Publications: Aldana EV, et al.

*This article seemed lazily submitted and circulated only through request. It seemed a matter of personal interest that it was written, although it had the approval and support of some of the University staff. Its purpose is clearly academic, but more of a theoretical nature than a practical demonstration of observable science.*



Di Aldana, EV, Cresline J. ”A Discussion on the Address of Lethal Hemorrhagic Trauma in the Pre-Surgical Environment.” University of Calidor Internal Review, July; 1765.


Disclaimer: The following discussion is a work of personal opinion, and does not represent the opinions of organizations formerly or presently affiliated with the author. All demonstrative data is retroactive or anecdotal to the experiences of the author. The nature of this work is purely academic with some inclusion of best practices, and does not demonstrate a thorough experimental approach meant for the review of peers.

Background: In modern forms of armed conflict, be it scaled to the point of conflicting militaries or more limited in scope, efficiency of inflicting fatality has surpassed the means of personal defense. The lethality of contemporary combat far exceeds that of only decades prior, where armor and individual ability had more merit and ability to defend one’s well-being. Presently, the introduction of firearms and the growing adoption of personnel-carried explosives have been responsible for injury patterns not easily amenable to treatment, even at the hands of experienced physicians. Despite the medical advancements in the treatment of infections and diseases, formerly some of the greatest enemies to an armed force, the statistics demonstrate that acute fatality is at unprecedented levels. Although surgical and anatomical knowledge have flourished, and alchemical means of sustaining life have reached the level of contemporary miracle, most fatalities of scaled armed conflict never reach a surgical environment where the administration of such skills or materiel means can make an impact [1]. The greatest threat to life at the point of injury has become traumatic bleeding, as it is responsible for acute fatality and is caused by the effects of most modern weaponry. The overwhelming majority of avoidable deaths in a combat scenario are due to bleeding of just this nature [1, 2].


Terminology: This section will concern the author’s choice for terminology, which is to sometimes break from convention or medical parlance in order to better demonstrate intent of the terms. The first recurring term in this discussion will be “Hemorrhage,” which for the purposes of this article will be termed as external bleeding that exceeds the rate of 250ml of vitae per minute. According to modern literature, such rates are typical of arterial bleeds at the level of the elbow, with bleeding in true hemorrhagic conditions where high internal pressure must exist, may exceed such almost anywhere else in the body. Venous bleeding may exhibit similar rates as well, but for the purposes of this discussion the primary vasculature of concern will be the arterial. At such rates, untreated hemorrhage will be singularly responsible for fatality within 8-9 minutes. Although varied with personal constitution, famed physician and anatomical expert Dr. Van Drissen has estimated that irrecoverable lethality from hemorrhage occurs at the body’s loss of a mere 40% of its blood content [3]. That is not to say that levels prior to the loss of approximately 2 liters will not be fatal, as quick loss of circulation lead to dramatic bodily chilling and a cascade of other conditions which are difficult to control, but that the estimate of 40% is placed at the point of no recovery, despite the best modern surgical and alchemical means.


The term of “hemorrhage” will be further divided into several sub-strata, depending on its anatomical location and severity. The most common form of hemorrhage, as defined by cause, has been termed “penetrating hemorrhage.” Bleeding of this manner is caused by any number of means, and involves the severance of skin and puncture of underlying vasculature. Be it from blade, bullet, or bomb, hemorrhage of this sort has a clear and present exodus of blood that may or may not be amenable to treatment.

A term used in some works to describe internalized bleeding, such as by Dr. Wilden and Dr. Del Cruz, is “blunt hemorrhage.” It is named such mainly because it is caused by non-penetrative means and through internal workings of the body, be it from sharpened broken bones or other factors, causes hemorrhage in internal bodily cavities [3, 4]. Particularly insidious, this type of bleeding is difficult to detect and no less lethal than penetrating hemorrhage. It may show itself only in the form of bruising, or sometimes in the bloodied saliva of the victim. In the cause of more minor internal bleeds, not categorized as hemorrhage, evidence of such can be found in one’s urine or stool.


The next exercise in categorization of this manner of trauma is the differentiation between “arterial hemorrhage” and “venous hemorrhage.” Perhaps the terms are self-evident, but arterial hemorrhage is defined as bleeding from the severance of a major artery, while venous hemorrhage is damage to a major vein. An interesting observation is that despite the similarity in size of both types of vasculature, the rates of bleeding from arterial damage far exceed that of the venous variety. The higher pressure exuded is the likely cause, and it makes arterial hemorrhage far more life-threatening. Further qualities of these two forms of vasculature merit longer discussion, but it is beyond the scope and necessity of this discussion [5].


Hemorrhage can be further stratified based on anatomical location of the injury. There are, essentially, three zones of the human form that are susceptible to hemorrhage with highly different considerations for each. Mind that these definitions all concern true hemorrhage, that is to say damage to a major vascular structure and resultant blood loss. More topical wounds can occur at any location and require different considerations of treatment.

