It was a cold January morning in 1979 at Colgate University when I was handed my copy of the American Red Cross Advanced First Aid Manual as part of my National Ski Patrol training. Although I had never seen severe bleeding in my life, my instructor assured me that four simple steps would stop almost any bleeding.
1. Application of direct pressure;
2. Elevation of the bleeding site above the heart;
3. Compression of a pressure point (femoral, brachial or temporal), and
4. Use of a tourniquet—only as a last resort (if all the above fail).
Almost 35 years later, I’ve treated thousands of lacerations, hundreds of gunshot and stab wounds, and scores of amputations. Based on that experience, I know one fact for certain: External bleeding can kill your patient unless you stop it. What it takes to control dangerous external bleeding is case-dependent and needs to be accomplished with the right sequence of interventions, coupled with common sense.
But are those four cardinal step-by-step interventions that I was taught in 1979 (both in that first aid course and again in my initial EMT course later that year) really effective interventions for bleeding?
Fast-Forward to 2010
In 2010, the journal Circulation published evidenced-based recommendations for hemorrhage control as part of the 2010 American Heart Association (AHA) and the American Red Cross (ARC) Guidelines for First Aid.1 These guidelines, which were based on current evidence, stated that only direct pressure was a definitively proven intervention (Class I) and that a tourniquet “is indicated only if direct pressure is not effective or not possible” (Class IIb).
Note: Remember that Class I means that the procedure should be performed, and Class IIb means that the benefits are equal to or greater than the risks of the procedure and the intervention may be considered.
Finally, the use of pressure points and elevation were deemed to be Class III interventions—meaning that the risks are greater than the potential benefits and the procedures should not be performed.
Many in EMS consider these guidelines to be etched in stone and have adopted the concept of two-step hemorrhage control (direct pressure, then tourniquet application) as the definitive steps in hemorrhage control. Most importantly to an EMT student, this is the position that has been taken by the National Registry of EMTs and is reflected in their testing process, including the practical station of “bleeding control/shock management.”
There are several problems with the 2010 AHA/ARC guidelines and their effect on EMS. First, the guidelines were written for the first aid provider level of care, not that of an EMT, advanced EMT or paramedic.
For example, the guidelines state when discussing tourniquet use that they have been “shown to control bleeding effectively on the battlefield, and during surgery and have been used by paramedics in a civilian setting without complications.” The intervention is proven for EMS providers, so shouldn’t it at least be considered a Class IIa intervention (i.e., the benefits greatly outweigh the potential risks and the procedure is reasonable to perform)?
My second major criticism of the AHA/ARC first aid guidelines is their dismissal of limb elevation as a means of hemorrhage control. When combined with direct pressure, the elevation of a bleeding extremity is an effective intervention to abate bleeding.
It’s true that there has never been a published, peer-reviewed study that proves the effectiveness of limb elevation. But there has also never been a study that shows it to be ineffective either. This is fundamental gap in “evidence-based” protocol development. Specifically, just because something hasn’t been studied doesn’t mean it’s always necessarily bad—and the combination of simultaneous direct pressure limb elevation is a perfect example.
The use of limb elevation is a common-sense intervention based on the basic physics of gravity and hydrostatic pressure. We know that a dependent limb has a greater venous pressure and blood volume than a limb that is elevated. That’s why you hang a patient’s arm down off the side of the stretcher when trying to start an IV in a rig so that the veins plump with greater blood volume and pressure, making the IV start easier.
Now, I completely agree that in the midst of a gun battle or in the setting of multiple patients with potentially life-threatening extremity bleeding, limb elevation (and perhaps even direct pressure) is impractical. This is an environment for liberal tourniquet use until the threat is neutralized or the scene stabilized.
The bottom line on the simultaneous use of limb elevation with direct pressure can be found in the lyrics of the Lee Brice song: “Don’t try to outsmart your common sense.”
I do agree with the AHA/ARC recommendation that the use of pressure points is likely to be ineffective and is logistically difficult because it’s hard (if not impossible) for a rescuer to simultaneously provide direct pressure to a wound and find and compress a pressure point.
