Severe external bleeding is a life-threatening condition requiring urgent first aid. The human body relies upon blood circulating around the body to deliver oxygen to organs and tissues such as the heart, brain and skin. If a person loses a lot of blood, their circulation system may fail and be unable to deliver enough oxygen. This can lead to shock and possibly death. Common causes of bleeding include road traffic collisions, machinery accidents, knife wounds and gunshot injuries. External bleeding forms the basis on this topic. See also Chest and abdomen injuries and Amputation for information on treating those types of injuries.
Internal bleeding, such as unseen bleeding into the chest or abdominal cavity, is also life-threatening. Management of internal bleeding is outlined in Shock, with emphasis on recognition and positioning.
Guidelines
- First aid providers should use direct manual compression for life-threatening external bleeding. **
- If direct manual compression is ineffective or unable to be performed, first aid providers may use a tourniquet for severe, life-threatening external extremity bleeding. *
- If a tourniquet is used, a manufactured tourniquet is preferred. An improvised tourniquet is less effective than a manufactured tourniquet but may be applied if that is all that is available for severe, life-threatening external extremity bleeding. *
- If direct manual compression is ineffective, and a tourniquet is not practical, available or appropriate, a haemostatic dressing may be used for severe, life-threatening external bleeding. The haemostatic dressing should be applied with direct pressure. *
- First aid providers should not use pressure points for severe, life-threatening external bleeding. **
Good practice points
- Emergency medical services (EMS) should be accessed for all severe bleeding.
- The first aid provider should protect themselves from the person’s blood by putting on gloves or covering their hands with plastic bags. If not available, bandages or clothes can act as a barrier between your hand and the person’s wound.
- The first aid provider should apply direct manual compression rather than applying a pressure dressing to a severe bleed. If bandages are available, they can be used to apply pressure. Once severe bleeding has been controlled, a bandage may be applied to the wound. Bandages are made of the ideal material, however, if none is available, clean materials such as clothes or towels may be used as improvised bandages.
- If the bleeding can’t be stopped the first aid provider should consider:
> applying greater pressure
> applying a tourniquet
> applying a haemostatic dressing on the wound while continuing to apply direct pressure. - The first aid provider should apply pressure around an embedded object (e.g., a knife), and try to stabilise the object. Avoid removing the object.
- Tourniquets should only be used for life-threatening limbs bleeding. They may help save a life but may have severe consequences (e.g., amputation of the limb), especially if applied for too long. Once a tourniquet has been applied, keep it in place until EMS arrives.
Chain of survival behaviours
Prevent and prepare
- Learn how to control bleeding using the resources likely to be available such as bandages, clothing, or manufactured tourniquets.
Early recognition
- Blood is flowing from a wound.
- Action to stem the flow of blood should be taken as soon as possible. Even a cupful of blood, although not immediately life-threatening, can lead to fast deterioration if not stopped early on.
First aid steps
- Ask the person to apply direct pressure to their own bleed with their hands.
- Help the person to lie down.
- Access emergency medical services.
- Apply direct pressure to the bleed. If blood soaks through the dressing, apply a second dressing over the first one, applying greater pressure.
- If direct pressure is ineffective and the person is bleeding from an arm or leg, consider applying a tourniquet if available. If no tourniquet is available or it cannot be applied, consider applying a haemostatic dressing, if available, and continue to put direct pressure on the bleed.
- Shock is likely to develop from significant bleeding. Help the person to lie down on their back and keep them warm by wrapping them in clothing if necessary.
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NOTE
- If the injured person can apply pressure to their own wound, this can reduce the risk of cross-infection and keep both the first aid provider and the injured person safe.
- To apply direct pressure to a wound and avoid contact with the person’s blood, use a bandage, cloth or some plastic as a barrier between your hand and the person’s wound.
- If the person becomes Unresponsive, open their airway and check for breathing.
- If there is an embedded object in the wound – such as a knife – apply pressure around the object and try to stabilise the object itself. Avoid removing the object.
