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Severe bleeding

Apply direct pressure to control the bleeding as quickly as possible.

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 toorgans 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 canlead to shock and possibly death. Common causes of bleeding include road trafficcollisions, machinery accidents, knife wounds and gunshot injuries. Externalbleeding forms the basis on this topic. See also Chest and abdomen injuries andAmputation for information on treating those types of injuries.

Internal bleeding, such as unseen bleeding into the chest or abdominal cavity, isalso life-threatening. Management of internal bleeding is outlined in Shock, withemphasis on recognition and positioning.

Guidelines

First aid providers should use direct manual compression for life-threateningexternal bleeding. **If direct manual compression is ineffective or unable to be performed, first aidproviders may use a tourniquet for severe, life-threatening external extremitybleeding. *If a tourniquet is used, a manufactured tourniquet is preferred. An improvisedtourniquet is less effective than a manufactured tourniquet but may be appliedif that is all that is available for severe, life-threatening external extremitybleeding. *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 appliedwith direct pressure. *First aid providers should not use pressure points for severe, life-threatening

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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 byputting 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’swound.The first aid provider should apply direct manual compression rather thanapplying a pressure dressing to a severe bleed. If bandages are available, theycan be used to apply pressure. Once severe bleeding has been controlled, abandage may be applied to the wound. Bandages are made of the idealmaterial, however, if none is available, clean materials such as clothes ortowels 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 applydirect 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 mayhelp save a life but may have severe consequences (e.g., amputation of thelimb), especially if applied for too long. Once a tourniquet has been applied,keep it in place until EMS arrives.

Guideline classifications explained

Chain of survival behaviours

Prevent and prepare

Learn how to control bleeding using the resources likely to be available suchas bandages, clothing, or manufactured tourniquets.

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Early recognition

Blood is flowing from a wound.Action to stem the flow of blood should be taken as soon as possible. Even acupful of blood, although not immediately life-threatening, can lead to fastdeterioration if not stopped early on.

First aid steps

Ask the person to apply direct pressure to their own bleed with their hands.1.Help the person to lie down.2.Access emergency medical services.3.Apply direct pressure to the bleed. If blood soaks through the dressing, apply a4.second dressing over the first one, applying greater pressure.If direct pressure is ineffective and the person is bleeding from an arm or leg,5.consider applying a tourniquet if available. If no tourniquet is available or itcannot be applied, consider applying a haemostatic dressing, if available, andcontinue to put direct pressure on the bleed.Shock is likely to develop from significant bleeding. Help the person to lie6.down on their back and keep them warm by wrapping them in clothing ifnecessary.

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NOTE

If the injured person can apply pressure to their own wound, this can reducethe risk of cross-infection and keep both the first aid provider and the injuredperson 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 theperson’s wound.If the person becomes Unresponsive, open their airway and check forbreathing. If there is an embedded object in the wound – such as a knife – apply pressurearound the object and try to stabilise the object itself. Avoid removing theobject.

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SPECIAL CASE

In situations of disaster or of conflict, including war, terror attack or violentattack (such as shooting or stabbing), the safety and security of the first aidprovider and the injured person are paramount and take precedence overproviding immediate care. See contexts Conflict or Disaster.The application of tourniquets in war, terror or other violent attacks may beused as the first short-term “stop the bleed” measure, to either deal with theoverwhelming number of injured people or to get people with severe life-threatening bleeding out of an immediate danger zone. In both cases, therelease of the tourniquet should only be considered under the guidance of amedical professional.

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Access help

Severe bleeding is a life-threatening condition requiring medical care. Clearlyexplain the cause of the injury and the condition of the person to EMS so they canprioritise your case accurately.

Education considerations

Consider the local health system, especially the availability of well-developedemergency care and manufactured tourniquets to decide whether to includetourniquet education.Consider local laws and regulation as well as the availability of haemostaticdressings before including them in learning design.Some contexts may have a high incidence of bloodborne pathogens (forexample of HIV) or there may be low incidence but high levels of fear aboutthem. In these contexts, allow learners to consider real versus perceived risksassociated with the transmission, and reinforce good universal precautions.Use scenarios built around the local industry (e.g., agriculture) or local factors

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such as road traffic behaviour or violent conflict or crime, to make educationon this topic relevant to learners.

