Severe Bleeding and the Tourniquet

Why this matters

A person can bleed to death from a limb wound in the time it takes an ambulance to cover a few miles. Saws, broken glass, sheet metal, a slipped utility knife and a shattered window are ordinary on residential jobs, and the injuries they cause are exactly the kind where what a coworker does in the first two or three minutes decides the outcome. For most of the last century, lay first-aid courses taught people to fear the tourniquet. Current guidance from the American Red Cross, the American Heart Association and the American College of Surgeons reverses that: for life-threatening bleeding from an arm or leg, a tourniquet applied early is the right tool, not a last resort.

This card is about the decision: recognizing which bleeding is life-threatening, which tool fits which wound, and the rules that govern a tourniquet once it is on. The hands-on steps for applying one and for packing a wound are on their own card. Reading either is not training; a hands-on bleeding-control course is what makes a responder.

What life-threatening bleeding looks like

The words that matter are about volume and behavior, not the size of the cut:

• Spurting or pulsing. Bright blood coming in surges is arterial, and arterial bleeding does not stop by itself.
• Steady flow that will not slow. Blood running out of the wound rather than welling up and oozing.
• Pooling. Blood collecting on the floor or ground around the person.
• Soaking through. Clothing, a towel or a bandage that turns fully red and keeps getting wetter.
• An amputation, partial or complete, of a finger or more.
• A person getting worse, confused, pale, cold and clammy, as the bleeding continues.

A wide, ugly gash that oozes slowly is frightening and usually not life-threatening; a small, deep wound in the groin or armpit that pools blood can be. Judge by what the blood is doing. Everything on this list is a call to 911 at once, and the bleeding is controlled while the call is made, not after.

The tools, matched to where the wound is

There are three tools, and the location of the wound picks between them:

Direct pressure means both hands, straight arms, body weight, on the bleeding point with a cloth or gauze, not a dab at the surface. It works on most bleeding, and it is always the first move while someone fetches the kit.

A tourniquet stops arterial flow to the limb below it by compressing the artery against bone. It is the tool when pressure is failing, when the wound is too large to press closed, or when the responder has to leave to do something else (a second casualty, the call, the street). Current guidance accepts going straight to a tourniquet on a limb when bleeding is obviously life-threatening.

Wound packing fills a deep wound with gauze so pressure reaches the bleeding vessel instead of the skin above it. It exists for the places a tourniquet cannot go. Hemostatic gauze, treated to promote clotting, is preferred where it is in the kit; plain gauze packed tightly also works.

The rules once a tourniquet is on

These rules exist because the mistakes they prevent are common:

• Place it 2 to 3 inches above the wound, not on a joint. That is the placement current lay courses such as Stop the Bleed teach. A tourniquet over a knee or an elbow cannot compress the artery against bone. If the wound is so close to a joint that 2 to 3 inches lands on it, go above the joint. Some tactical courses teach "high and tight", as high on the limb as possible, for when the wound cannot be found quickly through clothing or in the dark; that is a reasonable fallback when you cannot see the wound, not a contradiction.
• Tighten until the bleeding stops, not until it seems tight. A tourniquet that slows bleeding without stopping it is worse than none, because it blocks the veins returning blood while arterial blood still flows in, and the wound bleeds faster.
• It will hurt, a lot. A properly tight tourniquet is painful. That is not a sign it is wrong, and it is not a reason to loosen it.
• Note the time on the tourniquet or the person's skin. The hospital uses it.
• Never loosen or remove it. Taking a tourniquet off is a clinical decision made in a hospital, with blood products and a surgeon ready. Loosening it "to give the limb some blood" restarts the bleeding.
• If one does not stop the bleeding, add a second directly above the first.

The old fear was that a tourniquet costs the limb. Military and civilian experience has shown that limb loss from a correctly applied tourniquet left on for the time it takes to reach a hospital is rare, and complications rise mainly with prolonged application measured in hours. The limb is not what is at risk in the first hour; the person is.

