The control of catastrophic external bleeding (hemorrhaging) is a skill that can save lives. Simply put, a catastrophic (serious) bleed is one that cannot be controlled by traditional means alone (like direct pressure) and requires additional techniques to successfully stop the bleeding. These types of traumatic bleeds are more common than you might think – like with serious traffic accidents, gunshot or knife wounds, or deep cuts.

Being familiar with some of these techniques and the specialized equipment items that are currently available to help control and stop catastrophic bleeding are important tools for the modern first-aid provider. They can be easily applied in the field and are proven to help save lives when minutes count.

Here are some considerations when treating serious bleeding:

Consider the Site of Bleeding

The location of the wound site will largely dictate how you can effectively treat the bleed. Carefully evaluate the individual’s injuries – if there is a serious bleed, like arterial bleeding on an extremity for example, and direct pressure is not stopping the bleeding, your next best option is to apply a commercial tourniquet or, lastly, an improvised tourniquet. If the bleeding is not located on an extremity and direct pressure does not stop the bleeding, apply a hemostatic (blood coagulating) agent or dressing and pack the wound if possible. There are many readily available powders and dressings that contain hemostatic agents that make great additions to your first-aid kit.

Consider Your Control Methods

Depending on your local resuscitation council guidelines, what equipment you have available and the location of the bleeding, there is a wide variety of potentially effective methods to help control serious bleeding: Direct pressure, elevation, compression dressings, wound packing, indirect pressure, splinting, pressure enhancement and tourniquets are some examples. Each can be effective, however, when used in combination they produce the most desirable results. Always ensure that you monitor for signs of shock when treating catastrophic bleeding.

There are two types of serious bleeding control methods to highlight here: commercial tourniquet use, and improvised tourniquet use. Both can be highly effective tools in stopping serious bleeding on limbs, and they are fairly simple to use. These items are valuable additions to your first-aid kit and, when used properly, can help save a life! (Remember, these are meant to buy you time until emergency responders arrive on scene or definitive care is reached.)

Before applying a tourniquet or an improvised tourniquet, let the patient know that it may be painful, but this is better than bleeding out. If firm and direct pressure on the bleeding site is not stopping the bleeding, your next best option is a commercial tourniquet; if you do not have one, you may then consider improvising one with some common items. Let’s take a closer look.

Commercial Tourniquet Use:

There are many types of effective tourniquets widely available on the market today. Two of the most commonly encountered models are the Combat Applied Tourniquet (CAT) style, which uses a windlass style mechanism to apply pressure; and the Self-Applied Tourniquet (SAT) style, which uses a buckle-style mechanism to apply pressure (like a ratcheting mechanism). When selecting a tourniquet, consider models that can apply a wide area of pressure, therefore reducing pain/damage at the application site, and that allow for the ability to provide adjustable (correct)

amounts of pressure to stop bleeding. Quality of material and construction are also very important, as the tourniquet will be under a lot of tension.

Tourniquets should ideally be applied to bare skin if possible and practical, but can be applied over clothing when necessary. Again, let the patient know that applying the tourniquet may be painful; this not only prepares the victim, but often helps them endure the discomfort because they realize it benefits them. Where possible, apply the tourniquet approximately 5 centimetres/2 inches above the wound and never on a joint. For CAT-style tourniquets, tighten the tourniquet windlass to increase the pressure while monitoring bleeding. Continue to tighten until bleeding has stopped or has been significantly reduced – if you still see some oozing from the wound that’s okay, but you should not see bright-red, flowing blood.

Secure the windlass rod in place in the windlass clip to keep tension, and slide any remaining tourniquet band end after tightening through this same clip. Then, place the windlass/time strap over the top of the windlass clip.

You may need to apply a second tourniquet above the first, if bleeding hasn’t stopped. When possible, continue to apply direct pressure to the wound after applying a tourniquet. Always be sure to note the time of application and inform EMS of the application time. Some commercial tourniquets have a place to write the time, and some rescue experts advocate writing the time some place visible on the patient with a felt tip pen or similar.

Improvised Tourniquets:

Improvised tourniquets follow the same concepts as commercial tourniquets, but may require some creative thinking or compromise. Often, these can be improvised from items already found in your first-aid kit or on your person. Remember that the wound should have been treated with a dressing and direct pressure first, with a tourniquet – improvised or commercial – meant to enhance the effectiveness if those measures are not adequately controlling bleeding. As with a commercial tourniquet, the idea is to use an improvised windlass to apply direct pressure to the limb under the windlass, as well as circumferential pressure around the limb. Both of these measures constrict major blood vessels leading to the wound and can therefore reduce bleeding.