Learner considerations

Consider where learners live and work and discuss the most likely causes ofinjuries that cause bleeding in the local setting to give context and relevanceto the topic.This topic can be quite graphic (both in training and in reality). The use ofimages and video can be helpful and can prepare the learners for what theymight see in reality. However, this may be unsuitable for children and someother learner groups. Scenarios and storytelling with or without actors mightproduce engagement without fear and upset.Conversely, the use of fake blood to create scenarios and pretend injuries canbe fascinating and informative for learners and encourage engagement.Check whether learners have a first aid kit, dressings or manufacturedtourniquets 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 advancedfirst 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 iscoming 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 doand can be very effective.Support learners to practise feeling how much and what sort of pressure isneeded to stop a bleed and how this will feel for the injured person. Considerdifferent postures that learners could take to apply sufficient pressuredepending on their physical strength (Charlton et al., 2019).Discuss with learners what action they should take depending on where thebleed is coming from on the body: when to use a tourniquet (on a limb), when

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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 abandage is soaked through. Explain that the pressure will be reduced if moreand more bandages are applied (Charlton et al., 2018).Encourage learners to think creatively about what materials they have nearthem in their relevant contexts that they could use to stop a bleed, forexample, a clean towel or T-shirt. Emphasise that even if there is nothingavailable, they can apply pressure with their own hand if they do not have anyopen 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 topractise applying a bandage so that it is secure and maintains sufficientpressure. Try bandaging different body parts.The topic of bleeding has many potential barriers to helping for learners suchas infection, fear of blood or concerns of violence. While these should beexplored, the aim should be to develop pro-helping strategies.Explore ways learners could protect themselves and the injured person fromblood-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 applypressure to their own wound.) Avoid creating a barrier to helping through fearof infection. Explore what alternatives may be available if a person doesn’thave gloves (e.g., a plastic bag).Facilitate a discussion of the common fear people have of blood and highlightthis as a possible barrier to helping. Allow learners to practise dealing withbleeding if it may help build their confidence or develop other strategies toovercome their barriers (e.g. directing the injured person to apply pressure totheir own wound).Emphasise that objects embedded in a wound should be left where they are ifthere 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 usethem as this is essential for safe and effective use. Tourniquets are powerfultools for bleeding control but can also cause harm if used incorrectly.

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Emphasise that tourniquets should only be used when direct pressure on thebleed is ineffective and the injury is on a limb.Consider what style of a tourniquet is available locally, and train in thatspecific style. Training in applying one style of a tourniquet will not necessarilyfacilitate skill transfer to other tourniquet styles (McCarty et al., 2019).Discuss why improvised tourniquets might be less effective. This could bebecause they cannot be adequately tightened to provide the required amountof 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 thetourniquet. By being prepared for this the first aid provider can ensure theirown safety, but also prepare the injured person, which will make it easier forthem to cope with the pain.If haemostatic dressings are included in education, training in the properassessment of severe bleeding and the dressing application techniques arerequired. Emphasise they should only be used in instances of life-threateningbleeding (Goolsby et al., 2019; Zeitlow et al., 2015).

Facilitation tools

Provide a glossary of terms of words or phrases that may be usedinterchangeably (bleeding and haemorrhage for example).Discussing what ‘severe bleeding’ means and looks like could be a usefulstarter for this topic. This could take place as a discussion exercise using a flipchart with the heading, “What other words can you think of that describe‘severe’ bleeding?” (for example, gushing, flowing, spouting, running like anopen tap, soaking through the bandage, pooling on the floor etc). This could befollowed 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?

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> 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 hasbeen severe bleeding, and for groups of learners to explore the topic throughstorytelling and role-play scenarios. Roleplay can be particularly beneficial asa dynamic and interactive learning format.It may be useful to show how different clothing or flooring can affect theperception of how much blood has been lost. Soil or thick clothing for examplecan demonstrate how severe blood loss can be hidden.Use a range of objects to demonstrate bleeding and how to treat it. Forexample, get a plastic bottle (full of water coloured with food dye). This couldbe 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 someoneelse squashing the bottle (to simulate the blood pressure and cause the‘wound’ to bleed) learners could practise how to apply pressure, how tostabilise an embedded object or how to dress a wound.Alternatively, use fruit (such as an apple) to create ‘wounds’ which can be dressed. Or useteddy bears to practise applying pressure or bandaging.Use simulation to help learners experience the real challenges they may facewhen dealing with someone who has an object embedded in their body.Highlight the importance of reducing harm, when the possibility of not movingthe object is competing with the possibility of moving the person to a healthfacility.Creation of fake wounds using fake blood and other makeup products can helpcreate realistic scenarios to support learning.If you have multiple tourniquets, hand them out to the learners. Thendemonstrate the correct application of the tourniquet on a volunteer (withouttightening it completely) and ask learners to repeat it. Gradually increase thestress of the scenarios: put time limits on, increase background noise, shout(only once a level of trust has been created) and eventually have learnersapply 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.