What to carry, and what not to rely on

Carry a commercial windlass tourniquet, the kind with a strap, a rod that twists to tighten and a clip to lock the rod. The Committee on Tactical Combat Casualty Care publishes a list of tourniquet designs that have been tested, and buying from that list avoids the counterfeits sold online that break when twisted. Store it where it can be reached in seconds, not at the bottom of a kit under the bandages.

Do not plan on an improvised tourniquet. A belt, a zip tie or a strip of cloth usually cannot be tightened enough to stop arterial flow, is too narrow and cuts, or loosens. If nothing else exists, a wide strip of cloth tightened with a stick as a windlass can work, but the realistic plan is direct pressure until a real one arrives.

Carry gauze for packing, hemostatic if you can, and gloves. A bleeding-control kit with a tourniquet, packing gauze, a pressure bandage and gloves belongs on every truck that runs saws or handles glass. See related: The First-Aid Kit for a Service Van.

One gate, two outcomes

The gate a responder runs is a single question: is this bleeding life-threatening, and is direct pressure controlling it? Two injuries on a window crew's jobs, a few months apart, show how it splits. Both happened removing a fixed pane from an old frame, and both times the glass cracked as it was lifted.

Case one: the wrist. A shard opens the inside of the helper's right wrist. Blood is spurting in pulses. The lead tech presses a folded towel hard on the cut with both hands and leans in; the other crew member calls 911. The spurting stops under the pressure. After about a minute, blood begins wicking through the towel, and the lead adds a second towel on top without lifting the first and presses harder. The flow stays controlled. Gate result: life-threatening, but pressure is controlling it. The lead keeps holding until paramedics arrive. A tourniquet is laid out ready, placed on the forearm above the wound only if the pressure fails or the lead has to let go. Pressure working is a legitimate outcome, not a delay.

Case two: the armpit. On a later job a falling piece catches the lead tech high on the inside of his left upper arm, right at the armpit crease. Blood is pooling under him within seconds. Pressing on the skin with a towel slows it only briefly, because the bleeding vessel is deep in the wound and the pressure is not reaching it. Gate result: life-threatening, and pressure is not controlling it. A tourniquet cannot help: there is no room to place one 2 to 3 inches above a wound at the armpit, and a tourniquet does not compress the vessels in the armpit itself. This is a junctional wound. The third crew member, gloved, packs gauze into the wound until it is full, then presses down hard with both hands and holds. Hemostatic gauze is in the kit, so the pressure is held for at least three minutes as bleeding-control courses teach, and then not released at all, because nothing about this wound improves by checking it.

Why the gate splits them. Both wounds were life-threatening. What decided the tool was whether pressure on the surface was reaching the vessel. At the wrist it was, so pressure was enough and the tourniquet stayed in reserve. At the armpit it was not, and the location ruled out the tourniquet, so packing was the only way to get pressure to the vessel.

What changes the answer. Had the wrist case been a leg wound with a second casualty to attend, the responder would have put on a tourniquet early to free his hands rather than holding pressure indefinitely. A responder alone with a spurting limb wound who must make the call uses the tourniquet for the same reason. And had either wound been on the chest or belly, the answer would be pressure with a dressing and no packing.

Training: what Stop the Bleed is

Stop the Bleed is a bleeding-control program run by the American College of Surgeons, with courses taught by hospitals, fire departments and EMS agencies, typically in an hour or two, often at low or no cost. It covers recognizing life-threatening bleeding, direct pressure, packing and tourniquets, and the hands-on part, practicing on a simulated wound and tightening a tourniquet on a partner, is the part a card cannot give. Many shops add it alongside a standard first aid and CPR course rather than in place of one. See related: How to Choose First Aid and CPR Training for the Crew.

References

• American Red Cross and American Heart Association, current first aid guidelines on control of life-threatening bleeding and tourniquet use.
• American College of Surgeons, Stop the Bleed program materials.
• Committee on Tactical Combat Casualty Care, recommended tourniquet list.
• See related: How to Apply a Tourniquet and Pack a Wound; Amputations and Saving the Part.
• See related: Bloodborne Pathogens and Helping a Bleeding Coworker; The First Five Minutes After Someone Is Hurt.