Awareness
Internal bleeding can be difficult to recognise because, unlike a cut or wound, there is no visible blood.
Find out what emergency teams look for and what bystanders should do while waiting for help.
What is internal bleeding?
Wiets Botes, a paramedic at ER24’s Johannesburg North Sandton branch, explains that internal bleeding occurs when blood escapes from blood vessels and collects inside your body rather than leaving through an obvious external wound.
“If you cut your hand, you will see blood. With internal bleeding, there’s no blood to see, so you think you’re okay,” he says.
The danger is that a person may not realise how much blood they’re losing. Significant blood loss reduces the amount of blood circulating through the body, limiting the oxygen supply to vital organs. Without urgent treatment, severe internal bleeding can become life-threatening.
What causes internal bleeding?
Trauma is the most common cause of internal bleeding that emergency medical teams deal with, says Botes. In South Africa, this is most often the result of:
- Car, taxi and bakkie crashes
- Pedestrian accidents
- Assaults, including stabbing and gunshot wounds
- Other forms of blunt-force trauma.
What are the signs of internal bleeding?
Paramedics look for a combination of physical signs and changes in the patient’s vital signs.
These may include:
- Very pale skin, particularly around the lips, inside the eyelids, or on the palms
- Cold, clammy or sweaty skin
- Fast but weak pulse
- Fast, shallow breathing
- Low blood pressure
- Confusion, restlessness or unusual sleepiness
- Difficulty responding appropriately, or loss of consciousness
- Abdominal pain or swelling
- Hard or rigid abdomen.
These are all signs that the patient’s body may be struggling to maintain adequate circulation.
How paramedics assess a patient
When ER24 medics arrive, they conduct a structured assessment to identify and treat immediate threats to the patient's life.
They follow an X-ABCDE approach:
X – External bleeding. Check for severe external bleeding. If present, control it using direct pressure or a tourniquet.
A and B – Airway and breathing. Check whether the airway is open and whether the patient is breathing effectively. Assess the chest and listen for abnormalities, including reduced air entry on one side following trauma.
C – Circulation. The patient’s pulse, blood pressure, and other vital signs help indicate how seriously they’ve been affected by the injury.
D – Disability. Assess the patient's neurological status by checking their level of consciousness. Start with the AVPU scale – Alert, responds to Verbal cues; responds to Pain, or Unresponsive. Then refine the assessment using the Glasgow Coma Scale (GCS) – a standard tool for measuring a patient's level of consciousness after a head injury or other neurological event.
E – Exposure. Expose the patient in order to examine for injuries, then cover them again to keep them warm.
Internal bleeding can become apparent later
A person who initially feels well after an injury shouldn’t just assume they’re unharmed.
Internal bleeding may initially be limited enough for their body to compensate, or a clot may temporarily stop the bleeding. If the clot becomes dislodged, bleeding can start again.
Botes says it’s vital to seek immediate medical attention if someone develops unusual or worsening symptoms following an injury, such as:
- Increasing headaches or confusion
- Increasing difficulty breathing
- Worsening abdominal pain
- Swollen or hard abdomen
- Increasing dizziness
- Racing heart
- Blood from the ears
- Bruising around the eyes or behind the ears
- Unequal pupil sizes
- Vomiting after a head injury
- Vomiting blood
- Blood in the urine
- Difficulty being woken up.
“Anything that’s out of the ordinary for the patient, following any type of injury, warrants immediate medical attention,” warns Botes.
What to do if you suspect internal bleeding
If someone has suffered an injury and you suspect they could be bleeding internally, call an ambulance immediately. While waiting for help:
- Make sure you’re safe before approaching the patient
- Keep the patient calm and still
- Keep them warm
- Explain what is happening and reassure them that help is on the way
- Monitor their condition and note any changes
- If there is visible external bleeding, apply direct pressure where appropriate
- Tell the paramedics what happened and how the patient's condition changed.
What not to do
Any of the following actions could be dangerous and must be avoided:
- Moving the patient unnecessarily
- Giving them food, water, alcohol, or medication
- Pressing or probing painful areas
- Removing objects embedded in their body
- Attempting to straighten a deformed limb
- Pushing protruding organs back into the body.
If the patient complains of a dry mouth, you can moisten their lips with water, but don’t give them anything to drink.
Don't wait until you can see blood
Internal bleeding isn’t always obvious, particularly immediately after an injury. A person may be conscious and appear relatively well while their body is compensating for blood loss.
If someone has suffered a serious injury or their condition is deteriorating, seek emergency medical assistance at once.