Circulation part 2

When reviewing trauma and concern for haemorrhage, the ‘Blood on the floor plus 4’ saying can help in identifying and treating potential further bleeding;

  • Blood on the floor – Initial catastrophic haemorrhage should be identified and dealt with at the start of the survey. This is a review of any further external haemorrhage that may have been missed and requires stemming.
  • Chest – Bleeding into the thoracic area can reduce circulatory supply significantly. The pleural space of the lungs can hold up to 3 litres of blood. It may be difficult to identify bleeding into the thorax, keep a high index of suspicion and look for evidence of traumatic injury such as bruising, broken ribs, tenderness. Signs of a haemothorax developing will also identify blood collecting in the pleural space.
  • Abdomen – The abdomen is able to hold a large amount of blood within its’ cavity. Signs of injury can include tenderness, guarding, or rigidity on gentle palpation. Bruising or any further obvious injury, e.g., tissue penetration/tearing, must also be considered. Review mechanism of injury and if there is a potential for organ shearing injuries due to rapid deceleration.
  • Pelvis – The pelvis offers a large area for potential haemorrhage. Signs can include pain around the pelvis, deformity, haematuria, bleeding from the reproductive organs or rectum, an ‘open’ looking pelvis with splaying of the lower limbs. Also review mechanism of injury for the potential forces that may have been involved. A pelvic binder should be applied as to reduce the potential space for internal haemorrhage.
  • Long bones – The anatomy of long bone structures provide a large potential of internal haemorrhage. Blood loss from femoral shaft fractures can involve between 0.5 – 2 litres of blood. Signs include pain, deformity, compartment syndrome, obvious forms of injury such as tissue penetration, and an index of suspicion for the forces involved in the trauma. Splinting of the limbs can help stem further bleeding by reducing movement of potential sharp bone/fragments from tearing further tissue.


Within the context of certain haemorrhage situations (Trauma, Head injury, etc,) or major trauma and catastrophic bleeding, Tranexamic Acid can be administered to help reduce the breakdown of clots and further bleeding. Review your own drug guidelines when for how and when Tranexamic Acid should be given. Lastly in the circulation assessment, review any initial catastrophic haemorrhage to ensure that bleeding has completely stemmed. Ensure tourniquets are still tight and in place, and that any pressure bandages are still providing adequate pressure and haemorrhage control.