Massive Hemorrhage Control

BLUF: Aggressive control of massive, external hemorrhage is always THE priority. In this episode, we discuss the most high-yield methods for rapidly controlling a life-threatening bleed, as well as clinical pearls and pitfalls.
Correction: I made a mistake in saying that there are only two CoTCCC approved tourniquets. The Emergency Medical Tourniquet (EMT) is a body-approved device. That said, anecdotally, use of that device is uncommon in the prehospital realm. – Ryan

Amenable vs Non-Amenable Hemorrhage

Amenable: Limb hemorrhage that will facilitate tourniquet use

Non-Amenable: Junctional or internal hemorrhage that tourniquet use will have little to no effect on.

Tourniquet Pearls & Pitfalls


  • Place the tourniquet on an amendable site.
  • Turn the windlass until the distal pulse is OBLITERATED, if the anatomy of the injury allows. If not, tighten at least one turn past when hemorrhage stops.
  • Secure the TQ and mark the time.
  • If steps one through 4 fail, apply a second TQ until you’ve controlled the bleed. Some extremities and body habitus will require an additional TQ for adequate control.


  • Failure to properly tighten the band
  • Failure to apply rapidly
  • Failure to apply a second TQ
  • Fear of causing additional pain to the patient
  • Periodically loosening the TQ to allow distal bloodflow.

Wound Packing

  • PRESSURE – hold pressure over the wound area or on an applicable pressure point.
  • EXPOSE – Expose the wound margins as best possible.
  • IDENTIFY – Identify the major bleeding point within the wound. This may require some probing, but you need to evaluate where to best apply the gauze.
  • PACK – Using one finger to hold pressure on the ruptured vessel, take the other finger and ball bit of gauze around it. Then, while maintaining pressure with the other finger, direct that gauze right into the bleeding area.
  • PRESSURE – Maintain pressure the ENTIRE time you’ve packed the wound.
  • PILE gauze into and above the wound. If you need another roll, use it.
  • EVALUATE – While packing and following packing, ensure that blood isn’t leaking through or around the gauze. If blood continues to arise from around the gauze, you will need to repack – the broken vessel isn’t adequately occluded.
  • PRESSURE (Again) – Once you have the wound packed, take a compressive wrap or pressure dressing and hold pressure on that wound. If you’re using a hemostatic agent, most will require you to hold manual direct pressure on the wound for three minutes.

MARCH Algorithm for Trauma Management

M – Massive Hemorrhage

A- Airway

R – Respiration

H- Head/Hypothermia

References :

  1. Kragh, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2008). Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma. The Journal of Trauma: Injury, Infection, and Critical Care, 64(Supplement), S38–S50.
  2. J.F., K. J., T.J., W., D.G., B., C.J., F., C.E., W., J., S., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 249(1), 1–7.
  3. Kragh, J. F., & Dubick, M. A. (2017). Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science. Wilderness and Environmental Medicine.
  4. Kragh, J. F., Dubick, M. A., Aden, J. K., McKeague, A. L., Rasmussen, T. E., Baer, D. G., & Blackbourne, L. H. (2015). U.S. Military Use of Tourniquets from 2001 to 2010. Prehospital Emergency Care, 19(2), 184–190.
  5. Kragh, J. F., Swan, K. G., Smith, D. C., Mabry, R. L., & Blackbourne, L. H. (2012). Historical review of emergency tourniquet use to stop bleeding. American Journal of Surgery.
  6. Lee, C., Porter, K. M., & Hodgetts, T. J. (2007). Tourniquet use in the civilian prehospital setting. Emergency Medicine Journal, 24(8), 584–587.
  7. Kragh, J. F., Littrel, M. L., Jones, J. A., Walters, T. J., Baer, D. G., Wade, C. E., & Holcomb, J. B. (2011). Battle casualty survival with emergency tourniquet use to stop limb bleeding. Journal of Emergency Medicine, 41(6), 590–597.
  8. Rall, J. M., Cox, J. M., Songer, A. G., Cestero, R. F., & Ross, J. D. (2013). Comparison of novel hemostatic dressings with QuikClot combat gauze in a standardized swine model of uncontrolled hemorrhage. The Journal of Trauma and Acute Care Surgery, 75(2 Suppl 2), S150-6.
  9. Watters, J. M., Van, P. Y., Hamilton, G. J., Sambasivan, C., Differding, J. A., & Schreiber, M. A. (2011). Advanced Hemostatic Dressings Are Not Superior to Gauze for Care Under Fire Scenarios. The Journal of Trauma: Injury, Infection, and Critical Care, 70(6), 1413–1419.
  10. Littlejohn, L. F., Devlin, J. J., Kircher, S. S., Lueken, R., Melia, M. R., & Johnson, A. S. (2011). Comparison of Celox-A, Chitoflex, WoundStat, and combat gauze hemostatic agents versus standard gauze dressing in control of hemorrhage in a swine model of penetrating trauma. Academic Emergency Medicine, 18(4), 340–350.
  11. Kotwal, R. S. (2011). Eliminating Preventable Death on the Battlefield. Archives of Surgery, 146(12), 1350.

CoTCCC Guidelines:

Click to access TCCCGuidelinesforMedicalPersonnel170131Final.pdf


3 thoughts on “Massive Hemorrhage Control”

  1. I would guess that nearly all civilian EMS providers have never been given any training on wound packing or any advanced bleeding control skills. That said, I think a training update course should be developed covering these skills given the wide gap in knowledge. Wish I had the expertise to do it myself.

    1. Thanks for the comment, Kyle! I’d wager you’re right: the vast body of EMS providers probably haven’t recieved training in wound packing and associated techniques.

      The good thing is that these techniques aren’t technically complex, and anyone can learn them – you only need a good educational foundation and decent practice. PHTLS and associated NAEMT courses have been updated to reflect training on the topic, too. If you’re looking for a solid course, check out the Stop the Bleed campaign. Great folks doing great work. Check out course listings here:

      Best of luck, and thanks for the interest!

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