How to Apply a Tourniquet and Pack a Wound

Why this matters

A tourniquet in the kit does nothing if the person holding it has never tightened one. The two failures seen most often are the same two every bleeding-control instructor warns about: a tourniquet put on loose, so it slows bleeding without stopping it, and a tourniquet put on over a knee or elbow, where it cannot squeeze the artery against bone. Both look like a tourniquet is in place. Both leave the person bleeding.

These are the steps as taught in lay bleeding-control courses such as the American College of Surgeons' Stop the Bleed program, consistent with American Red Cross and American Heart Association first aid guidance. When to use a tourniquet instead of pressure or packing is decided on its own card. See related: Severe Bleeding and the Tourniquet. This card is the hands-on sequence, and the point of it is to send you to a course where you do it on a partner: a written step is a reminder, and only hands-on practice makes it a skill.

Before either procedure

Get the call made. If someone else is present, name them and send them to call 911 and bring the bleeding-control kit. If you are alone, call on speaker and start pressure with your other hand. Reason: everything below buys time until a surgeon, and the call is what brings the surgeon.

Put on gloves if they are in reach, and do not delay for them. Blood is a bloodborne-pathogen route through broken skin and the eyes, so gloves are the right default, but a person with arterial bleeding cannot wait while someone runs to the van for a box. Wash thoroughly afterwards and report any exposure. See related: Bloodborne Pathogens and Helping a Bleeding Coworker.

Applying a windlass tourniquet

1. Expose the wound. Cut or pull clothing away so you can see where the blood is coming from. Reason: you place the tourniquet relative to the wound, and a wound under a pant leg can be several inches from where the blood shows. What breaks if skipped: a tourniquet placed below the real wound, or over a pocket full of keys that keeps it from tightening.

2. Place the band 2 to 3 inches above the wound, never on a joint. Above means toward the body. On bare skin or over a single thin layer, not over a thick jacket or a pocket. If 2 to 3 inches above lands on a knee or an elbow, move it above the joint onto the thigh or upper arm. Reason: the tourniquet works by pressing the artery against a single long bone; a joint has no bone in the right place to press against. What breaks if skipped: a tourniquet that tightens and does nothing.

  LEG, side view (hip at left, foot at right)

  hip                   knee            foot
   |=====================| |==============|
   |      THIGH          |K|     CALF     |
   |=====================| |==============|
                   ^      ^      ^
                   |      |      |
          band goes here  |   wound 2 in
          on the thigh,   |   below knee
          above the knee  |
                      not here: the
                      knee is a joint

3. Pull the strap tight by hand before you twist. Run the strap through its buckle and pull it as tight as you can, so that no more than a few fingertips fit under it, and fasten it. Reason: the windlass, the rod you twist, has only a few turns of travel. Slack left in the strap uses those turns up before the artery is reached. What breaks if skipped: the rod hits the end of its travel with the limb still bleeding.

4. Twist the windlass until the bleeding stops. Turn the rod, and keep turning, past the point where it feels tight, until the bright flow from the wound stops. Reason: a tourniquet that is tight enough to block the veins but not the artery traps blood in the limb while arterial blood keeps arriving, and the wound bleeds faster. What breaks if skipped: a person who looks treated and is still bleeding out. Expect the person to cry out; a working tourniquet is very painful, and the pain is not a reason to back off.

5. Lock the windlass and secure the strap. Seat the rod in its clip or hook and wrap the remaining strap or time band over it. Reason: a rod that is not locked unwinds when the person moves or is lifted onto a stretcher. What breaks if skipped: bleeding that restarts during the move to the ambulance, where nobody is watching the leg.

6. Write the time. On the time band, on tape, or on the person's skin with a marker: "TQ 14:07". Reason: the hospital uses it to plan surgery. What breaks if skipped: a guessed time from a crew that did not look at a clock.

7. Re-check, and add a second tourniquet if bleeding continues. If the wound is still bleeding after the windlass is locked, tighten further. If it still bleeds, put a second tourniquet directly above the first and tighten it. Reason: large thighs and muscular limbs sometimes need two. What breaks if skipped: one tourniquet left alone because it "should be enough".

8. Leave it on. Do not loosen it to check, to relieve pain or because it has been on a while. Removal is done at a hospital. Keep the person flat and warm, and tell responders exactly where and when it went on.