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If appropriate to the learner group, use visual resources to enable realisticexposure to the sights and sounds associated with the subject and anopportunity 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 requirecareful management to ensure the wound can communicate with the air. SeeChest and abdomen injuries.Internal bleeding is a life-threatening condition, the management of which isoutlined in Shock, with the emphasis being on recognition and positioning.Maintaining the safety of the first aid provider is paramount. See Generalapproach.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 severalsystematic reviews on multiple interventions for the control of life-threateningexternal bleeding (Singletary, 2020).

Pressure dressings, bandages, devices or proximal manual pressure

Six studies compared the use of pressure dressings, bandages, or devices to direct manualpressure. Three in-hospital randomised controlled trials and one in-hospital cohort studydemonstrated a significantly longer time to haemostasis with the use of mechanical pressuredevices (pneumatic device, Femostrop, C-clamp) compared with the use of direct manualpressure. In contrast, one in-hospital cohort study showed a shorter time to haemostasis with theuse of a mechanical clamp. For the outcome of cessation of bleeding, one in-hospital randomised

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controlled trial showed benefit of a combined clamp and manual compression compared topneumatic compression. Also, one in-hospital cohort study showed higher rates of bleedingcessation when using a commercial, elasticized compression bandage compared with manualpressure. Three in-hospital randomised controlled trials and three in-hospital observationalstudies did not report a significant difference in complications with the use of either pressuredevices or with manual pressure. No evidence was identified for the critical outcome of mortalityresulting from bleeding or the important outcome of mortality from any cause. All evidence is ofvery low certainty.

Pressure points

No human studies were identified comparing the use of pressure points with directmanual pressure.

Tourniquets

In 13 studies, the use of a tourniquet was compared to direct manual pressure. Infour prehospital civilian cohort studies, there was no reduction in mortality frombleeding with the use of tourniquets compared to direct manual pressure alone. Ahigher cessation of bleeding was found in a large prehospital military cohort studywhen comparing tourniquet use to direct manual pressure alone, but this could notbe shown in an additional very small cohort study. In a large civilian prehospitalcohort study, a significant reduction of all-cause mortality was shown, but this wasnot the case in five other civilian studies with unadjusted analyses and sixprehospital military cohort studies. A difference in complications (e.g. amputation)or adverse effects could not be shown in five prehospital civilian cohort studies andone prehospital military cohort study. For the outcome of time to haemostasis, nostudies were identified. All evidence is of very low certainty.

One prehospital military cohort study was identified comparing tourniquets withhaemostatic dressings. No difference in mortality caused by bleeding was found,but there was a significant all-cause mortality risk reduction. However, in thisstudy, the types and locations of wounds weren’t reported, and it is unknown if theinjuries were comparable. For the outcomes of complications or adverse effects andtime to haemostasis, no studies were identified. Evidence is of very low certainty.

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No human studies were identified, comparing manufactured with improvisedtourniquets. Four observational simulation studies were found that providedinformation about the ability of first aid providers to stop bleeding with both typesof tourniquets. In one study, greater success of pulse cessation in lower and upperextremities was shown with manufactured compared with improvised tourniquets.In a second study, a decrease in bleeding cessation was shown to be greater withmanufactured tourniquets over improvised cravat tourniquets over bandanatourniquets. All evidence is of very low certainty.

No human studies were identified on the comparison of windlass-stylemanufactured tourniquets (i.e., one with a rod to tighten the tourniquet) with othertypes of manufactured tourniquets for the management of severe, life-threateningexternal extremity bleeding. Ten simulation studies provided information about thefeasibility of the use of windlass-style manufactured tourniquets compared withother designs of manufactured tourniquets.

Haemostatic dressings

19 studies were identified, comparing the combined use of haemostatic dressingsand direct pressure to direct pressure alone. For the outcomes of cessation ofbleeding (studied in three in-hospital randomised controlled trials and one in-hospital cohort study) and mortality (one prehospital military cohort study and twoin-hospital civilian randomised controlled trials), no benefit of the additional use ofhaemostatic dressings could be shown. In 15 in-hospital randomised controlledtrials, faster haemostasis was shown with the additional use of haemostaticdressings, and in one of these, a decrease in the number of blood-soaked gauzeswas found. In four randomised controlled trials and two cohort studies, a differencein complications and adverse events when using haemostatic dressings and directpressure, compared to direct pressure alone, could not be shown. No evidence forthe outcome of mortality caused by bleeding was identified. The evidence is of lowto very low certainty.

