The first step in controlling severe bleeding is to
Severe external bleeding is a life-threatening condition requiring urgent first aid. The human body relies upon blood circulating around the body to deliver oxygen to organs and tissues such as the heart, brain and skin. If a person loses a lot of blood, their circulation system may fail and be unable to deliver enough oxygen. This can lead to shock and possibly death. Common causes of bleeding include road traffic collisions, machinery accidents, knife wounds and gunshot injuries. External bleeding forms the basis on this topic. See also Chest and abdomen injuries and Amputation for information on treating those types of injuries. Internal bleeding, such as unseen bleeding into the chest or abdominal cavity, is also life-threatening. Management of internal bleeding is outlined in Shock, with emphasis on recognition and positioning. Guidelines
Good practice points
Guideline classifications explained Chain of survival behavioursPrevent and prepare
Early recognition
First aid steps
______________________________ NOTE
______________________________ SPECIAL CASE
______________________________ Access helpSevere bleeding is a life-threatening condition requiring medical care. Clearly explain the cause of the injury and the condition of the person to EMS so they can prioritise your case accurately. Education considerations
Learner considerations
Facilitation tips
Tourniquets and haemostatic dressings
Facilitation tools
> What do you think has happened here? > How badly is this person bleeding? > What happens when someone loses a lot of blood? > How do they look? > How do you think they might be feeling or might behave? > What do you think will happen next?
Learning connections
Scientific foundationSystematic reviews The International Liaison Committee on Resuscitation (ILCOR) conducted several systematic reviews on multiple interventions for the control of life-threatening external bleeding (Singletary, 2020). Pressure dressings, bandages, devices or proximal manual pressureSix studies compared the use of pressure dressings, bandages, or devices to direct manual pressure. Three in-hospital randomised controlled trials and one in-hospital cohort study demonstrated a significantly longer time to haemostasis with the use of mechanical pressure devices (pneumatic device, Femostrop, C-clamp) compared with the use of direct manual pressure. In contrast, one in-hospital cohort study showed a shorter time to haemostasis with the use of a mechanical clamp. For the outcome of cessation of bleeding, one in-hospital randomised controlled trial showed benefit of a combined clamp and manual compression compared to pneumatic compression. Also, one in-hospital cohort study showed higher rates of bleeding cessation when using a commercial, elasticized compression bandage compared with manual pressure. Three in-hospital randomised controlled trials and three in-hospital observational studies did not report a significant difference in complications with the use of either pressure devices or with manual pressure. No evidence was identified for the critical outcome of mortality resulting from bleeding or the important outcome of mortality from any cause. All evidence is of very low certainty. Pressure pointsNo human studies were identified comparing the use of pressure points with direct manual pressure.TourniquetsIn 13 studies, the use of a tourniquet was compared to direct manual pressure. In four prehospital civilian cohort studies, there was no reduction in mortality from bleeding with the use of tourniquets compared to direct manual pressure alone. A higher cessation of bleeding was found in a large prehospital military cohort study when comparing tourniquet use to direct manual pressure alone, but this could not be shown in an additional very small cohort study. In a large civilian prehospital cohort study, a significant reduction of all-cause mortality was shown, but this was not the case in five other civilian studies with unadjusted analyses and six prehospital military cohort studies. A difference in complications (e.g. amputation) or adverse effects could not be shown in five prehospital civilian cohort studies and one prehospital military cohort study. For the outcome of time to haemostasis, no studies were identified. All evidence is of very low certainty. One prehospital military cohort study was identified comparing tourniquets with haemostatic dressings. No difference in mortality caused by bleeding was found, but there was a significant all-cause mortality risk reduction. However, in this study, the types and locations of wounds weren’t reported, and it is unknown if the injuries were comparable. For the outcomes of complications or adverse effects and time to haemostasis, no studies were identified. Evidence is of very low certainty. No