Types of Bleeding & Initial Care

External Bleeding

A cut or other visible break in the skin causes external bleeding.

Some causes of external bleeding include: Cuts, Bullet Wounds, Shrapnel, Stabbings, Open Fractures, Partial or complete amputations.

You must remain calm while administering SABC to a bleeding casualty. Although uncontrolled bleeding can be fatal, you will usually have enough time to control it and save a life.

Capillary Bleeding: the most common type of external bleeding. It is usually not serious and is the easiest form of external bleeding to control.

Venous Bleeding: more serious than capillary bleeding. However, it is frequently controlled by effectively applying direct pressure.

Arterial Bleeding: the most serious type of external bleeding. It is easy to identify because the blood is bright red in color. Sometimes bleeding will sluggishly or rapidly spurt out of the body. This bleeding can lead to a large amount of blood loss in a short period of time because the blood flows at a faster rate and is less likely to clot. Quick administration of SABC can prevent the casualty from bleeding to death before additional medical help arrives.

Bleeding Control: 

The following describes a quick patient assessment for external bleeding.

 1: Evaluate the casualty.

-Check the casualty for blood-soaked clothing or pools of blood.

-Check for both an entry and exit wound.

-Make sure you check the casualty’s back, using your hands to feel for bleeding and wounds

 2: Expose the area around the wound by removing, tearing, or cutting away clothing.

 3: If there is more than one wound, treat the most serious wound first.

External Bleeding Treatment

You can control external bleeding by following these steps:

-Direct Pressure

-Elevation of extremities

-Pressure points

-Tourniquets

-QuickClot Combat Gauze

Each method will be discussed throughout the remainder of the lesson.

Emergency Bandage Application to the Extremities

Direct pressure is the first and most effective method to control bleeding. The IFAK contains two emergency bandages designed for this purpose. The emergency bandage combines a sterile, non adherent dressing and a bandage into one unit. The dressing is applied to the wound and the bandage into position to provide direct pressure and to control bleeding.

The following steps demonstrate the application of the emergency bandage to the leg. However, these same steps can be used when applying the bandage to any extremity.

 1: Place pad on wound and wrap the elastic bandage around the leg.

 2: Insert elastic bandage completely into the pressure bar.

 3: Once the elastic bandage is placed through the pressure bar, REVERSE the wrapping direction and continue bandaging the wound. This forces the pad onto the wound and provides direct pressure and controls bleeding.

 4: DO NOT remove the emergency bandage if the wound bleeds through it. Place another emergency bandage or an improvised dressing OVER the top of the existing bandage.

Direct Pressure: Emergency Bandage Application to the Head

The following s demonstrate application of the emergency bandage to the head.

 1: Place pad on wound, and wrap the elastic bandage around the head.

 2: Insert elastic bandage completely into the pressure bar.

 3: Once the elastic bandage is placed through the pressure bar, REVERSE the wrapping direction and continue bandaging the wound. This forces the pad onto the wound and provides direct pressure and controls bleeding.

 4: After wrapping the bandage around the head, wrap the bandage at least once underneath the chin so it looks like a helmet strap, and then continue wrapping around the head. Wrapping underneath the chin will prevent the bandage from shifting positions or coming off the casualty.

 5: DO NOT remove the emergency bandage if the wound bleeds through it. Place another emergency bandage or an improvised dressing OVER the top of the existing bandage.

Alternate Emergency Bandage:

You may find an alternate type of bandage in your IFAK with an “H” shaped closure bar to provide pressure to the wound instead of an arc shaped pressure bar. 

The following demonstrates the technique to secure the emergency bandage if it has an “H” shaped closure bar. The wrapping technique is the same for head and extremity wounds.

 1: Place the pad on the wound, with the “H” centered where you want the most pressure applied.

 2: Wrap the elastic bandage around the leg and use the Velcro strip to initially hold the first pass.

 3: Loop over the stem of the “H” and pull snug.

 4: REVERSE the strapping direction and loop the bandage over the opposite stem of the “H” and again pull snug. This forces the pad against the wound and provides direct pressure to control bleeding.