The application of hand or finger pressure to arteries against underlying bones proximal to a bleeding site as an intervention to stop bleeding had been taught for years in EMT textbooks, including the original EMT text book, the 1971 American Academy of Orthopaedic Surgeons “orange book,” Emergency Care and Transportation of the Sick and Injured.2
The classic sites of compression were at the femoral artery as it crossed the inguinal crease, the brachial artery against the underlying medial humerus and the temporal artery against the skull.
The technique really boiled down to a pseudo-tourniquet effect and never seemed logistically feasible. In all my years of clinical work, I’ve used a pressure point only once effectively to control bleeding, and that was while I had an assistant compress a branch of the temporal artery against the skull while I repaired a facial laceration in the ED.
Arriving in 2013
Two new commercial interventions have become mainstays of my management of external hemorrhage: commercial tourniquets and hemostatic dressings.
Commercial tourniquets: Traumatic limb injuries/amputations have pushed the envelope on tourniquet use and the development of newer commercial tourniquet technology that allows for more rapid and predictable application. (Read a related JEMS article at www.jems.com/article/major-incidents/tourniquet-first.)
Hemostatic dressings: Early hemostatic agents were somewhat problematic due to the exothermic reaction they caused when they came in contact with blood.3 The current generation of hemostatic dressings has corrected this issue and should be considered a part of the standard armamentarium of hemorrhage control and used in selective cases. In my capacity as an emergency department physician in a busy inner-city trauma center and, at scenes as an active EMS medical director, I use hemostatic dressings in cases of continued bleeding when direct pressure and elevation have not been fully effective in bleeding control and the circumstances don’t immediately justify the risks of a tourniquet.
A perfect example was a case in which a young man hobbled into the ED with an isolated gunshot wound to his lower leg (see photo). His heavy non-arterial bleeding from multiple fractures and a major vein injury couldn’t be controlled despite direct pressure with elevation. Application of a hemostatic dressing almost immediately stopped the bleeding and made the use of a tourniquet unnecessary. Hemostatic dressings are useful in heavily bleeding wounds in areas where a tourniquet can’t be used, such as the head, neck or torso. A perfect example of this potential use of hemostatic dressing is in an elderly patient on an anti-coagulant medication (e.g., warfarin) with a badly bleeding scalp laceration after a fall.
Based on my clinical experience in the field and in the ED, evaluation of the medical literature and use of common sense, the following is my routine approach to external hemorrhage control in 2013.
1. Apply direct pressure, first with a gloved hand followed by a dressing and bandage to continue necessary wound compression. This will control the vast majority of external bleeding.
2. Elevation should still be used in conjunction with direct pressure in extremity bleeding whenever feasible. This is especially helpful with wounds distal to the elbow or knee.
3. Consider use of hemostatic agents in the subset of patients whose bleeding can’t be completely controlled with direct pressure and elevation, when the patient does not immediately require a tourniquet or when the wound is in a location where you cannot use a tourniquet, such as the head, torso or neck.
4. Rapidly apply a tourniquet(s) to any patient with evident massive extremity bleeding that isn’t immediately controllable with direct pressure or at MCIs or in tactical situations to stop bleeding until triage is completed and you have the time and personnel to remove them and use other hemorrhage control modalities. Remember to always visually “announce” that a tourniquet has been applied via the traditional notation of a “T” on a patient’s forehead.
1. Markenson D, Ferguson JD, Chameides L, et al. Part 17: First aid: 2010 American Heart Association and American Red Cross guidelines for first aid. Circulation. 2010;122(18 suppl 3):S934–S946.
2. Pollack AN (Ed.) Emergency care and transportation of the sick and injured. American Academy of Orthopedic Surgeons. Jones & Bartlett Learning: Burlington, Mass. 1971.
3. McManus J, Hurtado T, Pusateri A, et al. A case series describing thermal injury from zeolite use for hemorrhage control in combat operations. Prehosp Emerg Care. 2007;11(1):67–71.