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Posted on 18/11/2019 by Benjamin Krynski

Author: Benjamin Krynski – Paramedic | Co-Founder Real Response

Recently we had a facebook post discussing bleeding management. Part of the post mentioned using limb elevation as an option in addition to direct pressure and tourniquet use. We did this knowing that in July 2017 the Australian Resuscitation Council (ARC) removed elevating limbs as a recommendation to control bleeding. Pretty quickly we had a few comments which questioned our suggestion that elevation could be used.

Although through my own clinical experience I have seen it work I wanted to unpack the ARC decision and share the and peer-reviewed literature which supported our statement my own observations.

Background:

The 2017 ARC update states;

“There is no evidence that elevating a bleeding part will help control bleeding and there is the potential to cause more pain/injury.“(1)

The ARC does an incredible job of developing clinical guidelines for first aiders and Advanced Life Support (ALS) practitioners to work with, and I have immense respect for the work they do. But it is also important to note that these are guidelines, not legislation, and there are situations where the guidelines have limitations and are not appropriate.


Secondly, a lot of the guidelines we rely on in prehospital medicine and first aid lack quality clinical evidence behind them. Examples of this Adrenaline in CPR which although currently being studied has minimal evidence for any long-term clinical benefit.

A second example more relevant to a first aid context is the historical use of hard backboards and hard collars for spinal immobilization. Only recently have studies begun to show they have been causing more harm than good. 

Returning to the discussion about limb elevation in bleeding, my questions about the update originated from own clinical practice as I have seen it work on many occasions.

It is important to note that I am NOT suggesting limb elevation replaces direct pressure or tourniquet use but to keep it as a tool on their tool belt if a situation arises where it may be useful.

The first case I refer to is a 22-year male who accidentally lacerated his radial artery with a piece of glass. He presented with uncontrolled arterial bleeding to the ED. The ED bandaged the wound to no effect. Only when they elevated the hand, hanging the arm in a sling onto an IV pole did the bleeding stop. 

Two hours later we (ALS Ambulance crew) were called in to transfer the patient to a specialist hand hospital. We noticed that the moment the hand fell below the level of the heart the bleeding continued. 

A tourniquet obviously may have been applied, but also would have caused considerable pain and as it took quite a long time for the patient to be transferred to an operating room, ischemia may have started and caused limb damage. In this case limb elevation worked very effectively even after 2 hours.

Another case is a classic situation when elevation works very well. We arrived to a 35-year-old female who has attempted self-harm using a serrated blade against her wrist. She had sawn through about 75% of the wrist and by our arrival, although the wrist was hanging at an awkward angle, there was no arterial bleeding. There was however blood still slowly flowing out of the wound (venous bleeding). In managing this wound, one of the first things I asked the patient to do was raise their hand up and support it with the other hand. Immediately the blood flow slowed, simultaneously I prepared to bandage her wrist. Once the bandage was applied, I was able to put the arm in a sling and safely transport her to the hospital with no further blood loss.

I have additional cases, but I feel both these are good examples to demonstrate how elevation can be used in both a venous and arterial bleed, even after 2 hours.

*Details have been changed to protect the patient’s identity

Managing bleeding during a training exercise using an arterial tourniquet

Research

On further research into the 2017 ARC guideline change, the ARC referenced the change on a 2010 article written in the American Heart Association (AHA) and American Red Cross Guidelines for First Aid (2). This article states that ‘elevation and pressure points are not recommended because there is evidence that other ways of controlling bleeding are more effective’. And that the hemostatic effect of elevation has no been studied. 

The article then suggests that because limb elevation has not been studied, it is possible that it may compromise first aiders applying proven methods such as direct pressure and bandaging leading to their suggestion that it may be harmful(2). The European Resuscitation Council guidelines mirrors this and the ARC change (3).

Discussion:

Based on the evidence provided in the AHA article, there is no proven net harm from using limb elevation, they just suggested that there is a possibility this could happen as it has not been studied. Furthermore, they have stated the main reason for removing this as a guideline is because there are better ways to control bleeding such as direct pressure. Neither reason indicating that if limb elevation works it can’t be used or is dangerous to use.

On further research, I found a 1992 paper from the UK(4) which investigated how limb elevation could reduce blood flow from a limb and recommendations on how to achieve maximum blood loss form the limb. 

The article concluded by recommending that an arm should be elevated for 5 min at 90 degrees to achieve maximum effect. It also makes reference to Lord Lister (British surgeon and a pioneer of antiseptic surgery) who was using elevation as a way to control bleeding at the turn of the 19th Century(4).

In 2016 a research abstract was submitted to the Annals of Emergency Medicine(5) which investigates and responds to the 2010 AHA change removing limb elevation as a recommendation.  This study was a prospective randomized crossover-controlled study. The researchers inserted an IV catheter into the dorsum of the right hand of volunteers to simulate a venous bleed and then the limb of a control subject and test subject who had their limb elevated was assessed to see how much blood loss in the two positions. 

Their results clearly demonstrated that the participants with an elevated limb bleed less than the control(p= 0.0002). The authors concluded that although further research is warranted, limb elevation should be reintegrated into standard hemorrhage control training and first aid standards(5).

Conclusion

In summary, The ARC, AHA, ERC provide comprehensive guidelines for most first aid situations. However, many of these recommendations rely on low levels of evidence, and users must remember that they are only guidelines and recommendations, not designed to be taken as legal direction for every situation. In reference to limb elevation for bleeding, there is no definitive evidence to demonstrate significant benefit or harm from limb elevation, in fact it seems to suggest more benefits than harm. In my clinical experience, limb elevation does work, not in every situation, but it’s a tool on my belt that I can use if I need it. It is not, however, to be used in replacement of direct pressure, or tourniquets, common sense must prevail.

References:

  1. Australian Resuscitation Council, 2017, ‘ANZCOR Guideline 9.9.1 First Aid for the management of bleeding’.
  2. David Markenson, Jeffrey D. Ferguson, Leon Chameides, Pascal Cassan, Kin-Lai Chung, Jonathan Epstein, Louis Gonzales, Rita Ann Herrington, Jeffrey L. Pellegrino, Norda Ratcliff, and Adam Singer, 2010, ’Part 17: First Aid. American Heart Association and American Red Cross Guidelines for First Aid.
  3. European Resuscitation Council Guidelines for Resuscitation 2015 Section 9. First aid David A. Zidemana,∗, Emmy D.J. De Buck b, Eunice M. Singletaryc, Pascal Cassand, Athanasios F. Chalkias e,f , Thomas R. Evans g, Christina M. Hafner h, Anthony J. Handleyi , Daniel Meyranj , Susanne Schunder-Tatzber k, Philippe G. Vandekerckhovel.
  4. Warren, Paul, Hardiman Paul, Woolf Victor, 1992, ‘Limb exsanguination. I. The arm: effect of angle of elevation and arterial compression’. Annals of the Royal College of Surgeons England, vol 74, pp 320-322.
  5. Du Pont D, Griesser C, Shofer F, Dickinson, 2016, ‘The effect of limb elevation on bleeding control in a human venous hemorrhage’. Annals of Emergency Medicine, vol 65 (4s) ppS117.