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SPECIAL CASE
- In situations of disaster or of conflict, including war, terror attack or violent attack (such as shooting or stabbing), the safety and security of the first aid provider and the injured person are paramount and take precedence over providing immediate care. See contexts Conflict or Disaster.
- The application of tourniquets in war, terror or other violent attacks may be used as the first short-term “stop the bleed” measure, to either deal with the overwhelming number of injured people or to get people with severe life-threatening bleeding out of an immediate danger zone. In both cases, the release of the tourniquet should only be considered under the guidance of a medical professional.
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Access help
Severe bleeding is a life-threatening condition requiring medical care. Clearly explain the cause of the injury and the condition of the person to EMS so they can prioritise your case accurately.
Education considerations
- Consider the local health system, especially the availability of well-developed emergency care and manufactured tourniquets to decide whether to include tourniquet education.
- Consider local laws and regulation as well as the availability of haemostatic dressings before including them in learning design.
- Some contexts may have a high incidence of bloodborne pathogens (for example of HIV) or there may be low incidence but high levels of fear about them. In these contexts, allow learners to consider real versus perceived risks associated with the transmission, and reinforce good universal precautions.
- Use scenarios built around the local industry (e.g., agriculture) or local factors such as road traffic behaviour or violent conflict or crime, to make education on this topic relevant to learners.
Learner considerations
- Consider where learners live and work and discuss the most likely causes of injuries that cause bleeding in the local setting to give context and relevance to the topic.
- This topic can be quite graphic (both in training and in reality). The use of images and video can be helpful and can prepare the learners for what they might see in reality. However, this may be unsuitable for children and some other learner groups. Scenarios and storytelling with or without actors might produce engagement without fear and upset.
- Conversely, the use of fake blood to create scenarios and pretend injuries can be fascinating and informative for learners and encourage engagement.
- Check whether learners have a first aid kit, dressings or manufactured tourniquets in their homes, or whether they might be able to access them (Andrade et al., 2020).
- Consider only including haemostatic dressings in training for more advanced first aid providers and in instances where learners may enter remote areas.
Facilitation tips
- Discuss with learners how to recognise a severe bleed: how much blood is coming out, what does it look like? Discuss it in terms of volume (e.g. cup-full, ounces); how it looks (forming a puddle or pool, soaking through the bandage); and the emotional reaction they might have (Pellegrino et al., 2020).
- Emphasise that timely intervention to stop bleeding is vital and may be a life-saving action. Applying pressure to a bleed is often a simple action, easy to do and can be very effective.
- Support learners to practise feeling how much and what sort of pressure is needed to stop a bleed and how this will feel for the injured person. Consider different postures that learners could take to apply sufficient pressure depending on their physical strength (Charlton et al., 2019).
- Discuss with learners what action they should take depending on where the bleed is coming from on the body: when to use a tourniquet (on a limb), when to apply pressure or use a dressing (Pellegrino et al., 2020).
- Discuss the practicalities of there being a lot of blood and what to do when a bandage is soaked through. Explain that the pressure will be reduced if more and more bandages are applied (Charlton et al., 2018).
- Encourage learners to think creatively about what materials they have near them in their relevant contexts that they could use to stop a bleed, for example, a clean towel or T-shirt. Emphasise that even if there is nothing available, they can apply pressure with their own hand if they do not have any open cut on their hand as the risk of infection is very low.
- Emphasise the primacy of direct pressure before finding a bandage to apply. Once the flow of blood has been stopped using pressure, help learners to practise applying a bandage so that it is secure and maintains sufficient pressure. Try bandaging different body parts.
- The topic of bleeding has many potential barriers to helping for learners such as infection, fear of blood or concerns of violence. While these should be explored, the aim should be to develop pro-helping strategies.