Applying an improvised tourniquet is very simple. From your first-aid kit, an ideal material is the broad fold triangular bandage (ideally it should be rolled to a width around 7-10 cm or 3-4 in). Failing that, you could also use a piece of clothing such as a necktie, bandana or other similar cloth items that can tie around the limb and be strong enough to be wound tightly. Wrap the triangular bandage (or other item) around the limb (again, about 5 centimetres/2 inches above the wound site) and tie a square knot over the top of the limb.

Then, look for a suitable and sturdy windlass – it has to be strong, like hardwood stick, a pen flash light, a carabiner, spoon, a pair of shears, a wrench or anything similar – and place it on top of the knot. Beware of objects like pencils and pens because they will snap and fail in use. Tie another square knot on top of the windlass to secure it in place.

Now, turn the windlass so that a large knot forms directly under it on the limb. This applies similar pressure to that of a commercial tourniquet. Tighten until bleeding is controlled, then secure the windlass by tying the loose knot tails over it. Another technique is to slide a keyring or something similar onto the tourniquet before tying in the windlass to slip over the windlass and secure it in place.

Treatment Sequence for Serious Bleeding:

Ensure safety – Conduct a scene assessmentAlert EMS and Apply barriers/PPEFind the bleeding site – Obvious signs include blood-soaked areas of clothing, or spurting/pouring from a wound, missing all or part of a limbApply Pressure to the Wound Site
– Compress – Apply a dressing(s) to wound site followed by direct pressure (pushing hard). Depending upon the injury location, you can use body weight to help apply firm pressure with both of your hands and keep pressure until EMS arrive. If available apply hemostatic dressings or agents.
– Commercial Tourniquet Application – If a dressing and direct pressure alone do not stop bleeding on a limb, apply a commercial tourniquet.
– Improvised Tourniquet Application – If a commercial tourniquet is unavailable, consider applying an improvised tourniquet on a limb.
– Once a tourniquet has been applied and/or bleeding controlled, consider limb positioning, immobilization and splinting. Use of pressure points may also help.
– Wound Packing – Pack the wound with gauze or dressings (hemostatic if you have it) or even a clean cloth or shirt if practical and possible, and then compress the wound with direct pressure. This is particularly effective in instances where tourniquets cannot be applied due to the location of the injury or are otherwise unavailable. Once in place, do not remove material packed into a wound. Additional material may be placed over material already in place.Monitor for shock

Considerations When Applying a Tourniquet:

Be sure to conduct a thorough scene and patient assessment.Remember AB-CABS – airway and ventilation support take priority.Alert EMS.Before treating hemorrhaging (bleeding) be sure to don appropriate personal protective equipment (PPE). Wear eye protection if available; even sunglasses may help reduce disease transmission risk if that’s all you have available and they would not impair providing aid.Always record the time of application of a tourniquet (or pressure enhancement dressing) immediately after you apply it because it will help EMS with subsequent care. Write it on the tourniquet, or even on the patient if necessary.Monitor the efficacy of application. You may need to apply a second tourniquet above the first or further tighten the tourniquet. Never loosen a tourniquet – leave it on once you apply it.Monitor for signs and symptoms of shock, and provide aid accordingly – remember to talk to the individual and keep them as calm and comfortable as possible. Shock almost always accompanies significant blood loss.If the individual loses consciousness, monitor for signs of breathing and circulation.Ensure that emergency services are notified quickly – evacuate the injured person to emergency medical care as soon as possible. Alert EMS that a tourniquet was applied, where and the time. Prolonged use (over two hours) of a tourniquet may potentially cause permanent damage or even life-threatening conditions. If evacuation to definitive care may be more than two hours away, you may wish to consider applying tourniquets as far from the body as possible while still being effective.

Keep in mind that tourniquets, by intent, severely restrict blood flow to the site of application. Tourniquets and pressure-enhancement dressings should only be used when bleeding cannot be stopped by direct pressure alone, or if you cannot apply direct pressure, and that these methods can potentially cause permanent tissue damage. Therefore, they are used when the risk of death due to blood loss is the greater concern.

Note also that improper technique can increase potential permanent tissue damage, or even cause permanent tissue damage when it might not have otherwise occurred. Improper application may also fail to adequately control bleeding. This is particularly true if you improvise a tourniquet with something not wide and soft enough. For example, the typical trouser belt, thin cord like shoelaces or wire and the like are considered poor choices for improvising tourniquets because they may not work well, may be significantly more painful and/or make tissue damage more severe and likely. That said, if they are all you have and the patient would likely die from blood loss, using even these to control blood loss as best you can, is better than doing nothing.

As with all first-aid equipment, your familiarity with the equipment is essential. Before using any piece of equipment, thoroughly study and practice using it. Practice improvising tourniquets as well as applying commercial ones. It is important to remember the limits of your training as well; seek additional formalized training in more advanced bleeding management techniques where available.   

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