Archives of Academic Emergency Medicine. 2020; 8(1): e11 OR I G I N A L RE S E A RC H Knowledge, Attitude, and Practice of Emergency Medical Services Staff in Bleeding Control of Trauma Patients; a Cross sectional Study Yaser Sharifi1 Malahat Nikravan Mofard2∗, Maryam Jamsahar2, Malihe Nasiri2, Mehdi Safari2 1. Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: November 2019; Accepted: December 2019; Published online: 26 January 2020 Abstract: Introduction: External hemorrhage is a leading cause of preventable death due to trauma and Emergency Med- ical Services (EMS) staff members play a vital role in the frontline of trauma management. This study aimed to assess the knowledge, attitude and practice of EMS staff in bleeding control. Methods: This knowledge, attitude and practice (KAP) study was conducted to assess the educational needs of EMS staff of Hormozgan province, Iran, regarding the bleeding control of trauma patients, during 2019. The participants were randomly selected and then their knowledge, attitude, and practice in management of hemorrhage and hemorrhagic shock were assessed using two researcher-made scenario-based questionnaires and one checklist. Results: The scores for knowledge of the EMS staff regarding actions during complete amputation, status of injured patients, and med- ical measures during transfer of injured patients were 3.22 ± 0.68, 2.28 ± 0.83, and 2.29 ± 0.62, respectively. The average participants’ attitude scores regarding the fear of bleeding, the importance of bleeding control, and con- fidence in bleeding control were 2.09±0.56, 2.4±0.58, and 1.76±0.55, respectively. The findings indicated that mean practice score was 1.72 ± 0.46 in capillary hemorrhage control, 1.41 ± 0.25 in venous bleeding control, 1.47 ± 0.25 in arterial bleeding control, and 1.56±0.27 in control of bleeding in the amputee limb. Conclusion: The knowledge, attitude, and practice of EMS staff regarding bleeding control were moderate, positive and ap- propriate, and incomplete, respectively. Since bleeding is a life threatening status and EMS staff skills are critical in this issue, it seems that we need to provide continuous education in this regard. Keywords: Hemorrhage; advanced trauma life support care; wounds and injuries; health knowledge, attitudes, practice Cite this article as: Sharifi Y, Nikravan Mofard M, Jamsahar M, Nasiri M, Safari M. Knowledge, Attitude, and Practice of Emergency Medical Services Staff in Bleeding Control of Trauma Patients; a Cross sectional Study. Arch Acad Emerg Med. 2020; 8(1): e11. 1. Introduction Road traffic deaths are expected to increase to 2 million per year by 2020, which will mostly occur in developing coun- tries, especially in South Asian countries (1). Acute, life- threatening hemorrhage after trauma is a major cause of early mortality after trauma, accounting for 40% of trauma deaths globally (2, 3). Managing a multiple trauma patient in the presence of se- vere hemorrhagic shock is naturally a challenge (4). Although active bleeding in the organs or local bleeding may be tem- ∗Corresponding Author: Malahat Nikravan Mofard, Department of Med- ical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: 00989027180330, Email: m.nikravan@sbmu.ac.ir porarily controlled by manual pressure or using a tourniquet, an urgent intervention is needed to stop uncontrolled bleed- ing (5). Traumatic hemorrhagic shock is associated with a high rate of mortality, depending on the duration and extent of reduction in tissue perfusion, most of which occurs in pre- hospital settings (8); and in severe trauma management, the aim of Emergency Medical Services (EMS) is to reduce the time between an injury and definitive medical care. EMS staff act as a bridge between the community and medi- cal services. The EMS is first department in healthcare sys- tems which mainly deal with emergency patients, and the more appropriate, accurate, and faster the services become, the lower the number of deaths and mortality rate and peo- ple’s confidence to EMS will be increased. In Iran, EMS, as an essential element in treatment of emergency patients in the pre-hospital setting, plays a decisive role in reducing This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Y. Sharifi et al. 2 mortality and improving patients’ outcome (6). Out of the 31,058 pre-hospital missions accomplished in 2017 in Hor- mozgan province, Iran, 13,103 were related to road accidents and traumas (7). To increase the chance of a patient’s survival, several national agencies, including the American Surgeons Committee on Trauma, have attempted to highlight the importance of rapid response to hemorrhage (9). Although the management of bleeding slightly varies between different systems, the overall methods are similar and are in accordance with the general principles of advanced trauma life support (ATLS) protocol (10). Identifying the strengths and weaknesses of EMS staff in this regard, and improving the quality of their approach is very important (11). Therefore, this study aimed to evaluate the knowledge, attitude and practice of EMS staff in bleeding control of trauma patients. 