- Explore ways learners could protect themselves and the injured person from blood-borne viruses while still providing life-saving care if this is a concern (e.g., they could wear gloves or ask the injured person who is bleeding to apply pressure to their own wound.) Avoid creating a barrier to helping through fear of infection. Explore what alternatives may be available if a person doesn’t have gloves (e.g., a plastic bag).
- Facilitate a discussion of the common fear people have of blood and highlight this as a possible barrier to helping. Allow learners to practise dealing with bleeding if it may help build their confidence or develop other strategies to overcome their barriers (e.g. directing the injured person to apply pressure to their own wound).
- Emphasise that objects embedded in a wound should be left where they are if there is the possibility of severe bleeding as the object may be acting as a ‘plug’. Removing it may make the bleeding worse.
Tourniquets and haemostatic dressings
- If teaching learners about tourniquets, train them on how and when to use them as this is essential for safe and effective use. Tourniquets are powerful tools for bleeding control but can also cause harm if used incorrectly. Emphasise that tourniquets should only be used when direct pressure on the bleed is ineffective and the injury is on a limb.
- Consider what style of a tourniquet is available locally, and train in that specific style. Training in applying one style of a tourniquet will not necessarily facilitate skill transfer to other tourniquet styles (McCarty et al., 2019).
- Discuss why improvised tourniquets might be less effective. This could be because they cannot be adequately tightened to provide the required amount of pressure and are more likely to break (McCarty et al., 2019).
- Emphasise that the application of a tourniquet is very painful if done correctly, and the injured person may respond violently and try to remove the tourniquet. By being prepared for this the first aid provider can ensure their own safety, but also prepare the injured person, which will make it easier for them to cope with the pain.
- If haemostatic dressings are included in education, training in the proper assessment of severe bleeding and the dressing application techniques are required. Emphasise they should only be used in instances of life-threatening bleeding (Goolsby et al., 2019; Zeitlow et al., 2015).
Facilitation tools
- Provide a glossary of terms of words or phrases that may be used interchangeably (bleeding and haemorrhage for example).
- Discussing what ‘severe bleeding’ means and looks like could be a useful starter for this topic. This could take place as a discussion exercise using a flip chart with the heading, “What other words can you think of that describe ‘severe’ bleeding?” (for example, gushing, flowing, spouting, running like an open tap, soaking through the bandage, pooling on the floor etc). This could be followed by exercises based on images and the questions to develop a ‘common language’ and understanding for the rest of the topic:
> What do you think has happened here?
> How badly is this person bleeding?
> What happens when someone loses a lot of blood?
> How do they look?
> How do you think they might be feeling or might behave?
> What do you think will happen next?
- Encourage learners to share their experiences of accidents where there has been severe bleeding, and for groups of learners to explore the topic through storytelling and role-play scenarios. Roleplay can be particularly beneficial as a dynamic and interactive learning format.
- It may be useful to show how different clothing or flooring can affect the perception of how much blood has been lost. Soil or thick clothing for example can demonstrate how severe blood loss can be hidden.
- Use a range of objects to demonstrate bleeding and how to treat it. For example, get a plastic bottle (full of water coloured with food dye). This could be wrapped up in clothing to look less like a bottle. Then an object (nail, knife, etc) could be pushed into it to simulate a penetrating object. With someone else squashing the bottle (to simulate the blood pressure and cause the ‘wound’ to bleed) learners could practise how to apply pressure, how to stabilise an embedded object or how to dress a wound.
- Alternatively, use fruit (such as an apple) to create ‘wounds’ which can be dressed. Or use teddy bears to practise applying pressure or bandaging.
- Use simulation to help learners experience the real challenges they may face when dealing with someone who has an object embedded in their body. Highlight the importance of reducing harm, when the possibility of not moving the object is competing with the possibility of moving the person to a health facility.
- Creation of fake wounds using fake blood and other makeup products can help create realistic scenarios to support learning.
