Chapter 10: Bleeding and Shock

What Can Happen

A care worker is helping a man in his seventies in his kitchen after a short walk. He reaches for a glass on a high shelf, the glass slips, and as he tries to catch it, a large piece cuts deep into his forearm. Blood runs quickly down his arm and onto the floor, and he sits down heavily, pale and frightened. The care worker has only a few seconds to decide what to do first, and that first choice matters.

Bleeding looks alarming, but most bleeding can be controlled with firm pressure and calm hands. This chapter explains how to stop severe bleeding, and how to recognise and care for shock, which can follow heavy bleeding and other serious injuries. It also explains how to care for small wounds, for nosebleeds and for the fragile skin of many older people. As in every chapter, follow your workplace's emergency procedures and report what happened.

Step by Step: Controlling Severe Bleeding

Step 1. Make sure the scene is safe for you and for the person, and put on disposable gloves if you have them within reach. Beside a road, make the scene safe first, as Chapter 9 explains, because no first aid helps if a car hits you or the person. If gloves are not at hand, do not delay; use a clean plastic bag or a clean cloth between your hand and the wound, or ask the person to press on the wound with their own hand while you get ready. Protecting yourself matters, but losing time with heavy bleeding is more dangerous.

Step 2. Help the person sit or lie down. A person who is losing blood can faint suddenly, and a fall from standing adds a new injury. Lying down also helps the body to cope with the loss of blood. If the person feels faint or dizzy while sitting, help them lie down on the floor with a cushion or folded coat under the head. If the person is in a wheelchair, put the brakes on and keep them seated safely until help comes.

Step 3. Look at the wound quickly to see where the blood is coming from. Move or cut away clothing only as much as you need to see it. If something is stuck in the wound, such as a piece of glass, leave it in place, because it may be holding back the bleeding. Press firmly on both sides of the object instead of on top of it. In older people, a vein in the lower leg can bleed very heavily after only a small knock; treat this as severe bleeding, even if the wound itself looks tiny.

Step 4. Press firmly and directly on the wound with a clean pad, such as a sterile dressing from the first aid kit, a folded clean cloth or a towel. Use the flat of your hand and lean in with steady, strong pressure. Firm pressure is the most important thing you can do for severe bleeding, so do not lift the pad to check whether the bleeding has stopped. If the person is able and willing, they can hold the pad in place for a moment while you reach for more dressings.

Step 5. Call the emergency number, or ask someone else to call, while you keep pressing. Put the phone on speaker so that your hands can stay on the wound. Tell the operator where you are, what happened and that the bleeding is heavy, and follow the operator's instructions. If a colleague is nearby, ask them to bring the first aid kit and extra gloves, and to tell your workplace as your procedure says.

Step 6. If blood soaks through the pad, do not remove it, because that can pull away the clot that is starting to form. Put another pad on top and press harder. When the bleeding is under control, bandage the pads firmly in place so that the pressure continues, but not so tightly that the hand or foot below the bandage turns cold, pale or numb.

Step 7. For life-threatening bleeding from an arm or a leg that firm pressure does not control, some courses teach the use of a tourniquet, a strong band tightened above the wound. Use one only if you have been trained in a course, and do exactly what the course taught. If you have not been trained, keep pressing as hard as you can until help arrives, and watch the person for the signs of shock described in the next section.

Step 8. Stay with the person until help arrives. Keep them lying or sitting still, keep them warm, and talk to them calmly, because fear makes everything harder. Put the used pads and gloves in a bag rather than throwing them away, so that the paramedics can see how much blood was lost. When the person is in the paramedics' care, wash your hands well, even if you wore gloves.

Step by Step: Caring for a Person in Shock

Step 1. Learn to recognise shock. Shock is a life-threatening condition in which the body's organs do not get enough blood, and it can follow heavy bleeding outside or inside the body, serious burns, a severe allergic reaction or another serious illness. The signs include pale, cold and clammy skin, fast and shallow breathing, a fast and weak pulse, thirst, nausea, restlessness, confusion and drowsiness. In older people, new confusion or unusual quietness may be the first sign you notice. After a fall or a road accident, signs of shock without any blood you can see can mean bleeding inside the body, which is an emergency.

Step 2. Call the emergency number at once if no one has called yet, and treat the cause you can see, such as bleeding, with firm pressure. Shock needs hospital care, and first aid helps the person until that care arrives. Tell the operator that you think the person is in shock and describe the signs you see. Do not leave the person alone except for the moment it takes to call, if no one else can do it.

Step 3. Help the person lie down on their back, on a blanket or a coat if the ground is cold or hot. Some courses teach raising the legs of a person in shock. Do this only if the course where you live teaches it and only if the legs, hips, back and head are not injured. If raising the legs causes pain, or if you are not sure, leave the person lying flat.

Step 4. Keep the person warm, because a person in shock loses heat easily. Loosen tight clothing at the neck, chest and waist, and cover the person with a blanket or a coat. On a hot day or beside a sunny road, give shade and use only a light cover, so that the person does not become too hot. Do not use a hot-water bottle or a heater to warm the person; a blanket that keeps in the person's own warmth is enough.

Step 5. Do not give the person anything to eat or drink, even if they say they are thirsty. They may need treatment in hospital, and a person in shock can vomit or become drowsy. Explain this gently, and tell the person that help is on the way. Holding the person's hand or simply staying close can ease the fear, and a calmer person is easier to care for.