2. Methods 2.1. Study design and setting This knowledge, attitude and practice (KAP) study was con- ducted during a 1-year period in 2019 to assess the educa- tional needs of EMS staff of Hormozgan province, Iran, re- garding bleeding control of trauma patients. The partici- pants were selected from EMS staff of the province and then their knowledge, attitude, and practice in management of hemorrhage and hemorrhagic shock were assessed using two scenario-based questionnaires and one checklist. The study protocol was approved by Ethics Committee of Shahid Be- heshti University of Medical Sciences, Iran, receiving the eth- ical code IR.SBMU.PHARMACY.REC.1398.27. 2.2. Participants All pre-hospital emergency staff members working in the EMS stations of Hormozgan province were selected using census sampling method. Having at least an associate de- gree in medical emergencies or a bachelor’s degree in nurs- ing, and experience of working in the pre-hospital emergency unit were among the inclusion criteria. The staff members working in the administrative unit of pre-hospital emergency or the dispatch unit were excluded. 2.3. Data gathering The data collection tools developed by the research team in- cluded a demographic survey, two scenario-based question- naires for assessing the knowledge (appendix 1) and attitude, and one checklist for evaluating the practice of EMS staff re- garding bleeding control in trauma patients. Questionnaires were given to ten experts to assess their face and content validity, which were confirmed after making modifications. To assess the reliability of the questionnaires, they were re- evaluated by 10 experts after a week. The intra-class corre- lation coefficient (ICC) was 0.9. Also, the reliability of the checklists was assessed using inter-rater agreement coeffi- cient (0.85). A demographic survey consisting of 8 items based on per- sonal information and work experience of EMS personnel in the pre-hospital setting was used to gather the data of the participants. The data were collected by an emergency nurse with a master’s degree. In order to collect data, the researcher referred to the pre-hospital emergency units of Hormozgan province. The researcher visited pre-hospital emergency ser- vices in Hormozgan, and following coordination with author- ities and obtaining consent from the pre-hospital staff mem- bers, first, the demographic survey and the knowledge do- main questionnaire were given to the participants. Then the attitude domain questionnaire was given to the participants, and the filled out questionnaires were collected. Finally, a moulage was used to assess their hemorrhage con- trol skills. After simulating the various vascular injuries on the moulage, emergency personnel were asked to perform re- medial measures based on the checklist questions. Then the scores for each section were recorded in the checklist by the researcher. 2.4. Knowledge assessment tool In order to assess the Knowledge level of participants, a ques- tionnaire containing two scenarios in the form of Key Fea- ture Problem (KFP) was used. Scenario 1 consisted of four questions regarding Arterial Bleeding Control and Scenario 2 included three questions regarding the management of am- putated injuries. Knowledge of EMS staff in this domain was evaluated and given a score from 0 to 4. The knowledge score of the participants was categorized as low (mean score < 2), moderate (mean score: 2–3), and high (mean score: 3–4). 2.5. Attitude assessment tool A questionnaire consisting of 14 items was used to survey the participants’ attitude toward bleeding and shock control measures. Attitudes questionnaire was set based on a 5-point Likert scale from "totally agree" to "totally disagree". Scores of the participants’ attitude were categorized as follows: neg- ative attitude (mean score: 3.5-5), moderate attitude (mean score: 2.5-3.5), and positive attitude (mean score: 1-2.5). 