- If you have multiple tourniquets, hand them out to the learners. Then demonstrate the correct application of the tourniquet on a volunteer (without tightening it completely) and ask learners to repeat it. Gradually increase the stress of the scenarios: put time limits on, increase background noise, shout (only once a level of trust has been created) and eventually have learners apply tourniquets in uncomfortable and challenging settings, such as upside-down or in the dark. Also, there is value in teaching them how to self-administer, especially when educating weapons bearers.
- If appropriate to the learner group, use visual resources to enable realistic exposure to the sights and sounds associated with the subject and an opportunity to see the graphic nature of some injuries.
Learning connections
- Learners should be taught to recognise the signs of Shock.
- Conditions which may result in severe external bleeding include Amputation, Chest and abdomen injuries, Cuts and grazes, Mammal bites and Fractures.
- Note particularly that an open chest wound may be bleeding but require careful management to ensure the wound can communicate with the air. See Chest and abdomen injuries.
- Internal bleeding is a life-threatening condition, the management of which is outlined in Shock, with the emphasis being on recognition and positioning.
- Maintaining the safety of the first aid provider is paramount. See General approach.
- Localised application of ice or something cold may be beneficial for a minor, closed bleeding injury such as bruising or a haematoma.
Scientific foundation
Systematic reviews
The International Liaison Committee on Resuscitation (ILCOR) conducted several systematic reviews on multiple interventions for the control of life-threatening external bleeding (Singletary, 2020).
Pressure dressings, bandages, devices or proximal manual pressure
Six studies compared the use of pressure dressings, bandages, or devices to direct manual pressure. Three in-hospital randomised controlled trials and one in-hospital cohort study demonstrated a significantly longer time to haemostasis with the use of mechanical pressure devices (pneumatic device, Femostrop, C-clamp) compared with the use of direct manual pressure. In contrast, one in-hospital cohort study showed a shorter time to haemostasis with the use of a mechanical clamp. For the outcome of cessation of bleeding, one in-hospital randomised controlled trial showed benefit of a combined clamp and manual compression compared to pneumatic compression. Also, one in-hospital cohort study showed higher rates of bleeding cessation when using a commercial, elasticized compression bandage compared with manual pressure. Three in-hospital randomised controlled trials and three in-hospital observational studies did not report a significant difference in complications with the use of either pressure devices or with manual pressure. No evidence was identified for the critical outcome of mortality resulting from bleeding or the important outcome of mortality from any cause. All evidence is of very low certainty.
Pressure points
No human studies were identified comparing the use of pressure points with direct manual pressure.
Tourniquets
In 13 studies, the use of a tourniquet was compared to direct manual pressure. In four prehospital civilian cohort studies, there was no reduction in mortality from bleeding with the use of tourniquets compared to direct manual pressure alone. A higher cessation of bleeding was found in a large prehospital military cohort study when comparing tourniquet use to direct manual pressure alone, but this could not be shown in an additional very small cohort study. In a large civilian prehospital cohort study, a significant reduction of all-cause mortality was shown, but this was not the case in five other civilian studies with unadjusted analyses and six prehospital military cohort studies. A difference in complications (e.g. amputation) or adverse effects could not be shown in five prehospital civilian cohort studies and one prehospital military cohort study. For the outcome of time to haemostasis, no studies were identified. All evidence is of very low certainty.
One prehospital military cohort study was identified comparing tourniquets with haemostatic dressings. No difference in mortality caused by bleeding was found, but there was a significant all-cause mortality risk reduction. However, in this study, the types and locations of wounds weren’t reported, and it is unknown if the injuries were comparable. For the outcomes of complications or adverse effects and time to haemostasis, no studies were identified. Evidence is of very low certainty.
No human studies were identified, comparing manufactured with improvised tourniquets. Four observational simulation studies were found that provided information about the ability of first aid providers to stop bleeding with both types of tourniquets. In one study, greater success of pulse cessation in lower and upper extremities was shown with manufactured compared with improvised tourniquets. In a second study, a decrease in bleeding cessation was shown to be greater with manufactured tourniquets over improvised cravat tourniquets over bandana tourniquets. All evidence is of very low certainty.