 5: Again REVERSE the wrapping direction and continue wrapping until you cover as much of the gauze as possible. You only need to hook around each stem once.

 6: Secure the end using the adherent Velcro strip.

 7. Do NOT remove the emergency bandage if the wound bleeds through it. Place another emergency bandage or an improvised dressing OVER the top of the existing bandage.

*If an emergency bandage is not available, these items may be used to control bleeding: T-shirts, Towels, Socks, and any other clean/absorbent material. If no improvised items are available, place your hand on top of the wound, apply firm pressure, and elevate until additional medical help arrives.

Elevation Procedures

Elevating a bleeding extremity above the level of the heart makes it difficult for the heart to pump blood to the extremity and will help control bleeding. 

You may use more than one method to control bleeding. If direct pressure alone is ineffective, elevating the extremity combined with direct pressure will often stop the bleeding. Use these techniques together IF the don’t cause the casualty more pain or worsen the severity of the wound.

Injured Arm

-If the casualty is lying on his back, you can elevate an injured forearm by placing it on his chest.

-If the casualty is sitting, you can elevate an injured forearm by placing it on top of his head.

-ONLY elevate the injured extremity if it WILL NOT cause further pain or injury to the casualty. If doing so will cause further pain or injury, place the casualty on a litter and elevate the HEAD of the litter approximately 8-12 inches high.

Injured Leg

-If the casualty’s leg is injured, you can elevate it by placing the foot and ankle on a pack, log, rock, or other object that is approximately 8-13 inches high.

-ONLY elevate the injured extremity if it WILL NOT cause further pain or injury to the casualty. If doing so will cause further pain or injury, place the casualty on a litter and elevate the foot of the litter 8-12 inches high.

Pressure Point Procedures

Bleeding from an artery can be controlled by applying pressure tot the appropriate pressure point. Pressure points are areas of the body where the blood flow can be controlled by pressing the artery against an underlying bone.

If you are pressing on the artery and not feeling the underlying bone, reposition your fingers, and apply firm pressure again until you feel the underlying bone.

By applying pressure to these areas of the body, blood flow to the area of the wound is further reduced. Pressure can be applied with the fingers, thumb, or heel of the hand.

Brachial Artery: To stop severe bleeding of the arm, use the pressure points on the inside of the upper arm.

Radial Artery: To stop severe bleeding of the hand, apply pressure to the thumb-side of the wrist.

Femoral Artery: To stop severe bleeding of the upper leg, use the pressure points in the groin.

By themselves, direct pressure, elevation of the limb, and pressure points may not effectively stop severe bleeding. Situations may require you to combine these procedures to quickly control the bleeding.

Combinations include:

-Simultaneously elevate the bleeding extremity and apply direct pressure. DO NOT elevate an injured extremity if you suspect a head, neck, or spinal injury.

-If the combination of extremity elevation and direct pressure do not control the bleeding, then add pressure to the appropriate pressure point.

Tourniquet to the Extremities

Before discussing how to apply the extremity, be familiar with tourniquet terminology (Windlass Omni tap Band, Windlass Rod, Windlass Strap, Self Adhering Band, Windlass Clip, Friction Adapter Buckle)The following s demonstrate application of the tourniquet to the leg, however the same steps can be used when applying the tourniquet to any extremity.

 1: Expose the wound by tearing or cutting the material around the wound. If possible, place the injured extremity through the loop of the omni-Tape band.

 2: Route the Omni-Tape strap through the friction adapter buckle.

WARNING: In the Care Under Fire phase, place the tourniquet as HIGH on the bleeding extremity as possible. In the Tactical Field Care phases, the tourniquet is applied directly to the skin TWO TO FOUR inches ABOVE the bleeding site on the injured extremity.

 3: pull the free end of the OMNI-Tape band tight, and secure it back onto itself using the velcro.

 4: Twist the windlass rod until the bleeding stops. If you are able to twist the windlass rod more than three times, then start over by re-tightening the free end of the OMNI-Tape band, secure it back onto itself using the velcro, and twist the windlass until bleeding stops.

