• The first aid provider should apply pressure around an embedded object (e.g., a knife), and try to stabilise the object. Avoid removing the object.
• Tourniquets should only be used for life-threatening limbs bleeding. They may help save a life but may have severe consequences (e.g., amputation of the limb), especially if applied for too long.
Once a tourniquet has been applied, keep it in place until EMS arrives.
Chain of survival behaviours
Prevent and prepare
• Learn how to control bleeding using the resources likely to be available such as bandages, clothing, or manufactured tourniquets.
Early recognition
• Blood is flowing from a wound.
• Action to stem the flow of blood should be taken as soon as possible. Even a cupful of blood, although not immediately life-threatening, can lead to fast deterioration if not stopped early on.
First aid steps
1. Ask the person to apply direct pressure to their own bleed with their hands.
2. Help the person to lie down.
3. Access emergency medical services.
4. Apply direct pressure to the bleed. If blood soaks through the dressing, apply a second dressing over the first one, applying greater pressure.
5. If direct pressure is ineffective and the person is bleeding from an arm or leg, consider applying a tourniquet if available. If no tourniquet is available or it cannot be applied, consider applying a haemostatic dressing, if available, and continue to put direct pressure on the bleed.
6. Shock is likely to develop from significant bleeding. Help the person to lie down on their back and keep them warm by wrapping them in clothing if necessary.
NOTE
• If the injured person can apply pressure to their own wound, this can reduce the risk of cross-infection and keep both the first aid provider and the injured person safe.
• To apply direct pressure to a wound and avoid contact with the person’s blood, use a bandage, cloth or some plastic as a barrier between your hand and the person’s wound.
• If the person becomes unresponsive, open their airway and check for breathing. (See Unresponsiveness topics).
• If there is an embedded object in the wound - such as a knife - apply pressure around the object and try to stabilise the object itself. Avoid removing the object.
Special case
• In situations of disaster or of conflict, including war, terror attack or violent attack (such as shooting or stabbing), the safety and security of the first aid provider and the injured person are paramount and take precedence over providing immediate care. See contexts Conflict or Disaster.
• The application of tourniquets in war, terror or other violent attacks may be used as the first short-term “stop the bleed” measure, to either deal with the overwhelming number of injured people or to get people with severe life-threatening bleeding out of an immediate
Access help
Severe 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
Context considerations
• Consider the local health system, especially the availability of well-developed emergency care and manufactured tourniquets to decide whether to include tourniquet education.
• Consider local laws and regulation as well as the availability of haemostatic dressings before including them in learning design.
• Some contexts may have a high incidence of bloodborne pathogens (for example of HIV) or there may be low incidence but high levels of fear about them. In these contexts, allow learners to consider real versus perceived risks associated with the transmission, and reinforce good universal precautions.
• Use scenarios built around the local industry (e.g., agriculture) or local factors such as road traffic behaviour or violent conflict or crime, to make education on this topic relevant to learners.
Learner considerations
• Consider where learners live and work and discuss the most likely causes of injuries that cause bleeding in the local setting to give context and relevance to the topic.
• This topic can be quite graphic (both in training and in reality). The use of images and video can be helpful and can prepare the learners for what they might see in reality. However, this may be unsuitable for children and some other learner groups. Scenarios and storytelling with or without actors might produce engagement without fear and upset.
• Conversely, the use of fake blood to create scenarios and pretend injuries can be fascinating and informative for learners and encourage engagement.
• Check whether learners have a first aid kit, dressings or manufactured tourniquets in their homes, or whether they might be able to access them (Andrade et al., 2020).
• Consider only including haemostatic dressings in training for more advanced first aid providers and in instances where learners may enter remote areas.
Facilitation tips
• Discuss with learners how to recognise a severe bleed: how much blood is coming out, what does it look like? Discuss it in terms of volume (e.g. cup-full, ounces); how it looks (forming a puddle or pool, soaking through the bandage); and the emotional reaction they might have (Pellegrino et al., 2020).
• Emphasise that timely intervention to stop bleeding is vital and may be a life-saving action. Applying pressure to a bleed is often a simple action, easy to do and can be very effective.
• Support learners to practise feeling how much and what sort of pressure is needed to stop a bleed and how this will feel for the injured person. Consider different postures that learners could take to apply sufficient pressure depending on their physical strength (Charlton et al., 2019).
• Discuss with learners what action they should take depending on where the bleed is coming from on the body: when to use a tourniquet (on a limb), when to apply pressure or use a dressing (Pellegrino et al., 2020).
• Discuss the practicalities of there being a lot of blood and what to do when a bandage is soaked through. Explain that the pressure will be reduced if more and more bandages are applied (Charlton et al., 2018).
• Encourage learners to think creatively about what materials they have near them in their relevant contexts that they could use to stop a bleed, for example, a clean towel or T-shirt. Emphasise that even if there is nothing available, they can apply pressure with their own hand if they do not have
• Emphasise the primacy of direct pressure before finding a bandage to apply. Once the flow of blood has been stopped using pressure, help learners to practise applying a bandage so that it is secure and maintains sufficient pressure. Try bandaging different body parts.
• The topic of bleeding has many potential barriers to helping for learners such as infection, fear of blood or concerns of violence. While these should be explored, the aim should be to develop pro- helping strategies.