Three in-hospital civilian randomised controlled trials compared one type ofhaemostatic dressing to other types, but a difference in time to haemostasis(moderate-certainty evidence), all-cause mortality (very low-certainty evidence) and

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adverse effects (very low-certainty evidence) could not be demonstrated. Nostudies were found on the outcomes of mortality due to bleeding, cessation ofbleeding, or any complications/adverse events.

No human studies comparing junctional tourniquets with direct pressure, orcomparing 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 forlearners on this topic.

Andrade et al. (2020) show the additional confidence learners gain by havingaccess to bleeding control equipment. They undertook a study with medicalprofessionals and community members to see if receiving a trauma first aid kit inaddition to bleeding control training improves self-reported confidence. Aftercompleting bleeding control training, participants assembled their own trauma firstaid kits in a provided tactical pouch, which included properly sized personalprotective equipment, a combat application tourniquet, haemostatic gauze andbandages, a flashlight, a marker and trauma shears. After receiving bleedingcontrol training, those who did not receive a trauma first aid kit were significantlyless confident to stop life-threatening bleeding among both medical professions andcommunity members.

Pellegrino et al. (2020) identified a gap of a standardised assessment tool tomeasure educational effectiveness of the ‘Stop the bleed’ campaign. More than amillion 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 toolwith the input of experts, educators and community learners. The tool coversrecognition of life-threatening bleeding and where, when and how to applypressure, a tourniquet or a dressing. Haemorrhage control experts identified 6 oz(≈177 ml) of blood loss to represent life-threatening bleeding for first aidproviders. The tool used everyday language to represent medical terms and

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constructs. For example, people looking at a 6 oz pool of “blood” described itsvolume, what it looks like and how it made them feel. The authors suggest the toolcan be used to compare outcomes from different teaching styles and methods inorder to allow for the development of best practice for future bleeding controleducation. In addition, this approach could help organisations demonstrate value tolearners, funders, and policymakers, and advance health sciences education. TheStop the bleed education assessment tool offers a measure for which educationalefficiency and effectiveness can be judged within a larger effort to prepare peoplefor personal emergencies or large-scale disasters.

Goolsby et al. (2019) identified which haemostatic dressings first aid providersmight best be trained in. They tested whether first aid providers could applyhaemostatic dressings, and which they could use most successfully. 360 peopleparticipated in a randomised prospective controlled trial to compare theapplication of plain gauze (control), z-folded gauze, s-rolled gauze, and injectablesponge (experimental). Participants learned using a video and practise and wereassessed on the pressure applied for a set amount of time, and the amount of timetaken to unpack and apply the dressing. Participants also completed pre and postsurveys on willingness to use the dressings. Overall, 202 participants (56%) applieddressings correctly. The most successful in terms of the correct application was theinjectable sponges (92%), followed by the s-rolled gauze (48%), the z-folded gauze(43%) and the plain gauze (40%). Participants in all cohorts saw significantimprovements in willingness to use haemostatic dressings.

To help educators identify the best techniques to teach direct pressure, Charlton etal. (2019) ran a study on the posture a first aid provider should adopt to applyadequate pressure to a severe bleed for a sustained period of time. They testedtwo-handed pressure with bent arms against two-handed pressure with straightarms. A sample of 30 participants of similar demographics were randomised to oneof the postures and asked to apply force to a standardised haemorrhage controltrainer 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. Participantsusing straight arms were above 3-psi 100% of the time. The difference between thetwo experimental arms remained statistically significant when examined by age,gender, or medical experience. The authors concluded that a straight-armed

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posture was the most efficient way to provide high-quality direct pressure to stoplife-threatening bleeding.

Advice for first aid providers when a serious bleed seeps through the dressing hasbeen 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 thepressure needed to stop a serious bleed could be maintained when additional layersof dressing are added. They used a tri-phase randomised cross-over trial of medicalpersonnel and a standardised bleeding simulator. Participants were randomised tocohorts of 10, 20 & 30 layers of 4×4 inch cotton gauze, and subsequently tothree different methods of pressure application: the finger pads of three digits ofthe right hand, three fingers of the dominant hand with the opposing hand applyingcounter pressure, or three digits of each of two hands on top of the other.Participants were asked to hold pressure continuously during each application for10 seconds. The researchers found that participants generated the most force whena single stack of gauze and when two hands were used to apply pressure over thewound and suggested that first aid educators may apply results to lessons indescribing the thickness of the material and need to apply sufficient pressure tostop bleeding.