 5: Secure the rod in position by inserting it into the windlass clip.

 6: Pull the velcro windlass strap tight over the windlass clip and Omni-Tape band.

 7: Sometimes one tourniquet will not adequately control extremity bleeding. In the Care Under Fire phase, apply the tourniquet over the shirt ABOVE the bleeding site/s on the extremity. If the life-threatening bleeding is not easy to locate, place the tourniquet “high and tight” (as high as possible) on the injured extremity and move the casualty to cover.

In the Tactical Field Care phase, if bleeding is not controlled with the first tourniquet, apply a second tourniquet side by side with the first.

 8: Mark the casualty’s forehead with the letter “T” and treat for shock. Annotate the date, time, location of the tourniquet and the care provided on the Casualty Card. The casualty is now ready for transport unless further medical assessment is required.

WARNING: ONLY use the tourniquet on an extremity. DO NOT cover the tourniquet. NEVER loosen or remove the tourniquet. Doing this may result in continued blood loss, shock, and possibly death.

*If needed, create an improvised tourniquet with a wide belt or cloth. Tighten with a stick/ruler/pencil/etc… Secure one side of the pencil when finished to hold the tourniquet in place.

Combat Gauze

Depending on the location of a wound, it may not be practical or feasible to apply a CAT or improvised tourniquet. Examples of the locations are wounds to the groin, armpit, and the chest. In these cases. The QuikClot Combat Gauze can be used to control the bleeding.

Combat gauze slows and controls bleeding by causing the blood to clot within the wound.

Combat gauze is not absorbed into the body, does not produce any heat, and is safe to leave in the wound until reaching the next level of medical care. 

The combat gauze should only be used in the Tactical Field Care phase due to the length of time that direct pressure needs to be performed.

The combat gauze is located within the IFAK and comes in one sterile strip. The following s demonstrate the application of the combat gauze.

 1: Expose the wound by removing, tearing, or cutting away the clothing.

 2: Remove any excess blood from the wound, while at the same time preserving any clots already in the wound. DO NOT scrub the wound clean as this may create more bleeding.

 3: Tear open the package and remove the combat gauze. Ensure you keep the empty package.

 4: Unroll the combat gauze and pack it directly into the wound while simultaneously applying direct pressure.

 5: After packing the wound, continue applying direct pressure for 3 minutes or until the bleeding stops.

 6: If one combat gauze does not control the bleeding, remove it and replace it with a second roll of gauze. The active chemical in the second roll of gauze must come in contact with bleeding tissues.

 7: Use the emergency or compression bandage to secure the combat gauze. Place the empty combat gauze wrapper between the folds of the emergency bandage and ENSURE the wrapper is visible.

 8: Check for an exit wound and control the bleeding using the same methods.

 9: Treat for shock. Annotate the care provided on the Casualty Card. The casualty is now ready for transport unless further medical assessment is required.

*Under CARE UNDER FIRE, you and the casualty are under effective hostile fire. The primary mission will always come first (fire superiority, scene security, etc…). The secondary mission is to provide prompt lifesaving measures. If there is massive uncontrollable bleeding from an extremity, immediately place the tourniquet over the clothing above the bleeding sites on the extremity. If the site of the life threatening bleeding is not easy to locate, place the tourniquet “high and tight” on the injured extremity and move the casualty to cover. DO NOT take the time to apply direct pressure, elevation, or the use of pressure points. Correct placement of the tourniquet in Care Under Fire is CRITICAL in stopping uncontrollable bleeding.

*In the TACTICAL CARE  phase, you and the casualty are no longer under effective enemy fire or the casualty was injured during a non-hostile situation. Once you and the casualty are in a safe location, medical care is provided to the best of your ability. If there is a massive bleeding from an extremity, apply direct pressure, elevation, and use pressure points. If these two methods do not control the bleeding, THEN apply the tourniquet directly to the skin TWO to FOUR inches ABOVE the bleeding sites on the injured extremity. Remember, DO NOT apply the tourniquet over a joint since this may keep the tourniquet from functioning properly.

You have the knowledge to quickly control bleeding and save your own or someone else’s life!