No human studies were identified on the comparison of windlass-style manufactured tourniquets (i.e., one with a rod to tighten the tourniquet) with other types of manufactured tourniquets for the management of severe, life-threatening external extremity bleeding. Ten simulation studies provided information about the feasibility of the use of windlass-style manufactured tourniquets compared with other designs of manufactured tourniquets.
Haemostatic dressings
19 studies were identified, comparing the combined use of haemostatic dressings and direct pressure to direct pressure alone. For the outcomes of cessation of bleeding (studied in three in-hospital randomised controlled trials and one in-hospital cohort study) and mortality (one prehospital military cohort study and two in-hospital civilian randomised controlled trials), no benefit of the additional use of haemostatic dressings could be shown. In 15 in-hospital randomised controlled trials, faster haemostasis was shown with the additional use of haemostatic dressings, and in one of these, a decrease in the number of blood-soaked gauzes was found. In four randomised controlled trials and two cohort studies, a difference in complications and adverse events when using haemostatic dressings and direct pressure, compared to direct pressure alone, could not be shown. No evidence for the outcome of mortality caused by bleeding was identified. The evidence is of low to very low certainty.
Three in-hospital civilian randomised controlled trials compared one type of haemostatic dressing to other types, but a difference in time to haemostasis (moderate-certainty evidence), all-cause mortality (very low-certainty evidence) and adverse effects (very low-certainty evidence) could not be demonstrated. No studies were found on the outcomes of mortality due to bleeding, cessation of bleeding, or any complications/adverse events.
No human studies comparing junctional tourniquets with direct pressure, or comparing wound clamps with direct pressure, for the management of severe, life-threatening external bleeding were identified.
Education review
Several additional papers were found through the educational literature search. Included below are papers which had specific educational considerations for learners on this topic.
Andrade et al. (2020) show the additional confidence learners gain by having access to bleeding control equipment. They undertook a study with medical professionals and community members to see if receiving a trauma first aid kit in addition to bleeding control training improves self-reported confidence. After completing bleeding control training, participants assembled their own trauma first aid kits in a provided tactical pouch, which included properly sized personal protective equipment, a combat application tourniquet, haemostatic gauze and bandages, a flashlight, a marker and trauma shears. After receiving bleeding control training, those who did not receive a trauma first aid kit were significantly less confident to stop life-threatening bleeding among both medical professions and community members.
Pellegrino et al. (2020) identified a gap of a standardised assessment tool to measure educational effectiveness of the ‘Stop the bleed’ campaign. More than a million people in the United States have received training on how to deal with life-threatening bleeding via this campaign. The authors developed and validated a tool with the input of experts, educators and community learners. The tool covers recognition of life-threatening bleeding and where, when and how to apply pressure, a tourniquet or a dressing. Haemorrhage control experts identified 6 oz (≈177 ml) of blood loss to represent life-threatening bleeding for first aid providers. The tool used everyday language to represent medical terms and constructs. For example, people looking at a 6 oz pool of “blood” described its volume, what it looks like and how it made them feel. The authors suggest the tool can be used to compare outcomes from different teaching styles and methods in order to allow for the development of best practice for future bleeding control education. In addition, this approach could help organisations demonstrate value to learners, funders, and policymakers, and advance health sciences education. The Stop the bleed education assessment tool offers a measure for which educational efficiency and effectiveness can be judged within a larger effort to prepare people for personal emergencies or large-scale disasters.