Step 6. Stay with the person, keep talking calmly, and watch their breathing and how they respond until help arrives. If the person becomes unresponsive but is breathing normally, place them in the recovery position as described in Chapter 3, unless an injury makes that unsafe. If the person stops breathing normally, start CPR as described in Chapter 4. Note any changes you see and the time you saw them, and tell the paramedics when they arrive.

Small Cuts, Grazes and Skin Tears

Most wounds in daily care are small: a cut finger in the kitchen, or a graze on a knee after a stumble on the pavement. Wash your hands and put on gloves, then rinse the wound under clean running water to remove dirt. Pat the skin around it dry with a clean cloth and cover the wound with a sterile, non-stick dressing from the first aid kit. Small bleeding usually stops with a little gentle pressure. On fragile skin, rinse gently and pat dry; never rub.

Watch for signs that a wound needs a doctor or a nurse: bleeding that does not stop with pressure, a wound that is deep or gaping, dirt or gravel that does not rinse out, a bite from a person or an animal, or a wound on the face. In the following days, redness that spreads, swelling, warmth, increasing pain or pus can be signs of infection. Follow your workplace's procedure for reporting these signs, and help the person get the care they need. A deep or dirty wound may need treatment the same day, so report it at once rather than at the end of your shift.

The skin of many older people is thin and dry, and it can tear with very little force, for example when an arm knocks against a wheelchair, a door frame or the edge of a bed. This is called a skin tear. Press gently with a clean, damp pad to stop the bleeding, and rinse the wound with clean water. If a flap of skin is still attached, do not pull it off or cut it; leave it as it is and follow your workplace's procedure, because a nurse may be able to ease it back into place.

Many workplaces choose special dressings for fragile skin, because ordinary sticky plasters and tape can tear the skin again when they are removed. Use the dressings your workplace chooses, and handle the person's arms and legs gently while you apply them. Prevent skin tears by moving slowly, padding hard edges, and never pulling the person by the wrist or the upper arm to help them move. Record and report every skin tear, even a small one.

Bruises are bleeding under the skin, and they are common in older people because the skin and the small blood vessels are fragile. For a fresh bruise after a knock, a cold pack wrapped in a cloth, held gently against the skin for a short time, can ease pain and swelling; never put ice directly on the skin. A large bruise that keeps growing, a bruise with severe pain or swelling, or bruising after a fall should be checked by a doctor or a nurse. If you find bruises that nobody can explain, record what you see and report it as your workplace's procedure says, because the person's safety is part of your care.

Step by Step: Helping With a Nosebleed

Step 1. Help the person sit down and lean forward, with the head tilted slightly down. Leaning forward lets the blood run out of the nose instead of down the throat. Never tilt the head back and never ask the person to lie down, because blood running down the throat can cause choking or vomiting. Outside on a hot day, help the person sit in the shade, and on an outing, find a bench or a seat in a quiet place away from traffic.

Step 2. Ask the person to pinch the soft part of the nose, just below the hard, bony part, and to breathe through the mouth. If the person cannot do this, put on gloves and pinch it for them. Give the person a bowl or tissues, and ask them to spit out any blood in the mouth rather than swallow it, because swallowed blood can make a person feel sick. Do not push tissue or cotton into the nose.

Step 3. Keep pinching steadily, without letting go to check, for the length of time your first aid course teaches. Use a clock or your phone to time it, because the minutes feel long when you are waiting. Then release the pressure gently and see whether the bleeding has stopped; if it has not, pinch again in the same way.

Step 4. Call the emergency number if the bleeding is heavy, if it does not stop after pinching again, or if the person feels faint or short of breath. Call also if the nosebleed followed a blow to the head or a fall, because a head injury needs checking, as Chapter 11 explains. If the person's care plan says that they bleed more easily than usual, tell the operator this. Call also if the person becomes pale, sweaty or confused, because these can be signs of shock.

Step 5. When the bleeding has stopped, help the person clean their face with a damp cloth, and ask them to rest quietly. For the rest of the day, the person should avoid blowing or picking the nose, lifting heavy things and very hot drinks, because these can start the bleeding again. Record the nosebleed and tell the nurse or your supervisor as your workplace asks, especially if nosebleeds happen often.

Things to Check

Check that the first aid kit at work and the one you take on outings have enough sterile dressings, pads, bandages and disposable gloves. Heavy bleeding uses many pads quickly, and a kit with only small plasters will not be enough.

Check that the first aid kit in the car or the bag you carry on outings is somewhere you can reach quickly, not under shopping or a folded wheelchair. Beside a road, every second spent searching is a second without pressure on a wound.

Check that the gloves in the kit fit your hands and are not torn or old. If you or the person you support reacts badly to some glove materials, make sure the kit has gloves of another kind.

Check the person's care plan for anything that affects bleeding, such as a note that the person bleeds or bruises easily. Knowing this in advance helps you to tell the operator what matters.

Check the home or the room for sharp edges, hard corners and things that can break, such as glass on high shelves. Moving these out of reach or padding them prevents many cuts and skin tears.

Check that you know where to wash your hands and how to throw away used dressings and gloves safely, as your workplace's procedure says. Clean hands before and after first aid protect both you and the person.

Check that you know your workplace's procedure for recording and reporting a wound, a skin tear or a nosebleed. A short, clear record helps the nurse or doctor to follow up and helps your team to prevent the next one.

Check that you have practised pressing on a wound and applying a bandage in a first aid course. Hands that have done it once in practice will do it more calmly when it really matters.