they trap heat and cause infection.
- Sunburn exception: Plain aloe or moisturizer is fine for superficial sunburn only
- Pain control: OTC pain medication (ibuprofen) — burns hurt, treat the pain
- Tetanus: Burns are tetanus-prone wounds. Check vaccination status just like a dirty wound (see Tetanus & Animal Bites in the Wound Care tab).
Burn Evacuation Criteria
- Any full-thickness burn — even a small one
- Partial-thickness larger than a few palm-areas (~5% body surface)
- Burns to face, hands, feet, genitals, or across joints — high-function areas that scar badly
- Circumferential burns (all the way around a limb or the chest) — burned skin tightens as it swells and can cut off circulation or restrict breathing. This is a tightening emergency.
- Electrical burns — internal injury is far worse than the skin suggests
- Very young or very old patients
Airway/inhalation involvement = EMERGENT evacuation. Burned face, singed nasal hair or eyebrows, soot in the mouth or sputum, hoarseness, or a persistent cough after fire or smoke exposure means the airway may be burned — and a burned airway can swell shut over hours. Do not wait for breathing trouble to start.
Exhaust Pipes & Road Rash: The Crossovers
- Exhaust-pipe contact burns are deceptively deep: A second of contact with metal at several hundred degrees makes a small but often deep partial- or full-thickness burn. Small size does NOT mean minor — assess depth honestly and reassess at 24-48 hours.
- Road rash is an abrasion: Manage it with aggressive cleaning and irrigation as covered under Abrasion in the Wound Care tab
- Large-area road rash thinks like a burn: When road rash covers a large area, use burn thinking for fluid loss, infection risk, and evacuation decisions
Case Scenarios
Scenario 1: Rock Climbing Fall with Arterial Bleeding
Setting: A climber falls 15 feet onto rock. Left thigh has a large laceration with bright red pulsatile bleeding. Patient is conscious, in pain, and shocked. You're 2 hours from the nearest road.
Immediate Actions:
- Bright red pulsatile bleeding in a patient becoming shocky = obviously life-threatening hemorrhage: apply a tourniquet IMMEDIATELY, 2-3 inches above the wound. Do NOT wait to see if direct pressure works.
- Press directly on the wound with a gloved hand only while the tourniquet is being readied
- Tighten until bleeding stops AND the pulse at the ankle is gone; if the first tourniquet doesn't stop it, apply a second just above/beside the first
- Document the application time on skin or tourniquet; do NOT remove or loosen it in the field
- Once bleeding controlled, perform a neurovascular check below the wound
Tourniquet Note: Tourniquets are safe in place for at least 2 hours. For obviously life-threatening extremity bleeding, the tourniquet is the FIRST move — direct pressure is for bleeding that is not clearly life-threatening, or to buy time while the tourniquet is readied.
Shock Management: Patient showing signs of shock (pale, diaphoretic). Position supine (flat), prevent heat loss with insulation, treat the cause (the bleeding is controlled), evacuate. Do not elevate the legs.
Evacuation: URGENT. Activate emergency services. Continue monitoring vitals every 5 minutes during evacuation.
Scenario 2: Backpacker with Rigid Abdomen & Shock
Setting: A backpacker fell hard on rocks 4 miles into a wilderness area. She reports abdominal pain but no external bleeding visible. On assessment: rigid abdomen, rapidly deteriorating, pale and clammy. No signs of external bleeding.
Recognition: Rigid abdomen + shock without external bleeding = internal bleeding from abdominal trauma (likely solid organ like spleen or liver)
Field Treatment:
- Position supine (flat) — do not elevate the legs
- Keep warm — prevent hypothermia
- Nothing by mouth
- Monitor closely for deterioration
Evacuation: URGENT — this is a surgical emergency. No field treatment will help. Immediate helicopter evacuation if available, otherwise fastest evacuation possible (may need litter carry).
Scenario 3: Exhaust-Pipe Burn at the Lunch Stop
Setting: On a dual-sport ride, a rider dismounts awkwardly on a rocky pull-out and presses her calf against the exhaust header. The burn is small — about half a palm-area — with a pale, waxy center, a red blistering rim, and a patch of melted riding-pant fabric stuck to one edge. She says it "barely hurts" and wants to keep riding.
Immediate Actions:
- Cool the burn with cool (not ice-cold) water for 10-20 minutes — still effective up to ~3 hours after injury. NO ice.
- Do NOT peel the melted fabric — cool over it, cut around it, and leave the adhered material in place
- Remove the boot and sock on that leg before swelling starts
- After cooling: loose, clean, non-stick dressing; leave blisters intact; ibuprofen for pain
The Red Flag: A pale, waxy center that "barely hurts" suggests FULL-THICKNESS burn — the nerve endings are destroyed. Exhaust-pipe contact burns are deceptively deep, and depth often declares itself over 24-48 hours. Small size does not make this minor.
Evacuation: Any suspected full-thickness burn is an evacuation, even a small one. She rides pillion or the group re-routes to get her to care — she does not "keep riding and see how it feels tomorrow." Burns are also tetanus-prone: check her vaccination status.
Knowledge Check
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Lesson Summary
Key Concepts
Direct pressure for minimum 10 minutes is the gold standard for hemorrhage control
Tourniquets save lives for life-threatening extremity bleeding
Wound packing controls junctional hemorrhage (areas where tourniquets don't apply)
Wound irrigation with clean water is the most important infection prevention step
Don't close bite wounds, punctures, or heavily contaminated wounds
Internal bleeding without external signs requires urgent evacuation
Red streaks from wound (lymphangitis) indicate urgent evacuation needed
Cool burns with cool (not ice-cold) running water for 10-20 minutes — no ice, no butter or home remedies, leave blisters intact
Evacuate: any full-thickness burn; partial-thickness over ~5% (a few palm-areas); burns to face/hands/feet/genitals/joints; circumferential burns; electrical burns; ANY inhalation signs (EMERGENT)
Small contact burns (exhaust pipes) are deceptively deep — and burns are tetanus-prone wounds