2.6. Practice assessment tool After simulating various vascular injuries on the moulage, the included EMS staff members were asked to perform remedial measures based on the checklist questions and the scores for each section were recorded in a checklist. The checklist was used to evaluate the hemorrhage control practice including capillary, venous, and arterial hemorrhage, as well as ampu- tation management. Skill of staff in doing each item was cal- culated as correct receiving 2 points, incomplete or incorrect This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2020; 8(1): e11 Table 1: Baseline characteristics of the studied emergency medical services (EMS) staff Variable Number (%) Age (year) <25 7 (4.2) 25-35 77 (46.7) 36-45 81 (49.1) Educational field Medical emergency 145 (87.9) Nursing 17 (10.3) Nurse anesthetist 3 (1.8) Education level Associate degree 130 (78.8) Bachelor 35 (21.2) Employment status Contractual 90 (54.5) Fee for service 47 (28.5) Fixed term 17 (10.3) Permanent 11 (6.7) Marital status Single 32 (19.4) Married 133 (80.6) Experience of working in dispatch (year) No experience 134 (81.2) <5 29 (17.6) 5-10 2 (1.2) Experience of working in EMS (year) <5 58 (35.2) 5-10 22 (13.3) 11-15 81 (49.1) 16-20 4 (2.4) Experience of working in hospital (year) No experience 130 (78.8) <5 35 (21.2) receiving 1 point, and no practice receiving 0 point. Average point of 1.7 to 2 was considered as good practice level, 1.2 to 1.7 as moderate, and lower than 1.2 as poor. 2.7. Statistical Analysis Collected data were analyzed using SPSS software version 21. Mean ± standard deviation or frequency (%) was used for re- porting the findings. For investigating the relationship be- tween knowledge, attitude, and practice with demographic characteristics of participants, analysis of variance (ANOVA) was used. P<0.05 was considered as significant. 3. Results 3.1. Baseline characteristics of studied EMS per- sonnel 165 EMS staff members with the mean age of 34.68 ± 5.11 years were evaluated (100% males). The demographic char- acteristics of the participants are presented in Table 1. 49.1% of the participants were in the 36–45 years age group, 133 Table 2: Mean Knowledge scores of the studied emergency medi- cal services (EMS) staff members regarding bleeding control Data are presented as mean ± standard deviation Items Score Examining injured person’s situation 2.28 ± 0.83 Diagnosing the severity of hemodynamic status 2.90 ± 0.92 Immediate measures to protect the injured per- son 2.58 ± 0.76 Therapeutic measures during the transfer of the injured person 2.29 ± 0.62 Actions in incomplete amputation of the limb 2.90 ± 0.67 Actions in complete amputation of the limb 3.22 ± 0.68 Actions in tightening tourniquet 2.43 ± 0.82 Total 2.67 ± 0.39 Table 3: Mean attitude scores of the studied emergency medical services (EMS) staff members regarding bleeding control Data are presented as mean ± standard deviation Attitude Score Fear 2.09 ± 0.56 Importance of bleeding control 2.4 ± 0.58 Confidence in bleeding control 1.76 ± 0.55 Total 2.08 ± 0.43 (80.6%) were married, and 145 (87.9%) had an associate de- gree in pre-hospital emergency care. The majority of par- ticipants were contractually employed, 90(54.5%) had 11-15 years of working experience in EMS, and 81 (49.1%) had no experience in emergency dispatch. 3.2. Knowledge of participants The overall knowledge of participants regarding bleeding control of trauma patients was in the moderate range (2.67 ± 0.39). The knowledge of EMS staff regarding the actions during complete amputation, status of injured patients, and medical measures during the transfer of injured patients were in high (3.22 ± 0.68), moderate (2.28 ± 0.83), and mod- erate (2.29 ± 0.62) range, respectively (table 2). There was a significant association between the knowledge levels of EMS staff and age (p = 0.001), marital status (p = 0.039), educa- tional level (p = 0.001), type of employment (p = 0.001), work experience as a dispatcher (p = 0.028), work experience in EMS (p = 0.001), and work experience in hospital (p = 0.004). 3.3. Attitude of participants The average attitude score of the participants regarding the fear of bleeding, the importance of bleeding control, and confidence in bleeding control were 2.09±0.56, 2.4±0.58, and 1.76±0.55, respectively (table 3). The ANOVA results demon- strated that there was a significant association between of at- titude of EMS staff and type of employment (p = 0.07). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Y. Sharifi et al. 4 Table 4: Practice scores of the studied emergency medical services (EMS) staff members regarding bleeding control Items Categories* Mean 2 1 0 Investigation of extent of capillary hemorrhage 92.7 7.3 0.0 1.93 Attention to creation of clotting in bleeding site 72.2 27.3 0.0 1.73 No manipulation of bleeding site 33.9 64.2 1.8 1.32 Covering all damaged surface 81.2 17.0 1.8 1.91 Venous bleeding control Washing or cleaning the area to identify the bleeding site 81.8 18.2 0.0 1.81 Applying direct pressure on site 68.5 31.5 0.0 1.68 Applying pressure on site for 3 min 0 74.5 25.5 0.74 Using pressure patching in case of bleeding continuation 44.2 52.7 3.0 1.41 Not removing the original gauze layer on the site 16.4 75.8 7.9 1.08 Attention to lower limbs for bleeding continuation 72.1 27.9 00. 1.72 Arterial bleeding control Identifying the exact location of the released artery 71.5 28.5 0.0 1.71 Applying direct pressure on the site 73.9 26.1 0.0 1.74 Squeezing the arterial pressure points in the arm or thigh 3.6 44.8 51.5 0.52 Putting on a tourniquet two fingers above wound 40.6 59.4 0.0 1.4 Not applying the tourniquet on the joint 70.3 29.7 0.0 1.7 Visibility of the wound while tightening the tourniquet 86.7 11.5 1.8 1.84 Loosening the tourniquet after bleeding stops 1.8 40.6 57.6 0.44 Applying pressure on the mild bleeding site and then wound dressing 49.1 49.7 1.2 1.48 Recording the time of putting on a tourniquet 94.5 5.5 0.0 1.94 Visibility of damaged limb 92.7 6.7 0.6 1.92 Bleeding control in amputated limb Covering the site with sterile gas 44.8 55.2 0.0 1.44 Wrapping crepe bandage twice over the site 10.3 73.3 16.4 0.94 Continuing bandage around the wound 93.3 6.7 0.0 1.93 Visibility of amputated limb 93.3 6.7 0.0 1.93 Data are presented as percentage in each category. *2: Correct; 1: incomplete or incorrect; and 0: no practice or failed. 3.4. Practice of participants The total hemorrhage control proficiency score of the partic- ipants was 1.54 ± 0.25. The findings indicated that the mean practice score was 1.72 ± 0.46 in capillary hemorrhage con- trol, 1.41 ± 0.25 in venous bleeding control, 1.47 ± 0.25 in ar- terial bleeding control, and 1.56±0.27 in bleeding control of the amputee limb (table 4). There was a significant association between the practice lev- els of EMS staff and age (p = 0.001), marital status (p = 0.001), educational level (p = 0.001), type of employment (p = 0.001), work experience in EMS (p = 0.001), and work experience in hospital (p = 0.001). 4. Discussion The results of the present study showed that the knowledge, attitude, and practice of the studied EMS staff regarding bleeding control were moderate, positive and appropriate, and incomplete, respectively. Findings by Ghaffari et al. suggested that the most impor- tant educational need of pre-hospital centers is cardiopul- monary resuscitation educational course, and a training course on examining consciousness level of the injured. In addition, three training courses were introduced as high pri- ority courses for hospital emergency care centers, which in- cluded courses on how to deal with specific cases (such as amputation and bleeding control), advanced burn training courses, and Advanced Trauma Life Support, all of which had the same degree of importance, followed by self-care educa- tional course in road accidents. The study indicated the ne- cessity for formulating and holding educational programs on the extracted priorities to promote the skills of staff in pre- hospital and hospital centers (12). In the first scenario of this study, findings indicate that partic- ipants had moderate performance in examining injured per- son’s condition, diagnosis of severity of hemodynamic status, taking immediate measures to protect the injured person, and therapeutic measures during the transfer of the injured person. In addition, regarding the second scenario, their de- cisions for preserving the incomplete amputated limb and tightening the tourniquet was categorized as average; how- ever, they had better decision-making regarding acting for complete amputation and were ranked as good. The studied EMS personnel had a positive attitude toward fear of bleed- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2020; 8(1): e11 ing and shock as well as hemorrhage control, but given the importance of hemorrhage