In these troubled times, traumatic wounds may be commonplace is scenarios where there is civil unrest or failure to enforce the rule of law. In survival scenarios, daily activities may cause injuries that could be life-threatening. Therefore, the person medically responsible for a family or mutual assistance group must always be prepared for the worst possible injuries in good times or bad. Some of these, especially those that cause bleeding in the abdomen and chest, are likely to be fatal without advanced medical care. This article is written on National Stop The Bleed Day, a national acknowledgment of the importance of learning to control hemorrhage.
How To Apply Direct Pressure
We’ve established in previous articles that, when you encounter a person with a bleeding wound, the first course of action is to stop the hemorrhage. In the grand majority of mild-moderate cases, direct pressure on the bleeding vessel might stop bleeding all by itself.
The medic should always have nitrile gloves in his or her pack; Gloves will help prevent the wound from contamination by a “dirty” hand. Try to avoid touching the palm or finger portions of the gloves as you put them on. If there are no gloves, grab a bandanna or other barrier; thick is better than thin. Although clean hands are important, don’t spend a lot of time looking for the hand sanitizer. Expose the wound and stop the bleeding immediately.
If you have a medical kit, you will have to get to the items you need. In this case, you can temporarily apply pressure on the wound with a knee to keep hands free for the few seconds it should take to access your equipment. Always keep the bleeding control items obviously accessible to anyone, as there may be circumstances when you’re the victim.
There isn’t a great deal of consensus regarding the proper way to apply direct pressure, but some actions are just common sense. Hold a barrier dressing or cloth item in one hand and place directly on the bleeding area. Place the other hand on top of the first and, arms straight, position the most weight directly over the wound and press downward. This will give the maximum amount of pressure possible on the bleeding area (usually, the part of the wound closest to the torso). Your goal is to allow the body to form a clot in the bleeding blood vessel, which stops bleeding long-term.
Bleeding in an extremity may sometimes be slowed by elevating the limb, while still maintaining direct pressure, above the level of the heart. This decreases the blood pressure in the limb and, thus, the force by which blood leaves the body. Although this strategy doesn’t always work, it’s unlikely to worsen the situation.
When Direct Pressure Doesn’t Work
It may become apparent very quickly that direct pressure is failing to work. Bleeding that doesn’t respond to direct pressure and may become life-threatening is characterized by:
- Blood spurting or pouring out.
- Clothes saturating with blood.
- Amputation injury.
- Victim becoming confused, disoriented, or loses consciousness.
If life-threatening bleeding involves an extremity, it is time to skip or abandon direct pressure and immediately place a tourniquet. Waiting will only cause further loss of precious oxygen-carrying blood.
For those with training, a curved instrument known as a “hemostat” can be used to clamp a damaged vessel. This should only be done if you can easily reach and clearly visualize the point of bleeding. The vessel is then tied off with suture string. This isn’t always possible, as transected veins and arteries may retreat into the soft tissue, especially in those who are obese.
If bleeding is controlled at this point, pack the wound tightly with dressings towards the bleeding blood vessel (see below for detailed instructions) and cover with a pressure bandage.
Commercially Available Tourniquets
Since tourniquets became a recommended first course of action for heavy bleeding, quite a few have come onto the market. Let’s review some of the tourniquets available for inclusion in your survival medical storage. Note: All of the below require practice to place appropriately.
(Note: “Nurse” Amy has a series of instructional videos on several types of individual tourniquets and their placement, how to stop bleeding, “The Ten Principles of Tourniquet Use,” plus much more on our YouTube channel titled “drbones nurseamy.”)
Tourniquets are generally grouped in two categories: Inflatable or “pneumatic” and non-inflatable (most commonly found in medical kits). Many of these are possible to be applied with one hand by the casualty if necessary. Your choices include:
The CAT (Combat Application Tourniquet): The current generation of CAT tourniquets (Gens 7) has a wide 2.4-inch Velcro band and a one-handed hard plastic bar called a “windlass.” The windlass tightens the band, which should be placed 2 inches or higher above the wound. The windlass can then be secured into place to allow the caregiver use of both hands. The TCCC recommends several tourniquets; the CAT is preferred by the committee.
The SOFT-T (Special Operations Forces Tourniquet): Developed in response to concerns about the sturdiness of the plastic windlass in the CAT tourniquet, the SOF-T has a windlass made of fuselage-grade aluminum. A sturdy buckle eliminates the need for threading the tourniquet and secures the strap in place. Like the CAT tourniquet, it is also TCCC approved; newer generations with different designs are available.
The SAM-XT Extremity Tourniquet: Designed by the maker of Structural Aluminum Malleable (SAM) splints, the SAM XT is another option approved by the TCCC. Slack is the main cause of failed tourniquet application; SAM XT’s buckle technology auto-locks at a predetermined amount of circumferential force, eliminating nearly all tourniquet slack.