On yourself. Commercial windlass tourniquets are designed to be applied one-handed to your own arm or leg. On an arm, slide the loop over the hand, pull the strap with your teeth or against your body, and twist with your free hand. It is worth practicing this once in a course, because a solo tech is the person most likely to need it.

Packing a wound where a tourniquet cannot go

Packing is for junctional wounds, the groin, the armpit, the side of the neck and the base of a limb, and for deep limb wounds when no tourniquet is available. It is not for chest or belly wounds, which get pressure with a dressing only.

1. Expose the wound and find where the blood is coming from. Reason: gauze has to go onto the bleeding point at the bottom of the wound, not across the top of it.

2. Pack gauze into the wound with your fingers. Push the end of the roll in, onto the bleeding point, and keep feeding gauze in, pressing each fold down, until the wound is full and the gauze stands slightly above the skin. Use hemostatic gauze if the kit has it; plain gauze packed tightly works too. Reason: packing carries your pressure down to the vessel. What breaks if skipped: pressure on the skin over a deep wound, which slows bleeding briefly and then fails.

3. Press hard and hold. Both hands on top of the packed wound, arms straight, body weight over it. Hold for at least three minutes with hemostatic gauze, and longer, about ten minutes, with plain gauze, as bleeding-control courses commonly teach. Do not lift to look. Reason: clotting needs undisturbed pressure, and lifting to check undoes it. What breaks if skipped: the bleeding restarts every time someone peeks.

4. If blood soaks through, add more, do not remove. Put more gauze on top and press harder. Pulling out soaked packing tears away whatever clot has formed. Once bleeding is controlled, keep holding pressure or wrap a pressure bandage over the packing until responders take over.

A worked case: the calf wound below the knee

A lawn crew is clearing brush. A chain saw kicks back and cuts the outside of a crew member's right calf about 2 inches below the knee. Blood is pulsing out of the wound and pooling on the ground.

0:00. The crew lead shouts to the second crew member, "Call 911, then get the red bag." The chain brake has stopped the chain; the lead kills the engine, sets the saw well clear and kneels, pressing on the wound with his bare hand because the gloves are in the kit. Pressure slows the pulsing but blood still runs between his fingers.

0:45. The kit arrives. The lead cuts the pant leg open with trauma shears and sees the wound is 2 inches below the kneecap. Measuring 2 to 3 inches above it would put the band on the knee, which step 2 rules out, so he places it above the knee on the lower thigh, on bare skin.

1:10. He pulls the strap tight by hand, fastens it, and twists. After two turns the bleeding slows but does not stop. He keeps turning; a little past the third turn the flow stops. He locks the rod in its clip. The crew member is shouting with pain; the lead tells him that means it is working.

1:40. He writes "TQ 10:52" on the time band; 10:52 was the time on his phone when the rod locked. He checks the wound: no fresh bleeding. A second tourniquet is not needed. The crew member is laid flat with a jacket over him. The second crew member, still on the line, tells the dispatcher a tourniquet is on and at what time.

What changes the answer. A wound 6 inches below the knee would have taken the tourniquet on the upper calf, 2 to 3 inches above the wound, because that placement would not have reached the joint. A wound at the groin crease, where the leg's main artery runs close to the surface, would have meant packing and pressure rather than any tourniquet. And had the bleeding continued past the third turn with the rod at the end of its travel, the next move was a second tourniquet directly above the first, not loosening and starting over.

The failure this avoids. The tempting placement is 2 inches above the wound because that is the number people remember, which here is the middle of the knee. A tourniquet tightened there feels firm and leaves the artery open.

How to know you can actually do this

Reading these steps is a reminder, not a capability. You can do this when you have, in a course and on a partner or a training limb: placed a tourniquet on an arm and a leg in under a minute each, felt how many turns it takes to stop flow on a training model, packed a simulated wound until full, and applied a tourniquet one-handed to your own arm. If any of those has not happened, the gap is closed by the course, not by rereading. Check that each truck's tourniquet is a real commercial model, sealed, and stored where it can be reached in seconds. See related: How to Audit First Aid Kits Across a Fleet.

References

• American College of Surgeons, Stop the Bleed course materials on tourniquet application and wound packing.
• American Red Cross and American Heart Association, current first aid guidelines on control of life-threatening bleeding.
• See related: Severe Bleeding and the Tourniquet.
• See related: The First-Aid Kit for a Service Van; How to Choose First Aid and CPR Training for the Crew.