Removal of First Dressing for a Wound

[JRJ26]

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Hey guys,
I'm an EMT, and tonight, one of my roommates cut his hand and asked me to help him. I placed a dressing on his wound after cleaning it, etc., and wrapped it with tape. After awhile, it started to bleed through. He said that was going to take off the first dressing and replace it. Of course, I know that it's common medical knowledge that you shouldn't take it off, just place the second dressing over the first then wrap it. However, the problem was that I couldn't explain WHY we do that. He ended up taking off the first dressing. Sigh, waste of my time...But could someone explain why you shouldn't take off the first dressing when dressing a wound? Thanks.

 

[Karl_Hungus]

This is by no means a comprehensive answer, and I'm sure others will be along to correct me/fill in the details, but...

The wound will begin clotting rapidly. Removing the first dressing will take away all the blood that has started to clot, tearing the wound open again and presumably make it bleed more.
A completely new, dry dressing will soak with blood faster than the saturated one, pulling it away from the wound (where it is needed, to make the clot) faster.
This new dressing also opens more opportunity for infection compared to leaving the first dressing in place.
Time spent doing this is time that should be spent applying more direct pressure or escalating up the progression of hemorrhage control.

Even if these reasons aren't entirely 100% accurate, it is doubtful your roommate will know the difference. Just say it convincingly.

 

[JRJ26]

Thanks a lot Karl, that definitely makes sense.

 

[nytrauma911]

Karl, that is the most accurate answer I could come up with. Good explanation.

 

[docB]

Remember that direct pressure and elevation are the starting points to get hemostasis, not application of a dressing. Effective direct pressure means holding direct pressure on the wound with a hand. Applying a dressing to a freely bleeding wound usually provides ineffective direct pressure. I've seen way too many pateints rolled into the ED with layer upon layer of dressings, towels and so on filled with hundreds of ccs of blood. If a pt has significant bleeding through a dressing then you have not stopped the bleeding and I say take the first dressing off and apply direct pressure until it's stopped. Putting more dressings over the first just hides the problem and keeps the rig clean but it does nothing for the patient.

 

[Apollyon]

Remember that direct pressure and elevation are the starting points to get hemostasis, not application of a dressing. Effective direct pressure means holding direct pressure on the wound with a hand. Applying a dressing to a freely bleeding wound usually provides ineffective direct pressure. I've seen way too many pateints rolled into the ED with layer upon layer of dressings, towels and so on filled with hundreds of ccs of blood. If a pt has significant bleeding through a dressing then you have not stopped the bleeding and I say take the first dressing off and apply direct pressure until it's stopped. Putting more dressings over the first just hides the problem and keeps the rig clean but it does nothing for the patient.

This is a rare incomplete answer from docB.

Direct pressure and elevation will stop 90+% of bleeding. Put the new dressing over the old, but APPLY DIRECT PRESSURE! The money isn't in the dressing, but pressure.

As far as "hundreds of cc's of blood" - possible, but unlikely. A little blood goes a LONG way. Veterinarians, EMT/Paramedics, and doctors all fail to visually estimate blood loss accurately. The blood only has to be one cell layer thick to appear opaque - it's not like cherry Kool-Aid, that looks more pink the more spread out it is on the floor.

Provided the person applying direct pressure is, well, applying direct pressure, the additional dressing provides bulk and can have a transmitted "pressure dressing" effect.

 

[docB]

This is a rare incomplete answer from docB.

Direct pressure and elevation will stop 90+% of bleeding. Put the new dressing over the old, but APPLY DIRECT PRESSURE! The money isn't in the dressing, but pressure.

As far as "hundreds of cc's of blood" - possible, but unlikely. A little blood goes a LONG way. Veterinarians, EMT/Paramedics, and doctors all fail to visually estimate blood loss accurately. The blood only has to be one cell layer thick to appear opaque - it's not like cherry Kool-Aid, that looks more pink the more spread out it is on the floor.

Provided the person applying direct pressure is, well, applying direct pressure, the additional dressing provides bulk and can have a transmitted "pressure dressing" effect.

We're not talking about blood on the floor. We're talking about blood in a multi layer dressing. I've seen many patients BIBA with layer upon layer of dressings, towels, OB pads, etc wrapped around wounds. When that mush cloth and gauze is saturated with blood I'll go with hundreds of ccs. These wounds are usually described by EMS as "atrerial pumpers." They almost never are. They are usually brisk venous bleeds that just need apprppriate, effective pressure and elevation. In the reare event of an arterial lac no dressing will stop the bleeding. Direct pressure with a gloved hand is the ticket.

 

[leviathan]

Hey guys,
I'm an EMT, and tonight, one of my roommates cut his hand and asked me to help him. I placed a dressing on his wound after cleaning it, etc., and wrapped it with tape. After awhile, it started to bleed through. He said that was going to take off the first dressing and replace it. Of course, I know that it's common medical knowledge that you shouldn't take it off, just place the second dressing over the first then wrap it. However, the problem was that I couldn't explain WHY we do that. He ended up taking off the first dressing. Sigh, waste of my time...But could someone explain why you shouldn't take off the first dressing when dressing a wound? Thanks.

As an EMT you should know to apply a bandage WITH direct pressure. Clotting takes ~5 minutes so if you let go before and it's a significant bleed, you'll get soaking through. You might have applied direct pressure and I just didn't read your post properly, but it sounds like you didn't.