Goolsby et al. (2019) identified which haemostatic dressings first aid providers might best be trained in. They tested whether first aid providers could apply haemostatic dressings, and which they could use most successfully. 360 people participated in a randomised prospective controlled trial to compare the application of plain gauze (control), z-folded gauze, s-rolled gauze, and injectable sponge (experimental). Participants learned using a video and practise and were assessed on the pressure applied for a set amount of time, and the amount of time taken to unpack and apply the dressing. Participants also completed pre and post surveys on willingness to use the dressings. Overall, 202 participants (56%) applied dressings correctly. The most successful in terms of the correct application was the injectable sponges (92%), followed by the s-rolled gauze (48%), the z-folded gauze (43%) and the plain gauze (40%). Participants in all cohorts saw significant improvements in willingness to use haemostatic dressings.
To help educators identify the best techniques to teach direct pressure, Charlton et al. (2019) ran a study on the posture a first aid provider should adopt to apply adequate pressure to a severe bleed for a sustained period of time. They tested two-handed pressure with bent arms against two-handed pressure with straight arms. A sample of 30 participants of similar demographics were randomised to one of the postures and asked to apply force to a standardised haemorrhage control trainer with electronic feedback (Z-Medica), set to record a minimum pressure of 3-psi (155 mmHg) for a three-minute time period. When using bent arms, participants provided pressure at or above 3-psi 63.7 % of the time. Participants using straight arms were above 3-psi 100% of the time. The difference between the two experimental arms remained statistically significant when examined by age, gender, or medical experience. The authors concluded that a straight-armed posture was the most efficient way to provide high-quality direct pressure to stop life-threatening bleeding.
Advice for first aid providers when a serious bleed seeps through the dressing has been to add an additional layer on top rather than replacing the original dressing. This was questioned by Charlton et al. (2018) who sought to establish whether the pressure needed to stop a serious bleed could be maintained when additional layers of dressing are added. They used a tri-phase randomised cross-over trial of medical personnel and a standardised bleeding simulator. Participants were randomised to cohorts of 10, 20 & 30 layers of 4×4 inch cotton gauze, and subsequently to three different methods of pressure application: the finger pads of three digits of the right hand, three fingers of the dominant hand with the opposing hand applying counter pressure, or three digits of each of two hands on top of the other. Participants were asked to hold pressure continuously during each application for 10 seconds. The researchers found that participants generated the most force when a single stack of gauze and when two hands were used to apply pressure over the wound and suggested that first aid educators may apply results to lessons in describing the thickness of the material and need to apply sufficient pressure to stop bleeding.
Zeitlow et al. (2015) sought to establish if bleeding control techniques applied in a military context could be translated into a civilian setting effectively. A retrospective review of people who received a tourniquet or haemostatic dressing pre-hospital. 77 tourniquets were used for 73 people and 62 haemostatic dressings were applied to 52 people. Seven people required both interventions. Mean tourniquet time was 27 minutes, with 98.7% success. Haemostatic bandage application had a 95% success rate. Training for both interventions was computer-based and hands-on, with ability to do skills greater than 95% maintained after two years. The authors concluded that civilian prehospital use of tourniquets and haemostatic gauze is feasible and effective at stopping the bleed. Online and practical training programs result in the ability to use skills, which can be maintained despite infrequent use. Kragh Jr et al. (2008) considered the efficacy and challenges of teaching first aid providers to use tourniquets. They studied morbidity and tourniquet use specifically in a conflict setting and draw attention to the fact that tourniquets can complicate care if used inappropriately, and that the education of the first aid provider in their use is critical.
Educators in a lower resource setting or where tourniquets are not readily available might be informed about the effectiveness of improvised tourniquets as studied by McCarty et al. (2019). They showed that improvised tourniquets tend to have very poor effectiveness and high failure rates. In a randomised clinical trial that saw first aid providers trained to apply different tourniquet types, Combat application tourniquets (CATs) were compared to other commercial and improvised models. In the cases of ‘improvised tourniquets,’ the learners were allowed to choose from a selection of materials including leather belts or shoelaces, and plastic (PVC) or wooden rods to act as a windlass. Improvised tourniquets were found to fail in a number of cases due to breakage of the windlass (70%) when using a plastic windlass, or the leather belt strap snapping (almost 45.8% of the cases) where a wooden windlass and belt were used together. For the ‘non-windlass design’ improvised devices, the pressure applied was deemed insufficient in all simulation assessments and demonstrated increased estimated blood loss when compared to the purpose made CAT device provided for training. Only 1 of 22 (4.6%) applications of a non-windlass improvised tourniquet was successfully applied. Their findings supported an earlier observation during the Boston Marathon incident, where 27 improvised tourniquets were applied in the field, and all were deemed ineffective on post-event review (King et al., 2015, cited by McCarty et al., 2019).