The most perhaps commonly witnessed form of potentially survivable hemorrhage occurs at the extremities. Most often unprotected by armor, legs below mid-thigh (just distal to the beginning of the femoral artery) and arms several inches below the joint of the shoulder are susceptible to “extremity hemorrhage”. Bleeding from these locations, although likely to be severe, benefits from a relatively simple anatomy and therefore straightforward means to temper the blood loss.

Higher in lethality and severity (and location) comes a term only newly coined as “junctional hemorrhage.” As the name implies, bleeding of this sort occurs from trauma in the junctions of the limbs and body. This generally concerns groin or high-thigh, high arm and shoulder, and even the neck. Not only do injuries at these locations imply damage to arteries at some of their thickest locations in that particular extremity, but the anatomical constraints make treatment and sustainment of it extremely difficult. In the inguinal region, proximal application of pressure is difficult to achieve and maintain, as while the artery in question is relatively superficial, constant manual attention is required to apply deliberate and staying pressure. In the shoulder region, around the beginning of the axilla, most humans have arteries beneath pectoral muscles. Not only does this make application of pressure difficult, the artery hardly has any hard surface with which to be compressed against. Truly, one of the few benefits of axillary bleeds is that the rates of blood loss are slower than in the groin, considerably. Difficulties of controlling a bleeding in the neck are perhaps self-evident. Application of a tourniquet is a creative solution, but ill-advised.

“Truncal hemorrhage” is the most complicated form of bleed. Its complexity and difficulty of definition comes from the fact that the torso houses many important physiological structures, to say the least. Hemorrhage of this form may include damage to the aorta itself, or damage to a supplied organ peripheral to the aorta, such that simple external compression is insufficient for its control. Generally, trauma to this region of the body is considered almost immediately fatal. Skilled surgeons may perform adequate intervention, but rarely would the outcome be decided by the standard of medical care at the point of injury.


The last differentiator in trauma relevant to this conversation refers to the outcome of the event. Simply put, if the victim were to sustain an injury immediately proximal to every modern benefit of surgical and alchemical medicine and still be denied the chance at recovery, such a fatality can be concluded as “non-survivable” and will be abbreviated as “NS.” On the other hand, if an injury is destined to be fatal, as hemorrhage so often is, but immediate care can intervene in the outcome, the victim has a chance of survival. Any fatality of this type is termed as “Potentially Survivable,” and will be abbreviated as “PS.” Although the theoretical definition of PS trauma is that it can be treated and averted, the presence of immediate care, implementation of best practices, and materiel solutions may simply not be available. Generally, all of hemorrhage is PS, except for cases of extreme aortic or organ damage. In these situations, the blood loss itself may not be the primary cause of death.



Best Practices: The pervasive theme of this discussion will revolve around the immediate address of bleeding, and thus the supply of fluids and longer-term care will not make its way into this discussion. Although pressure of one form or another will be the focus of the topic, some attention will be given to recent advances in hemostatic alchemical agents, both topical and imbibed.

The chief method to control hemorrhage of any variety is sufficient pressure. One of the unique properties of vasculature is that it exhibits elasticity and is not truly anchored in the body. The implications of this are twofold. The first is that external pressure required to mostly* seal an artery is relatively little; most of the challenge in such comes from surrounding tissue and what lies under the artery in question, as softer tissue below may simply displace the vasculature rather than compress it. The second implication is that if an artery sustains sufficient damage to be severed, it does not simply stay put. In fact, the artery retracts, sometimes on the order of whole inches [6]. This fact of physiology is one of high consequence, as it entirely changes the nature of care for such an injury. Topical application of pressure becomes irrelevant, and only proximal pressure is likely to be of effect.


For extremity trauma, the shape of the limb both complicates and simplifies the closure of the artery. The location of the artery is generally somewhat central to the limb, which places thick musculature between the surface of the skin and the vasculature in question. This makes point pressure ineffective. Circumferential pressure, on the other hand, is able to uniformly compress the entire limb around its bone, which will include the artery. A great deal of pressure is required to achieve the desired effect, but the use of a tourniquet and windlass is generally effective. A larger moment arm of the windlass may be necessary to show effect in some individuals, especially in the thigh, as musculature may be extremely dense and size may be quite large. Due to the elastic nature of arteries, a best practice is to place the tourniquet two inches or more above the injury itself. This, in part, limits to definition of extremity hemorrhage to not include the entire limb.

Junctional hemorrhage is considered more complex for more than the fact that it implies damage to large arteries. Physiology conspires to make adequate supply of pressure difficult. Circumferential pressure is no longer applicable, and only topical point pressure on a retracted artery is. Very often, this manner of hemorrhage is the result of a traumatic limb amputation, which indicates a severed artery and mandatory proximal occlusion. In the inguinal region, the iliac artery is superficial, and so the challenge becomes sustainment of that pressure until a surgical environment can be reached. Materiel means for this are so far only improvised, although some better devices are in consideration.