human studies were identified, comparing manufactured with improvised tourniquets. Four observational simulation studies were found that provided information about the ability of first aid providers to stop bleeding with both types of tourniquets. In one study, greater success of pulse cessation in lower and upper extremities was shown with manufactured compared with improvised tourniquets. In a second study, a decrease in bleeding cessation was shown to be greater with manufactured tourniquets over improvised cravat tourniquets over bandana tourniquets. All evidence is of very low certainty. No human studies were identified on the comparison of windlass-style manufactured tourniquets (i.e., one with a rod to tighten the tourniquet) with other types of manufactured tourniquets for the management of severe, life-threatening external extremity bleeding. Ten simulation studies provided information about the feasibility of the use of windlass-style manufactured tourniquets compared with other designs of manufactured tourniquets. Haemostatic dressings19 studies were identified, comparing the combined use of haemostatic dressings and direct pressure to direct pressure alone. For the outcomes of cessation of bleeding (studied in three in-hospital randomised controlled trials and one in-hospital cohort study) and mortality (one prehospital military cohort study and two in-hospital civilian randomised controlled trials), no benefit of the additional use of haemostatic dressings could be shown. In 15 in-hospital randomised controlled trials, faster haemostasis was shown with the additional use of haemostatic dressings, and in one of these, a decrease in the number of blood-soaked gauzes was found. In four randomised controlled trials and two cohort studies, a difference in complications and adverse events when using haemostatic dressings and direct pressure, compared to direct pressure alone, could not be shown. No evidence for the outcome of mortality caused by bleeding was identified. The evidence is of low to very low certainty. Three in-hospital civilian randomised controlled trials compared one type of haemostatic dressing to other types, but a difference in time to haemostasis (moderate-certainty evidence), all-cause mortality (very low-certainty evidence) and adverse effects (very low-certainty evidence) could not be demonstrated. No studies were found on the outcomes of mortality due to bleeding, cessation of bleeding, or any complications/adverse events. No human studies comparing junctional tourniquets with direct pressure, or comparing wound clamps with direct pressure, for the management of severe, life-threatening external bleeding were identified. Education reviewSeveral additional papers were found through the educational literature search. Included below are papers which had specific educational considerations for learners on this topic. Andrade et al. (2020) show the additional confidence learners gain by having access to bleeding control equipment. They undertook a study with medical professionals and community members to see if receiving a trauma first aid kit in addition to bleeding control training improves self-reported confidence. After completing bleeding control training, participants assembled their own trauma first aid kits in a provided tactical pouch, which included properly sized personal protective equipment, a combat application tourniquet, haemostatic gauze and bandages, a flashlight, a marker and trauma shears. After receiving bleeding control training, those who did not receive a trauma first aid kit were significantly less confident to stop life-threatening bleeding among both medical professions and community members. Pellegrino et al. (2020) identified a gap of a standardised assessment tool to measure educational effectiveness of the ‘Stop the bleed’ campaign. More than a million people in the United States have received training on how to deal with life-threatening bleeding via this campaign. The authors developed and validated a tool with the input of experts, educators and community learners. The tool covers recognition of life-threatening bleeding and where, when and how to apply pressure, a tourniquet or a dressing. Haemorrhage control experts identified 6 oz (≈177 ml) of blood loss to represent life-threatening bleeding for first aid providers. The tool used everyday language to represent medical terms and constructs. For example, people looking at a 6 oz pool of “blood” described its volume, what it looks like and how it made them feel. The authors suggest the tool can be used to compare outcomes from different teaching styles and methods in order to allow for the development of best practice for future bleeding control education. In addition, this approach could help organisations demonstrate value to learners, funders, and policymakers, and advance health sciences education. The Stop the bleed education assessment tool offers a measure for which educational efficiency and effectiveness can be judged within a larger effort to prepare people for personal emergencies or large-scale disasters. Goolsby et al. (2019) identified which haemostatic dressings first aid providers might best be trained in. They tested whether first aid providers could apply haemostatic dressings, and which they could use most successfully. 