• Explore ways learners could protect themselves and the injured person from blood-borne viruses while still providing life-saving care if this is a concern (e.g., they could wear gloves or ask the injured person who is bleeding to apply pressure to their own wound.) Avoid creating a barrier to helping through fear of infection. Explore what alternatives may be available if a person doesn’t have gloves (e.g., a plastic bag).
• Facilitate a discussion of the common fear people have of blood and highlight this as a possible barrier to helping. Allow learners to practise dealing with bleeding if it may help build their confidence or develop other strategies to overcome their barriers (e.g. directing the injured person to apply pressure to their own wound).
• Emphasise that objects embedded in a wound should be left where they are if there is the possibility of severe bleeding as the object may be acting as a ‘plug’. Removing it may make the bleeding worse.
Tourniquets and haemostatic dressings
• If teaching learners about tourniquets, train them on how and when to use them as this is essential for safe and effective use. Tourniquets are powerful tools for bleeding control but can also cause harm if used incorrectly. Emphasise that tourniquets should only be used when direct pressure on the bleed is ineffective and the injury is on a limb.
• Consider what style of a tourniquet is available locally, and train in that specific style. Training in applying one style of a tourniquet will not necessarily facilitate skill transfer to other tourniquet styles (McCarty et al., 2019).
• Discuss why improvised tourniquets might be less effective. This could be because they cannot be adequately tightened to provide the required amount of pressure and are more likely to break (McCarty et al., 2019).
• Emphasise that the application of a tourniquet is very painful if done correctly, and the injured person may respond violently and try to remove the tourniquet. By being prepared for this the first aid provider can ensure their own safety, but also prepare the injured person, which will make it easier for them to cope with the pain.
• If haemostatic dressings are included in education, training in the proper assessment of severe bleeding and the dressing application techniques are required. Emphasise they should only be used in instances of life-threatening bleeding (Goolsby et al., 2019; Zeitlow et al., 2015).
Facilitation tools
• Provide a glossary of terms of words or phrases that may be used interchangeably (bleeding and haemorrhage for example).
• Discussing what ‘severe bleeding’ means and looks like could be a useful starter for this topic. This could take place as a discussion exercise using a flip chart with the heading, “What other words can you think of that describe ‘severe’ bleeding?” (for example, gushing, flowing, spouting, running like an open tap, soaking through the bandage, pooling on the floor etc).
> This could be followed by exercises based on images and the questions:
 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?
> Facilitators can use this to develop a ‘common language’ and understanding for the rest of the topic.
• Encourage learners to share their experiences of accidents where there has been severe bleeding, and for groups of learners to explore the topic through storytelling and role-play scenarios. Role- play can be particularly beneficial as a dynamic and interactive learning format.
• It may be useful to show how different clothing or flooring can affect the perception of how much blood has been lost. Soil or thick clothing for example can demonstrate how severe blood loss can be hidden.
• Use a range of objects to demonstrate bleeding and how to treat it. For example, get a plastic bottle (full of water coloured with food dye). This could be wrapped up in clothing to look less like a bottle. Then an object (nail, knife, etc) could be pushed into it to simulate a penetrating object.
With someone else squashing the bottle (to simulate the blood pressure and cause the ‘wound’ to bleed) learners could practise how to apply pressure, how to stabilise an embedded object or how to dress a wound.
• Alternatively, use fruit (such as an apple) to create ‘wounds’ which can be dressed. Or use teddy bears to practise applying pressure or bandaging.
• Use simulation to help learners experience the real challenges they may face when dealing with someone who has an object embedded in their body. Highlight the importance of reducing harm, when the possibility of not moving the object is competing with the possibility of moving the person to a health facility.
• Creation of fake wounds using fake blood and other makeup products can help create realistic scenarios to support learning.
• If you have multiple tourniquets, hand them out to the learners. Then demonstrate the correct application of the tourniquet on a volunteer (without tightening it completely) and ask learners to repeat it. Gradually increase the stress of the scenarios: put time limits on, increase background noise, shout (only once a level of trust has been created) and eventually have learners apply tourniquets in uncomfortable and challenging settings, such as upside-down or in the dark. Also, there is value in teaching them how to self-administer, especially when educating weapons bearers.
• If appropriate to the learner group, use visual resources to enable realistic exposure to the sights and sounds associated with the subject and an opportunity to see the graphic nature of some injuries.
Learning connections
• Learners should be taught to recognise the signs of Shock.
• Conditions which may result in severe external bleeding include Amputation, Chest and abdomen injuries, Cuts and grazes, Mammal bites and Fractures.
• Note particularly that an open chest wound may be bleeding but require careful management to ensure the wound can communicate with the air. See Chest and abdomen injuries.
• Internal bleeding is a life-threatening condition, the management of which is outlined in Shock, with the emphasis being on recognition and positioning.
• Maintaining the safety of the first aid provider is paramount. See General approach.
• Localised application of ice or something cold may be beneficial for a minor, closed bleeding injury such as bruising or a haematoma.
Scientific foundation
Systematic 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 pressure
Six 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
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 points
No human studies were identified comparing the use of pressure points with direct manual pressure.
Tourniquets
In 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 dressings
19 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 review
Several 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