control and its irreparable conse- quences, more attention should be paid to these skills and EMS personnel need more training in this regard. In their study, Parvaresh et al. compared the effects of scenario- based and lecture-based education methods on knowledge and attitude of emergency medical technicians towards pa- tients with chest trauma and the results showed that in the scenario-based education method, the mean knowledge and attitude scores were significantly higher (p <0.001). Given the impact of scenario-based education and its role in making use of the learner’s intellectual abilities and their creativity, scenario-based education seems to be an appropriate alter- native to traditional teaching methods (13). Regarding hem- orrhage control practice, findings indicated that in capillary bleeding control, the highest score belonged to examining the extent of capillary bleeding and the majority of staff paid attention to it. In addition, they often covered the entire sur- face of injured site correctly. However, paying attention to the clotting at the wound site, and not manipulating the site of bleeding was less considered. The average performance of the emergency personnel was satisfactory. Regarding venous bleeding control, the findings showed that the majority of staff cleaned or rinsed the area correctly to identify the bleeding area and paid close attention to the lower limbs for the purpose of examining the continuation of bleeding. However, they were less skilled in using pressure patching in case of bleeding and not eliminating the original gauze layer on the site. In addition, despite having sufficient skill in applying pressure on the site, the majority of the staff showed negligence to maintaining pressure on the site for 3 minutes, their average performance was not generally satis- factory. Regarding arterial bleeding control, the findings showed that the majority of staff paid close attention to the exact location of the released artery and the use of direct pressure on the site. But they did not show mastery on the use of pressure points for the arm and thighs. In terms of using the tourni- quet, they didn’t pay attention to tightening the tourniquet and observing the joint. The majority knew that they should expose the injured limb and use the symbol of the tourni- quet. However, their performance was poor regarding the last stage of using tourniquet, i.e. loosening the tourniquet, for creating mild bleeding current in order to preserve distal limb. Their average performance was not generally satisfac- tory. Regarding bleeding control in amputated limp, it was found that less attention was paid to sterility of dressing on the wound site. In addition, they did not show mastery on bandaging the amputated limb. However, they observed ex- posure of the amputated limb. Their average performance was not generally satisfactory. In the study by Oyeniyi et al. in two periods of 2005-2006 and 2012-2103 in Huston Trauma Hospital, role of implementing a multi-purpose package of bleeding control was analyzed. Results indicated that mortality did not correlate with gender and race, and the main factors resulting in death were brain damage and bleeding. By implementing this training pack- age, mortality due to bleeding dropped from 36% to 25% (14). The results of the Down Port study on pre-hospital control- ling of bleeding in traumatic patients indicated that the most common cause of traumatic deaths is bleeding, which usu- ally occurs within three hours of injury. This study indicates that identification of severe bleedings should be performed as part of the primary evaluation on the scene, and poten- tial clinical interventions should be performed as soon as possible. Effective treatment of bleeding in the pre-hospital phase depends on quick identification of severe bleeding, di- rect anatomic control of vascular damage, bleeding restora- tion, and transfer to hospital (15). There is a need for formulating in-service educational courses to eliminate any deficiencies in bleeding control and improve the knowledge of pre-hospital emergency personnel for enhancing decision-making. 5. Limitation Special job condition and personal problems might have af- fected the psychological condition of the participants at the time of completing the questionnaire and this might have affected the answers given; however, this was out of the re- searchers’ control. Additionally, observing the staff when implementing bleeding control skills might have influenced their performance. 