360 people participated in a randomised prospective controlled trial to compare the application of plain gauze (control), z-folded gauze, s-rolled gauze, and injectable sponge (experimental). Participants learned using a video and practise and were assessed on the pressure applied for a set amount of time, and the amount of time taken to unpack and apply the dressing. Participants also completed pre and post surveys on willingness to use the dressings. Overall, 202 participants (56%) applied dressings correctly. The most successful in terms of the correct application was the injectable sponges (92%), followed by the s-rolled gauze (48%), the z-folded gauze (43%) and the plain gauze (40%). Participants in all cohorts saw significant improvements in willingness to use haemostatic dressings. To help educators identify the best techniques to teach direct pressure, Charlton et al. (2019) ran a study on the posture a first aid provider should adopt to apply adequate pressure to a severe bleed for a sustained period of time. They tested two-handed pressure with bent arms against two-handed pressure with straight arms. A sample of 30 participants of similar demographics were randomised to one of the postures and asked to apply force to a standardised haemorrhage control trainer with electronic feedback (Z-Medica), set to record a minimum pressure of 3-psi (155 mmHg) for a three-minute time period. When using bent arms, participants provided pressure at or above 3-psi 63.7 % of the time. Participants using straight arms were above 3-psi 100% of the time. The difference between the two experimental arms remained statistically significant when examined by age, gender, or medical experience. The authors concluded that a straight-armed posture was the most efficient way to provide high-quality direct pressure to stop life-threatening bleeding. Advice for first aid providers when a serious bleed seeps through the dressing has been to add an additional layer on top rather than replacing the original dressing. This was questioned by Charlton et al. (2018) who sought to establish whether the pressure needed to stop a serious bleed could be maintained when additional layers of dressing are added. They used a tri-phase randomised cross-over trial of medical personnel and a standardised bleeding simulator. Participants were randomised to cohorts of 10, 20 & 30 layers of 4×4 inch cotton gauze, and subsequently to three different methods of pressure application: the finger pads of three digits of the right hand, three fingers of the dominant hand with the opposing hand applying counter pressure, or three digits of each of two hands on top of the other. Participants were asked to hold pressure continuously during each application for 10 seconds. The researchers found that participants generated the most force when a single stack of gauze and when two hands were used to apply pressure over the wound and suggested that first aid educators may apply results to lessons in describing the thickness of the material and need to apply sufficient pressure to stop bleeding. Zeitlow et al. (2015) sought to establish if bleeding control techniques applied in a military context could be translated into a civilian setting effectively. A retrospective review of people who received a tourniquet or haemostatic dressing pre-hospital. 77 tourniquets were used for 73 people and 62 haemostatic dressings were applied to 52 people. Seven people required both interventions. Mean tourniquet time was 27 minutes, with 98.7% success. Haemostatic bandage application had a 95% success rate. Training for both interventions was computer-based and hands-on, with ability to do skills greater than 95% maintained after two years. The authors concluded that civilian prehospital use of tourniquets and haemostatic gauze is feasible and effective at stopping the bleed. Online and practical training programs result in the ability to use skills, which can be maintained despite infrequent use. Kragh Jr et al. (2008) considered the efficacy and challenges of teaching first aid providers to use tourniquets. They studied morbidity and tourniquet use specifically in a conflict setting and draw attention to the fact that tourniquets can complicate care if used inappropriately, and that the education of the first aid provider in their use is critical. Educators in a lower resource setting