Patient Care, Trauma

Hemorrhage Control Concerns

Issue 4 and Volume 40.

This month, authors Dennis Filips, MD, and Joe Holley, MD, FACEP, of the December 2014 article “Hemorrhage Control Myth Busters: 10 myths that need to be understood & addressed by emergency personnel,” respond to feedback on their article from members of the American College of Surgeons Committee on Trauma. Both letters were edited for space.

Clarifying Hemorrhage Control

This is a good article covering many of the fundamentals of hemorrhage control by prehospital personnel and for that the authors are to be commended. … Additionally, some of the issues raised don’t reflect the current position of the American College of Surgeons (ACS) Committee on Trauma and several recent references should be included. We wish to clarify the following points:

1. ATLS (advanced trauma life support) is an inappropriate resource to cite for prehospital care providers. ATLS’s primary audience is physicians working in heavily resourced environments, such as EDs and trauma centers. Additionally, the authors didn’t cite the most recent edition of ATLS. PHTLS (prehospital trauma life support) is a much more relevant resource for prehospital care providers and stresses techniques for external hemorrhage control and the importance of early hemorrhage control, particularly in tactical situations.

2. Direct pressure without digital pressure is effective in many instances; it depends on the depth, size and location of the wound. We don’t think it’s appropriate to dismiss direct pressure as a technique for prehospital providers.

3. Pressure dressings may be effective, again, depending on the depth, size and location of the wound.

4. We direct the authors and readers to the following article published in 2014, titled “An evidenced-based guideline for external hemorrhage control,” that involved a comprehensive review using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology of the extant literature regarding external hemorrhage control, including the use of commercially available tourniquets. The benefits of tourniquet use, when properly applied, are well defined, particularly in military literature. PHTLS, once again, has a strong presentation of techniques for tourniquet application. Clearly, tourniquets can’t be used for injuries involving junctional hemorrhage.1 Additionally, an article published in 2013 supports the use of tourniquets even by the general public in situations involving external hemorrhage of the limbs.2

5. We agree that wound packing isn’t often taught to prehospital care providers. However, as a relatively easy technique it can be very effective when augmented by the use of hemostatic agents, particularly impregnated gauze. This technique should be further emphasized in prehospital training programs, just as it’s taught to military first responders and medics.

6. PHTLS notes that in patients with adequate breathing and in the face of external bleeding, hemorrhage control may take precedence over the standard ABCDE approach. This approach has also been promoted for mass casualty situations via the SALT mass casualty triage algorithm, endorsed by the ACS Committee on Trauma.3

7. The use of helicopters for trauma patients is discussed in a position statement titled, “Appropriate use of helicopter emergency medical services for transport of trauma patients: Guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons.”4

Clearly there’s still much work needed to prepare all healthcare providers and the general public in hemorrhage control techniques. There’s a good deal of evidence that outlines what the ACS Committee on Trauma promotes as state-of-the-art. Our recent and ongoing conflicts in Iraq and Afghanistan have informed this practice and are now being translated into the civilian EMS community.

Eileen Bulger, MD, FACS;
Nels D. Sanddal, PhD, CEMSO, REMT
& Donald H. Jenkins, MD, FACS

Via email


1. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guide for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163–173.

2. Jacobs LM, McSwain NE Jr, Rotondo MF, et al. Improving survival from active shooter events: The Hartford Consensus. J Trauma Acute Care Surg. 2013;74(6):1399–1400.

3. SALT Mass Casualty Traige Algorithm (Sort, Assess, Lifesaving Interventions, Treatment/Transport) – Adapted for a very large radiation emergency. (Nov. 21, 2014.) Radiation Emergency Medical Management. Retrieved Feb. 12, 2015, from

4. Doucet J, Bulger E, Sanddal N, et al. Appropriate use of helicopter emergency medical services for transport of trauma patients: Guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons. J Trauma Acute Care Surg. 2013;75(4):734–741.

Authors Dennis Filips, MD & Joe Holley, MD, FACEP, respond: Thank you for formulating these great questions and concerns regarding our article. We believe the ACS Committee on Trauma, PHTLS, and the authors are in alignment on attempting to provide thoughtful trauma education.

Although PHTLS is more relevant to prehospital care providers, it has only recently introduced its bleeding control course since the publication of our article; the subtle realities of obtaining hemorrhage control were the article’s focus. A large percent of ATLS providers are family doctors working in community hospitals. Although more heavily resourced than an ambulance, community hospitals are often less equipped to deal with bleeding than many ambulances, which may carry tourniquets, iTClamps, hemostatic dressings, etc.

The community hospital should be thought of as an extension of the prehospital environment and physicians need to be taught hemorrhage control. Hemorrhage control from compressible regions isn’t a skill taught in ATLS. Perhaps the ACS Committee on Trauma will consider incorporating the PHTLS bleeding control course into its ATLS courses.

Direct pressure wasn’t dismissed. It’s an important skill that’s often poorly taught because it isn’t well understood and there are no published standards on how to apply direct pressure. The purpose of this myth was to point out that providers attempting direct pressure often apply diffuse pressure over a wide area instead. It also points out the limitations of maintaining direct pressure during transport and understanding the time limits in which an individual can apply effective manual direct pressure.

We agree with the comment on pressure dressings. Problems arise when pressure dressing failures are recognized late and not adequately dealt with because more dressings are placed on top of the old ones.

This article provides an overview of hemorrhage control that articulates the levels of supporting evidence well. … The myth buster article stresses the importance of good education to make these recommended techniques work and to understand their limitations in the field.

The Hartford Consensus is an important article that highlights the need to have hemorrhage control tools widely available for use by the general public with minimal training. Let’s not overlook the article by David R. King, MD, showing 83% of tourniquets applied in the military setting weren’t tightened enough to occlude distal pulses.1 We also know that extensive training, such as what U.S. Rangers experience, results in properly applied tourniquets. Providing hemorrhage control at the earliest possible time will improve clinical outcomes. The ease in which these tools can be used and need for wider availability can’t be overstated.

Our backgrounds include extensive experience teaching wound packing with hemostatic agents to prehospital care providers. Teaching how to pack a wound is critical, no matter what you’re packing it with. The subtleties of wound packing are at times lost in training because the models are often unrealistic. The U.S. military has made extensive use of live tissue training to provide realistic models to practice on, though this training isn’t widely available to civilians. The purpose of this myth was to highlight that hemostatic agents don’t work by magically placing it over or in a wound; they need to be properly packed into a wound. The new PHTLS bleeding control course should help educators address this issue.

Hopefully mass casualty management can be standardized and we commend the ACS Committee on Trauma for its ongoing efforts to bring hemorrhage control into the forefront of trauma management. We fully support the position statement referenced. Our goal was to emphasize the need to control hemorrhage early, regardless of the mode of transportation or certification of the transportation’s providers. Rapid transportation is vital, but hemorrhage control shouldn’t wait until arrival at a trauma center.


1. King DR, van der Wilden G, Kragh JF Jr, et al. Forward assessment of 79 prehospital battlefield tourniquets used in the current war. J Spec Oper Med. 2012;12(4):33–38.