The MATCOMBAT (Mechanical Advantage Tourniquet): This tourniquet is a cuff with a “key” that you wind like an old-fashioned wind-up toy. There is a spot on the MAT that, when pressed, releases pressure instantly. Pressure may also be released by disengaging the buckle (which must be clipped into place at the beginning of the procedure). Best used with two hands.
The SWAT Tourniquet: SWAT stands for “Stretch, Wrap, And Tuck.” The SWAT tourniquet is a wide elastic band that can serve as a tourniquet or pressure dressing, and is very simple to use. It is compact, lightweight, inexpensive, and effective on very small children or adults and animals. The SWAT is often carried as a backup to other tourniquets due to its versatility. A SWAT tourniquet is able to be placed higher than military style tourniquets, and may be used to stop bleeding even in the groin, shoulder, and axilla (armpit). It can serve as a pressure dressing, an elastic (ACE) wrap, a sling, and also to stabilize splints. This is one of the few tourniquets that does not have a risk of pressure loss (re-bleeding) shortly after placement, as it maintains steady pressure to the tissue underneath.
The Ratcheting Medical Tourniquet-Tactical (RMT-T): Another ratcheting-style (self-locking) tourniquet, the RMT-T is lightweight and compact, but is marketed, at present, mostly for law enforcement and military use. TCCC approved.
The Tactical Mechanical Tourniquet (TMT): The TMT claims to be faster than other tourniquets for both one- and two-handed use, with a wider band and dual locking system to prevent pressure loss, a common problem that occurs shortly after application of non-elastic tourniquets and may start re-bleeding. Targeted for adults and older children. TCCC approved.
The TX2-inch and TX3-inch tourniquet: Another wide-strap ratcheting (self-locking) tourniquet meant for rapid one- or two-handed use. TCCC approved.
The Parabelt: The Parabelt is a utility belt designed for daily wear that becomes a ratcheting tourniquet with a self-locking system when needed. Available in several different sizes.
The RATS (Rapid Application Tourniquet System): The RATS tourniquet is essentially a flattened bungee cord that is wrapped around the extremity above the wound and then fitted into a metal clip to maintain pressure. Relatively inexpensive, it must be placed appropriately to avoid ligature effects on the skin. Each successive coil of the cord must be placed next to, not on top of, the first coil around the extremity. One of the few tourniquets that may work effectively on small children and pets.
The EMT (Emergency and Military Tourniquet): Commonly used in operating rooms, pneumatic tourniquets are reminiscent of a blood pressure cuff and are inflated until bleeding stops and pulses disappear. It is important to make sure the application avoids crinkling or folding of the cuff to avoid skin damage and other issues. This item imparts the unique ability of knowing exactly how much pressure is being applied. TCCC approved.
The TPT2 and TPT3 (Tactical Pneumatic Tourniquet 2-inch and 3-inch versions): Another brand of pneumatic tourniquet, it’s highly effective in stopping hemorrhage, but took slightly longer than the EMT to apply in one comparison study. The TPT2 is TCCC approved.
In addition to tourniquets for extremity wounds, there are “junctional” tourniquets which are meant to be used in areas like the groin, pelvis, and underarm. For specialized tourniquets in junctional areas like the armpit, pelvis, hip, and groin, the TCCC guidelines approve the use of the Combat Ready Clamp (CRoC), SAM Junctional Tourniquet (SAM-JT), and Junctional Emergency Treatment Tool (JETT). These use mechanical or pneumatic compression to achieve their goals, but are more complex to use than extremity tourniquets. A minority of life-threatening wounds in the field will occur in these locations, however.
Be aware that there are many products available online that are imitations of the real thing. When investing in life-saving equipment, it’s important to know its origin. For example, CAT tourniquets are distributed in the USA only by North American Rescue; they do not have a jumping “cat” logo as some imitations do.
Fully 38 percent of civilian bleeding injuries and 42 percent of battlefield wounds involve the head and neck. Penetrating neck injuries are particularly concerning, as the death rate can range up to 50 percent. A simple item for hemorrhage control approved by the military’s TCCC guidelines for head and neck bleeding is the iTClamp. The iTClamp is not a tourniquet, but a hemorrhage control device for use in the extremities, underarm, groin, scalp, and neck, where wound edges are close together and tourniquet use is not an option.
The iTClamp® works by closing the skin breach overlying a wound. This action forms a collection of blood (a “hematoma”) inside the wound cavity that generates pressure which reduces further blood loss from the injured vessel. The action of the device is similar to applying direct pressure, while leaving the medic’s hands free to perform other duties. It’s compact enought that several can be carried by the medic. It is placed similarly to how you place a clamp to hold documents together. An added benefit of the iTClamp® is that it does not require additional direct pressure once deployed. Of course, in neck wounds, close monitoring of the airway is important.
