Catastrophic Bleeding in Sport

The recognition problem is not the dramatic bleed. Nobody misses an arterial spurt. It is the bleed quietly filling a sock, soaking into grass, or hidden inside a tracksuit leg while the athlete talks to you normally.

Life-threatening bleeding is bleeding that will kill in minutes: rapidly flowing or spurting blood, a major limb wound, or a wound that direct pressure does not quickly control. It is treated on appearance rather than on numbers. A fit young athlete compensates well, so tachycardia may be an early warning that something is wrong, while a falling blood pressure is a late one, and by the time it falls you are behind.

Expose to find it. Blood tracks under clothing and pools where you cannot see, and a glance at a trouser leg is not an examination.

Call 999 first, and keep working. The call goes out while you are controlling the bleeding, not once you have finished.

Apply firm, direct manual pressure to the bleeding point. Not a dressing laid on top: a hand, pressed hard, on the place the blood is coming from. Pressure that is not working is usually pressure in the wrong place, or pressure that is too polite.

Then a dressing, ideally a haemostatic one, applied directly onto the bleeding injury with firm pressure held over it. At some sites that means packing the dressing into the wound rather than laying it across, and where nothing purpose-made is available, any clean material used the same way is better than waiting. Hold the pressure for as long as the product you are using specifies. Once the bleeding is controlled, a pressure dressing maintains it.

For life-threatening bleeding from an arm or a leg that direct manual pressure does not control, a tourniquet goes on as soon as possible. It does not wait for you to try packing first. UK guidance is specific about the rest: place it around the limb 5 to 7 centimetres above the injury and not over a joint, tighten it until the bleeding slows and stops, accept that this will hurt, and write down the time. Do not release it. Releasing it is a decision for a healthcare professional at hospital. If the bleeding continues, a second tourniquet goes above the first.

An open chest wound is different and it catches people out. It is left exposed and open to the air. You do not cover it and you do not dress it, because sealing it can produce a tension. Localised bleeding around it can be controlled with direct pressure, and a trained clinician with the right kit may apply a specialised vented dressing that lets air out on exhalation, but the default is to leave it alone.

If a body part is amputated, deal with the bleeding first. Then wrap the part in a clean cloth moistened with saline or water, seal it in a bag, and put that bag into another containing ice or ice water so that the part is kept cold without ever touching ice directly. Label it and send it with the athlete.

Controlling the bleeding is the start of the assessment, not the end of it. Once it is under control you work through airway, breathing, circulation, disability and exposure, because the athlete who has lost significant blood needs oxygen if they are hypoxic or compromised, warmth, and repeated observations rather than one reassuring set.

Preventing hypothermia is treatment. Cold impairs the enzymatic clotting cascade, which worsens the bleeding, which worsens the shock, and that is the trauma triad of death: hypothermia, acidosis and coagulopathy, each feeding the next. In practice it means removing wet clothing, insulating with something dry, shielding from wind, and putting something between the athlete and the cold ground. An athlete lying on wet grass in February is losing something you cannot give back.

Wear gloves. That is not fastidiousness, it is the start of the exposure question, which is covered properly on the Blood-Borne Virus Exposure in Sport page.

And the honest question underneath all of this is whether you have the kit and the training for it. UK first aid guidance is explicit that you use only equipment you have been trained to use, and a tourniquet in the bag of someone who has never applied one is a claim rather than a capability.

• •Current Resuscitation Council UK first aid guidance sets the approach to life-threatening bleeding: call 999, firm direct manual pressure, a haemostatic dressing applied directly and packed into the wound where the site requires it, and a tourniquet as soon as possible for extremity bleeding not controlled by direct pressure, placed 5 to 7 centimetres above the injury and not over a joint.
• •The same guidance covers open chest wounds, which are left exposed rather than dressed, and the preservation of an amputated part.
• •Current NICE guidance on major trauma covers assessment and initial management, including haemorrhage and the trauma network pathway that determines destination.
• •Faculty of Pre-Hospital Care course endorsement supports education in immediate care; what an individual may actually do depends on their current competence, governance and scope of practice.

• •Call 999 while controlling the bleeding, not after it is controlled.
• •Direct manual pressure on the bleeding point comes first, not a dressing laid over it.
• •A tourniquet goes on as soon as possible for uncontrolled limb bleeding; it does not wait behind packing.
• •Place it 5 to 7 centimetres above the injury, never over a joint, and write down the time.
• •Do not release a tourniquet; that is a decision for a healthcare professional.
• •An open chest wound is left exposed and uncovered, not sealed with a dressing.