Controlling Severe Bleeding

Severe uncontrolled haemorrhage is the most preventable cause of death in trauma. Across both military and civilian settings, studies consistently show that 20–30% of trauma deaths are potentially preventable, and bleeding control is the single largest category of preventable death. The STOP THE BLEED campaign, developed following the 2012 Sandy Hook shooting in the US, has now trained millions of civilians in basic haemorrhage control — because in a mass casualty event or a remote emergency, bystanders are the first and sometimes only line of care.

You do not need medical training to save someone's life from severe bleeding. You need to know three things: direct pressure, wound packing, and tourniquet application. This guide teaches all three.

Recognising Life-Threatening Bleeding

Not all bleeding is life-threatening, but some wounds can cause fatal blood loss within minutes:

• Arterial bleeding — bright red, pumping or spurting in pulses with the heartbeat; the most immediately life-threatening
• Venous bleeding — dark red, continuous steady flow; serious and potentially fatal but slightly more time
• Massive wounds — large lacerations, degloving injuries, blast injuries
• Extremity injuries — leg and thigh injuries particularly; the femoral artery can cause death from exsanguination in 2–3 minutes

A person can survive losing approximately 30% of blood volume (about 1.5 litres in an adult) before going into hypovolemic shock. Significant arterial wounds can reach this volume of loss in minutes. Act immediately.

Direct Pressure

Direct pressure is the first and most fundamental bleeding control technique. It works for most wounds by compressing the damaged vessels against each other and allowing clotting to begin.

How to Apply Direct Pressure

1. Use a haemostatic dressing if available (QuikClot, Celox, HemCon) — pack directly into the wound. If no haemostatic dressing, use the cleanest material available: a first aid pad, a folded cloth, clothing.
2. Place the dressing directly on the wound
3. Apply firm, constant, hard pressure with both hands — if you think you are pressing hard enough, press harder
4. Do not remove the dressing to check the wound — this disrupts forming clots. If blood soaks through, add more material on top and press harder
5. Maintain pressure for a minimum of 5–10 minutes without releasing
6. If the wound is on a limb and accessible, elevate the limb above heart level while maintaining pressure

⚠️ The most common failure mode in bystander bleeding control is applying pressure that is too light and releasing it too early to check. Proper direct pressure is uncomfortable for the casualty — it needs to be firm.

Wound Packing

Deep penetrating wounds — stab wounds, bullet wounds, deep lacerations — cannot be controlled with surface pressure alone. The vessel damage is deep inside the wound, and the opening may not allow effective compression from outside.

Wound packing fills the wound cavity with material to create internal pressure against the damaged vessel.

How to Pack a Wound

1. Use a haemostatic gauze (preferred) or regular rolled gauze or clean cloth
2. Using one or two fingers, push the packing material into the deepest part of the wound — do not just cover the surface; push it in until the cavity is full
3. Pack firmly — the packing needs to create internal pressure
4. Continue packing with more material as the wound absorbs blood, pushing each layer deeper
5. Once the wound is full, apply firm external pressure with both hands on top of the packed wound
6. Maintain pressure for 3–5 minutes, then maintain firm pressure dressing

⚠️ Packing a wound is uncomfortable and will cause pain. This is necessary. Inadequate packing — pushing gauze into the opening without packing to the full depth — will not control bleeding effectively.

Tourniquets

Tourniquets are life-saving devices for severe limb bleeding that cannot be controlled with direct pressure. Modern military and civilian evidence is clear: proper tourniquet use saves lives, and complications from properly applied tourniquets are far less common than previously believed.

When to Use a Tourniquet

• Direct pressure is not controlling limb bleeding
• The wound is on an arm or leg and is life-threatening
• You are alone and cannot maintain sufficient pressure (e.g., needing to move the casualty)
• The wound is so large that packing is not practical

Tourniquets are for limbs only. They cannot be used on the neck, torso, or junctional areas (groin, armpit, shoulder — see below).