or where tourniquets are not readily available might be informed about the effectiveness of improvised tourniquets as studied by McCarty et al. (2019). They showed that improvised tourniquets tend to have very poor effectiveness and high failure rates. In a randomised clinical trial that saw first aid providers trained to apply different tourniquet types, Combat application tourniquets (CATs) were compared to other commercial and improvised models. In the cases of ‘improvised tourniquets,’ the learners were allowed to choose from a selection of materials including leather belts or shoelaces, and plastic (PVC) or wooden rods to act as a windlass. Improvised tourniquets were found to fail in a number of cases due to breakage of the windlass (70%) when using a plastic windlass, or the leather belt strap snapping (almost 45.8% of the cases) where a wooden windlass and belt were used together. For the ‘non-windlass design’ improvised devices, the pressure applied was deemed insufficient in all simulation assessments and demonstrated increased estimated blood loss when compared to the purpose made CAT device provided for training. Only 1 of 22 (4.6%) applications of a non-windlass improvised tourniquet was successfully applied. Their findings supported an earlier observation during the Boston Marathon incident, where 27 improvised tourniquets were applied in the field, and all were deemed ineffective on post-event review (King et al., 2015, cited by McCarty et al., 2019). There is a gap in the evidence available on how to prepare first aid providers to deploy tourniquets in a multiple casualty scenario. ReferencesSystematic reviewsSingletary, E. M., Zideman, D. A., Bendall, J. C., Berry, D. C., Borra, V., Carlson, J. N., … & Douma, M. J. (2020). 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation, 142(16_suppl_1), S284-S334. DOI 10.1161/CIR.0000000000000897 Education referencesAndrade, E. G., Hayes, J. M., & Punch, L. J. (2020). Stop the bleed: The impact of trauma first aid kits on post-training confidence among community members and medical professionals. The American Journal of Surgery, 220(1), 245-248. Abstract only. Retrieved from Charlton, N. P., Solberg, R., Singletary, N., Goolsby, C., Rizer, J., & Woods, W. (2019a). The use of a “CPR posture” for hemorrhage control. International Journal of First Aid Education, 2(1), 31. Full article. Retrieved from https://digitalcommons.kent.edu/ijfae/vol2/iss1/6/ Charlton, N. P.; Solberg, R. Rizer, J., Singletary, E.M.; Woods, W. (2018). Pressure Methods for Primary Hemorrhage Control: A Randomized Crossover Trial. International Journal of First Aid Education, 2(1) 19. doi: 10.21038/ijfa.2018.0011. Retrieved from Kragh Jr, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2008). Practical use of emergency tourniquets to stop bleeding in major limb trauma. Journal of Trauma and Acute Care Surgery, 64(2), S38-S50. Retrieved from McCarty, J. C., Hashmi, Z. G., Herrera-Escobar, J. P., de Jager, E., Chaudhary, M. A., Lipsitz, S. R., … & Goralnick, E. (2019). Effectiveness of the American College of Surgeons Bleeding Control Basic training among laypeople applying different tourniquet types: a randomized clinical trial. JAMA Surgery, 154(10), 923-929. Retrieved from Pellegrino J. L., Charlton N., Goolsby, C. (2020). “Stop the Bleed” Education Assessment Tool (SBEAT): Development and Validation. Cureus 12(9): e10567. DOI 10.7759/cureus.10567. Zietlow, J. M., Zietlow, S. P., Morris, D. S., Berns, K. S., & Jenkins, D. H. (2015). Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in civilian trauma care. J Spec Oper Med, 15(2), 48-53. Retrieved from Related topics Shock Amputation Chest and abdominal injuries Related resources First Aid Reference CentreVideo outlining first aid to someone bleeding. Available in 2 languages (English, español). American Red CrossThis brief video outlines the basic First Aid steps to help someone with severe bleeding. It also outlines the importance and application of tourniquets. Available in 1 language (English). First Aid Reference CentreFirst aid video outlining the steps for dealing with a nosebleed. Available in 2 languages (English, español). Search for more resources on this topic… Explore the guidelines Published: 15 February 2021 First aidExplore the first aid recommendations for more than 50 common illnesses and injuries. You’ll also find techniques for first aid providers and educators on topics such as assessing the scene and good hand hygiene. First aid educationChoose from a selection of some common first aid education contexts and modalities. There are also some education strategy essentials to provide the theory behind our education approach. About the guidelinesHere you can find out about the process for developing these Guidelines, and access some tools to help you implement them locally. |