6. Conclusion The knowledge, attitude, and practice of the studied EMS personnel regarding bleeding control were moderate, pos- itive and appropriate, and incomplete, respectively. Since bleeding is a life threatening condition and EMS staff skills are critical in this issue, it seems that we need continuous ed- ucation in this regard. 7. Declarations 7.1. Acknowledgements We would like to thank the pre-hospital emergency staff working in pre-hospital emergency stations of Hormozgan province. We also appreciate the “Student Research Commit- tee” and “Research & Technology Chancellor” in Shahid Be- heshti University of Medical Sciences for their financial sup- port of this study. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Y. Sharifi et al. 6 7.2. Author contribution All the authors met the 4 criteria recommended by the in- ternational committee of medical journal editors for gaining authorship. Authors ORCIDs Yaser Sharifi: 0000-0002-9903-3982 Malahat Nikravan Mofard: 0000-0002-3003-8363 Maryam Jamsahar: 0000-0002-0216-6747 Malihe Nasiri: 0000-0003-1496-7442 Mehdi Safari: 0000-0002-0449-3688 7.3. Funding/Support None. 7.4. Conflict of interest None. References 1. Dadashzadeh A, Dehghannejhad J, Shams Vahdati S, So- heili A, Sadeghi Bazarghani H. The nature of prehospital medical interventions delivered to traumatic patients in Tabriz. Journal of Urmia Nursing And Midwifery Faculty. 2017;15(3):159-67. 2. Drucker NA, Wang SK, Newton C, editors. Pediatric trauma-related coagulopathy: Balanced resuscitation, goal-directed therapy and viscoelastic assays. Seminars in pediatric surgery; 2019: Elsevier. 3. Rijnhout TW, Wever KE, Marinus H, Hoogerwerf N, Geer- aedts Jr LM, Tan EC. Is prehospital blood transfusion ef- fective and safe in haemorrhagic trauma patients? A sys- tematic review and meta-analysis. Injury. 2019. 4. Lima GL, Byk J. Trauma and early blood transfusion: the challenging hemorrhage management in Jehovah’s Witnesses. Revista do ColÃl’gio Brasileiro de CirurgiÃţes. 2018;45(6). 5. Matsushima K, Conti B, Chauhan R, Inaba K, Dutton RP. Novel Methods for Hemorrhage Control: Resuscita- tive Endovascular Balloon Occlusion of the Aorta and Emergency Preservation and Resuscitation. Anesthesiol- ogy clinics. 2019;37(1):171-82. 6. Ezati P, Vaziri M, Adli F. Educational Needs Assessment in the Medical Emergency Technicians of Tehran Emer- gency Center. Safety Promotion and Injury Prevention. 2017;5(2):109-19. 7. Hormozgan Disaster and Emergency Medical Manage- ment Center [persian]. 2017. 8. Berry MJ, Darby JR, O’Byrne DM, Dyson RM, Sixtus R, Holman SL, et al. Arginine Vasopressin improves cere- bral perfusion following controlled haemorrhage in adult ewes. The Journal of physiology. 2019. 9. Hegvik JR, Spilman SK, Olson SD, Gilchrist CA, Sidwell RA. Effective hospital-wide education in hemorrhage control. Journal of the American College of Surgeons. 2017;224(5):796-9. e1. 10. Tobey N, Waseem M. EMS, Chest Injury. StatPearls [Inter- net]: StatPearls Publishing; 2019. 11. bayrami r, ebrahimipour h, HASANZADEH A. Challenges in Pre hospital emergency medical service in Mashhad: A qualitative study. 2017. 12. Ghaffari M, Soori H, Harooni J. Prioritizing pre-hospital and hospital emergency staff’s training needs regarding traffic accidents: Comparing the viewpoints of experts and target group. Journal of Health in the Field. 2018;5(4). 13. Parvaresh Masoud M, Farhadloo R, Vahedian M, Kasha- ninejad M, Hasanpoor L, Mohebi S. A Comparison be- tween the Effects of Scenario and Lecture-based Edu- cation Methods on Knowledge and Attitude of Emer- gency Medical Technicians towards Patients with Chest Trauma. Qom University of Medical Sciences Journal. 2016;10(5):47-54. 14. Oyeniyi BT, Fox EE, Scerbo M, Tomasek JS, Wade CE, Hol- comb JB. Trends in 1029 trauma deaths at a level 1 trauma center: impact of a bleeding control bundle of care. In- jury. 2017;48(1):5-12. 15. Davenport R. Haemorrhage control of the pre-hospital trauma patient. Scandinavian journal of trauma, resus- citation and emergency medicine. 2014;22(1):A4. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 7 Archives of Academic Emergency Medicine. 2020; 8(1): e11 Appendix 1: Knowledge measuring questionnaire to manage the bleeding and hemorrhagic shock (Please select only four options from the following answers). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitation Conclusion Declarations References