Lastly, truncal hemorrhage has a very limited range of best practices. As with junctional hemorrhage, external application of pressure is one of the few means available. If convenient, packing the wound with clean gauze and attempting to create a source of internal pressure is advisable. Short of a full body’s weight of pressure on a knee, closure of the descending aorta in case of damage is extremely difficult. Surgical means to repair it are also imperfect, and any well-trained medic would be well advised to focus their efforts on other patients, if available.


*The term mostly is of some note, as the full closure of an artery requires a gradient of pressure far larger than that to “mostly” close it. In simple terms, the tubular structure of an artery may adopt a thinned shape but open features to either side will persist, however small. The details and mechanics relate to the theory of collapsible tubes, which has held import for not only vascular surgery, but also industrial applications.



Equipment: It is important to augment one’s own skills with the presence of deliberate equipment intended for the task at hand. It is a very general truth, but extremely applicable to the treatment of hemorrhage. One of the most universal tools at a first-responder’s disposal is gauze. Gauze is, in most medical environments, near ubiquitous. It can be used as a light pressure dressing for less major injuries, or in the case of trauma, as a packing material to fill any cavity left by shrapnel or other projectiles. Cleanliness of the gauze is important, as it is width. Gauze too narrow will be unable to be folded, and thus may not retain any worthwhile thickness. Packing is also more effective with wider, pliant gauze.

For extremity trauma, the singular best tool is a tourniquet. As a base invention, the tourniquet has been in military and clinical use for decades and more. Often, these will be improvised strips of cloth and any available means of leverage to tighten it. While nominally effective, I would like to introduce a new concept. The standardization and more universal distribution of tourniquets may yield more effect. It will reduce the time until address of injury, discourage for potentially ineffective ad-hoc methods, and increase safety. If a device of this sort is to be standardized, then it should feature two main components. The band itself must be of some adjustable size, such that it could fit any individual’s limbs at any location. It must also be no thinner than an inch and one half, although two inches or more are preferred. The material must be such that it is not too pliant and not liable to “cut” into the skin. The windlass itself must be of a length no less than four inches, to provide leverage. It must also be of a durable material, such as steel.

It bears saying that there are forms of tourniquets, or vascular clamps, that are intended to be effective for junctional hemorrhage. These solutions are simple, and effective in a laboratory setting, but it is this author’s opinion that their design does not yet meet the combat context ; in a limited window of time, the deployment of these clumsy means is too lengthy and unstable.

On the merits of alchemical and other means, there is as of yet little to be said. Much of the science is still in its early stages of development, although some advances demonstrate efficacy. I am not qualified to detail the function of imbibed or topical means to control bleeding and repair flesh that are not surgical, but I have borne personal witness to their effect. It is varied in speed and thoroughness, likely due to an individual’s constitution among many other factors inherent to the design of the substance itself. Most forms are liquid, though some come powdered, and may be applied this way. These substances are imbibed or applied topically, although merits to a suppository application have been discussed at length within the community. The largest argument against it is its impracticality.



Risks: In much of medicine, there is no perfect solution to any one problem, simply solutions that address one problem well and cause smaller, more manageable secondary problems with far less acuity. One of the simplest and most readily apparent risks to the use of alchemical solutions for the control of hemorrhage or wound recovery is the toxicity of the substances. There is a quantifiable limit to what an individual can endure before their body rejects the substance, sometimes violently. It is a risk insufficient enough to discourage the use of these compounds, especially in times of great need, but it does preclude tonics from being a “miracle” cure-all as many may hope to see them as. The risks are reduced for more hale individuals, and a weaker ill individual may suffer more severe secondary effects that discourage the use of tonics in the first place. For the purpose of hemorrhage, the use of other means prior to alchemical substances is encouraged.

One of the most prominent risks of addressing any type of hemorrhage has to do with one of the core principles on the purpose of blood. The premise of addressing hemorrhage seeks to internalize blood rather than lose it to the environment, lest the body have insufficient amounts to support nominal function and sustain life. In the case of hemorrhage, though, there is usually tissue distal to the site of injury that also depends on vitae. While the “need” of a foot or bicep are not comparable to that of the brain or major organ systems, denial of blood to these extremities can have dramatic consequences given time. In the case of extremity hemorrhage, any point below the tourniquet’s application is denied blood. As with any tissue, denial of sustenance will lead to death of that tissue. After a certain time, the length of which depends on many factors but is safely estimated to be near four hours by the author given existing data, the damage to the tissue is unrecoverable even through surgical means [3, 7, 8, 9]. This is more dramatic for junctional hemorrhage, as closure of the artery in the groin denies the entire limb blood, if it is still present. If the limb tissue in either case begins to fail, the only course of suggested action is the removal of the tissue; amputation is a common and necessary practice.

Another risk to consider for the implementation of tourniquets is a more immediate form of tissue damage. A tourniquet that is both narrow and tight may deliver high pressure, but in doing so is likely to cause tissue injury at the point of application. Furthermore, as each artery in the major limbs travels near to nervous structures, extreme pressure may impinge the nerve and further increase the risk of irrecoverable limbs after the use of a tourniquet. For this reason, standardization and minimal width for tourniquets is necessary.