Packing A Bleeding Wound
Some wounds that are deep or wide may require packing gauze dressings tightly towards the bleeding blood vessel while maintaining firm pressure at all times. If possible, fill the wound all the way to the skin surface. If you don’t have special blood-clotting gauze, use plain bandages, dressings, or even clean cloth to pack the wound. Vacuum-packed dressings (also called “compressed gauze”) are so compact that it’s easy to fit several into your pack. They’re an excellent addition to medical storage.
Packing of wounds with dressings is useful in many situations, but not all. Wounds of the neck, for example, are problematic due to the risk of compressing airways. Packing injuries in the abdomen, pelvis, and chest may not be effective due to the depth of the bleeding vessels. This is one reason why, in an off-grid setting, the death rate (called “mortality”) from these wounds is so high. Statistics from the Civil War put mortality rates for major injuries in these regions at close to 70 percent. This figure might also be expected in long-term austere settings.
To pack a deep or wide wound:
- Use specialized hemostatic gauze (QuikClot, ChitoSam, Celox, etc.); if not available, use clean gauze or cotton.
- Pack towards the bleeding blood vessel directly.
- Keep two fingers firmly against the gauze in the wound and use one or two fingers of the other hand to push in successive folds of gauze.
- Quickly move the fingers inside the wound over the new folds of gauze to maintain pressure against the bleeding vessel.
- Add more folds of gauze quickly until the entire wound is filled.
- Maintain direct firm pressure towards the bleeding vessel for at least 10 minutes (3 minutes for hemostatic gauze).
What if you don’t have hemostatic gauze and more than one dressing is required to keep the wound from bleeding? If so, don’t remove the dressings that are in place, even if soaked. Removing them may disturb forming clots. Just add more on top. If you, however, do have hemostatic dressings like QuikClot and they become saturated, remove and place a new one directly on the bleeding vessel. Their action depends on direct contact with the bleeding vessel to help form a clot.
It’s important to make sure that you begin the packing process and put the most pressure where the damaged blood vessel is located. For example, if the blood was coming from the top (closest to the torso) of a large wound, start packing there and apply firm and direct pressure. You’re especially trying to pack against intact bone, for example, the humerus in the upper arm. This increases the effectiveness of the packing.
If bleeding is controlled at this point, cover with a pressure bandage like the Israeli Battle Dressing, also called the “Emergency Bandage”, a pile of gauze pads covered with an ace wrap or other stretchy wrap, or thick cotton material (sterile is best) covered in wraps of fabric.
Here’s Nurse Amy’s demonstration of a bystander encountering a victim of an active shooter, using our bleeding control kit that’s used at schools, churches, and other public venues:
In off grid scenarios, the control of major bleeding in non-extremity sites, where tourniquets or pressure dressings are not effective, can be the greatest challenge to saving lives. Abdominal injuries are the least compressible wounds and there is usually little that can be done without rapid access to modern medical facilities. Survival rates will be lower from these injuries.
A junctional hemorrhage is defined as bleeding from certain areas where the torso meets the extremities, i.e., the base of the neck, shoulder, axilla (armpit), perineum (area between the vagina and anus), buttocks, and groin.
Principles of non-extremity tourniquets and hemostatic gauze packing:
- Junctional tourniquets, if available, should be used for axillary and groin hemorrhage as the first option. If not available, use hemostatic gauze.
- All hemostatic gauze should be packed tightly towards the bleeding vessel and held in place for at least three minutes with firm direct pressure. Add additional hemostatic gauze or plain gauze to tightly pack and fill up wound after bleeding stops. If bleeding is under control, do not remove hemostatic gauze while packing the wound.
Common Mistakes While Treating Hemorrhage
Errors committed in the approach to bleeding wounds can lead to tragic consequences. Some common mistakes include:
- Panic leading to inaction.
- Not applying firm direct pressure to the wound.
- Hesitating to apply a tourniquet in cases of heavy or life-threatening bleeding.
- Failing to apply pressure to a hemostatic dressing for the required three minutes.
- Loosening and retightening of tourniquets.
- Lack of equipment in at-risk situations.
Obviously, there’s a lot more to it than what’s in this article. In future articles, we’ll the discuss the best way to control hemorrhage by its location on the body.
Joe Alton MD
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Hey, don’t forget to check out our entire line of quality medical kits and individual supplies at store.doomandbloom.net. Also, our Book Excellence Award-winning 700-page SURVIVAL MEDICINE HANDBOOK: THE ESSENTIAL GUIDE FOR WHEN HELP IS NOT ON THE WAY is now available in black and white on Amazon and in color and color spiral-bound versions at store.doomandbloom.net.