There is a gap in the evidence available on how to prepare first aid providers to deploy tourniquets in a multiple casualty scenario.
References
Systematic reviews
Singletary, E. M., Zideman, D. A., Bendall, J. C., Berry, D. C., Borra, V., Carlson, J. N., … & Douma, M. J. (2020). 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation, 142(16_suppl_1), S284-S334. DOI 10.1161/CIR.0000000000000897
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., Chang, … Lee, C.C. (2020). 2020 International Consensus on First Aid Science With Treatment Recommendations. Resuscitation, 2020 Nov;156:A240-A282.
DOI 10.1016/j.resuscitation.2020.09.016
Education references
Andrade, E. G., Hayes, J. M., & Punch, L. J. (2020). Stop the bleed: The impact of trauma first aid kits on post-training confidence among community members and medical professionals. The American Journal of Surgery, 220(1), 245-248. Abstract only. Retrieved from
https://www.sciencedirect.com/science/article/abs/pii/S0002961019315429
Charlton, N. P., Solberg, R., Singletary, N., Goolsby, C., Rizer, J., & Woods, W. (2019a). The use of a “CPR posture” for hemorrhage control. International Journal of First Aid Education, 2(1), 31. Full article. Retrieved from https://digitalcommons.kent.edu/ijfae/vol2/iss1/6/
Charlton, N. P.; Solberg, R. Rizer, J., Singletary, E.M.; Woods, W. (2018). Pressure Methods for Primary Hemorrhage Control: A Randomized Crossover Trial. International Journal of First Aid Education, 2(1) 19. doi: 10.21038/ijfa.2018.0011. Retrieved from
https://oaks.kent.edu/ijfae/vol2/iss1/pressure-methods-primary-hemorrhage-control-randomizedcrossover-trial
Goolsby, C., Rojas, L., Moore, K., Kretz, E., Singletary, E., Klimczak, V., & Charlton, N. (2019). Layperson ability and willingness to use hemostatic dressings: a randomized, controlled trial. Prehospital Emergency Care, 23(6), 795-801. Retrieved from
https://www.tandfonline.com/doi/abs/10.1080/10903127.2019.1593566
Kragh Jr, 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. Journal of Trauma and Acute Care Surgery, 64(2), S38-S50. Retrieved from
https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.914.6478&rep=rep1&type=pdf
McCarty, J. C., Hashmi, Z. G., Herrera-Escobar, J. P., de Jager, E., Chaudhary, M. A., Lipsitz, S. R., … & Goralnick, E. (2019). Effectiveness of the American College of Surgeons Bleeding Control Basic training among laypeople applying different tourniquet types: a randomized clinical trial. JAMA Surgery, 154(10), 923-929. Retrieved from
https://jamanetwork.com/journals/jamasurgery/article-abstract/2738052
Pellegrino J. L., Charlton N., Goolsby, C. (2020). “Stop the Bleed” Education Assessment Tool (SBEAT): Development and Validation. Cureus 12(9): e10567. DOI 10.7759/cureus.10567.
Full text article.
Zietlow, J. M., Zietlow, S. P., Morris, D. S., Berns, K. S., & Jenkins, D. H. (2015). Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in civilian trauma care. J Spec Oper Med, 15(2), 48-53. Retrieved from
https://www.jsomonline.org/FeatureArticle/2015248Zietlow.pdf
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Explore the guidelines
Published: 15 February 2021
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