Commercially Available Tourniquets

• CAT (Combat Application Tourniquet) — most widely used in military and civilian EMS
• SOFTT-W (Special Operations Forces Tactical Tourniquet) — alternative widely used design
• These can be applied one-handed, which is important when the casualty has injured themselves

Applying a Tourniquet

1. Position: Place the tourniquet 5–7 cm (2–3 inches) above the wound, toward the torso — not over a joint
2. Loop: Thread the band around the limb through the buckle; secure snugly
3. Tighten: Twist the windlass (rod) until bleeding stops — this should take several turns; it will be painful for the conscious casualty — this is unavoidable and necessary
4. Secure the windlass: Lock it in the retaining clip so it cannot unwind
5. Note the time: Write the application time on the tourniquet or the casualty's forehead with a marker or blood — "T" and the time (e.g., "T 14:32")
6. Do not cover the tourniquet — it must be visible to medical personnel
7. Do not remove the tourniquet — once applied, only medical personnel should remove it

Time Considerations

Tourniquet-related complications (nerve damage, tissue necrosis) are significantly more likely after 6+ hours of application. Modern guidelines indicate that outcomes are generally good for up to 2 hours; there is increasing risk beyond that point. However: the alternative to a tourniquet in a life-threatening bleed is death. Apply it.

Improvised Tourniquets

A commercial tourniquet is strongly preferred. If you do not have one:

• Use a belt (looped twice; cinched with a buckle), or
• A strip of cloth 5 cm (2 inches) wide — narrower materials (rope, cord) cause severe tissue damage and are less effective
• Tie around the limb and thread a rod (stick, pen) through the knot; twist until bleeding stops; secure the rod with another knot or tape

Improvised tourniquets are significantly less reliable and more damaging than commercial ones. Keep a commercial tourniquet in your home first-aid kit, vehicle, and workplace.

Junctional Wounds

Junctional wounds are injuries at the junction between the limb and the torso — the groin, armpit (axilla), and base of the neck/shoulder area. These cannot have a tourniquet applied, yet they involve major vessels (femoral artery in the groin, axillary artery in the armpit, subclavian artery at the shoulder).

Management

1. Wound packing with haemostatic gauze is the primary technique — pack deeply and firmly
2. Apply firm, sustained pressure directly over the packed wound
3. Junctional tourniquets (specialist devices like the SAM Junctional Tourniquet) are used by trained responders
4. Get emergency services on the way immediately — these injuries require surgical intervention

Neck wounds involving the major vessels (carotid, jugular) are managed with firm direct pressure — never circumferential bandaging around the neck, which would compress the airway. Apply pressure to the bleeding side only.

Pressure Dressings

After wound packing and initial pressure, a pressure dressing maintains ongoing compression:

• Wrap a rolled bandage or elastic bandage firmly over the wound packing
• Secure so that steady pressure is maintained without ongoing manual pressure
• Recheck regularly — if bleeding soaks through, increase pressure

Shock Recognition

Severe bleeding leads to hypovolemic shock. Recognise it by:

• Pale, cold, clammy skin
• Rapid, weak pulse
• Confusion or anxiety
• Rapid breathing
• Thirst

Position: Lay the casualty flat; elevate legs 30 cm if injury allows; keep them warm — heat loss accelerates coagulation failure.

Quick Reference

Situation	Action
Accessible wound	Direct pressure: firm, continuous, minimum 5–10 min
Deep penetrating wound	Wound packing to full depth; then pressure
Life-threatening limb bleed not controlled	Tourniquet: 5–7 cm above wound; tighten to stop flow; note time
Junctional wound (groin, armpit)	Deep packing; firm sustained pressure; emergency services
Dressing soaks through	Add more on top; press harder — do not remove
Tourniquet removal	Medical personnel only
Time limit	Note application time; optimal within 2 hours
Shock signs	Lay flat; legs up if possible; keep warm; call for help

This guide provides general haemorrhage control information. It does not replace certified Stop the Bleed, TCCC, or first aid training. Taking a hands-on course is strongly recommended. Commercial tourniquets and haemostatic dressings should be kept in readily accessible first-aid kits.