Zeitlow et al. (2015) sought to establish if bleeding control techniques applied in amilitary context could be translated into a civilian setting effectively. Aretrospective review of people who received a tourniquet or haemostatic dressingpre-hospital. 77 tourniquets were used for 73 people and 62 haemostatic dressingswere applied to 52 people. Seven people required both interventions. Meantourniquet time was 27 minutes, with 98.7% success. Haemostatic bandageapplication 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 twoyears. The authors concluded that civilian prehospital use of tourniquets andhaemostatic gauze is feasible and effective at stopping the bleed. Online andpractical training programs result in the ability to use skills, which can bemaintained despite infrequent use. Kragh Jr et al. (2008) considered the efficacyand challenges of teaching first aid providers to use tourniquets. They studiedmorbidity and tourniquet use specifically in a conflict setting and draw attention tothe fact that tourniquets can complicate care if used inappropriately, and that theeducation of the first aid provider in their use is critical.

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Educators in a lower resource setting or where tourniquets are not readilyavailable might be informed about the effectiveness of improvised tourniquets asstudied by McCarty et al. (2019). They showed that improvised tourniquets tend tohave very poor effectiveness and high failure rates. In a randomised clinical trialthat saw first aid providers trained to apply different tourniquet types, Combatapplication tourniquets (CATs) were compared to other commercial and improvisedmodels. In the cases of ‘improvised tourniquets,’ the learners were allowed tochoose from a selection of materials including leather belts or shoelaces, andplastic (PVC) or wooden rods to act as a windlass. Improvised tourniquets werefound to fail in a number of cases due to breakage of the windlass (70%) whenusing a plastic windlass, or the leather belt strap snapping (almost 45.8% of thecases) where a wooden windlass and belt were used together. For the ‘non-windlass design’ improvised devices, the pressure applied was deemed insufficientin all simulation assessments and demonstrated increased estimated blood losswhen compared to the purpose made CAT device provided for training. Only 1 of 22(4.6%) applications of a non-windlass improvised tourniquet was successfullyapplied. Their findings supported an earlier observation during the BostonMarathon incident, where 27 improvised tourniquets were applied in the field, andall were deemed ineffective on post-event review (King et al., 2015, cited byMcCarty et al., 2019).

There is a gap in the evidence available on how to prepare first aid providers todeploy 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 ScienceWith Treatment Recommendations. Circulation, 142(16_suppl_1), S284-S334. DOI10.1161/CIR.0000000000000897

Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N.,

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Cassan, P., Chang, … Lee, C.C. (2020). 2020 International Consensus on First AidScience 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 oftrauma first aid kits on post-training confidence among community members andmedical professionals. The American Journal of Surgery, 220(1), 245-248. Abstractonly. Retrieved fromhttps://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 Journalof First Aid Education, 2(1), 31. Full article. Retrievedfrom https://digitalcommons.kent.edu/ijfae/vol2/iss1/6/

Charlton, N. P.; Solberg, R. Rizer, J., Singletary, E.M.; Woods, W. (2018). PressureMethods for Primary Hemorrhage Control: A Randomized Crossover Trial.International Journal of First Aid Education, 2(1) 19. doi: 10.21038/ijfa.2018.0011.Retrieved fromhttps://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: arandomized, controlled trial. Prehospital Emergency Care, 23(6), 795-801.Retrieved fromhttps://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 inmajor limb trauma. Journal of Trauma and Acute Care Surgery, 64(2), S38-S50.Retrieved fromhttps://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.914.6478&rep=rep1&ty

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pe=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 Collegeof Surgeons Bleeding Control Basic training among laypeople applying differenttourniquet types: a randomized clinical trial. JAMA Surgery, 154(10), 923-929.Retrieved fromhttps://jamanetwork.com/journals/jamasurgery/article-abstract/2738052

Pellegrino J. L., Charlton N., Goolsby, C. (2020). “Stop the Bleed” EducationAssessment Tool (SBEAT): Development and Validation. Cureus 12(9): e10567. DOI10.7759/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 militaryexperience to implementation in civilian trauma care. J Spec Oper Med, 15(2),48-53. Retrieved fromhttps://www.jsomonline.org/FeatureArticle/2015248Zietlow.pdf

Related topicsShockAmputationChest and abdominal injuries

Related resources

First Aid Reference Centre

Video outlining first aid to someone bleeding.

Severe bleeding | 18

International first aid, resuscitation, and education guidelines 2020.https://www.globalfirstaidcentre.org/ Severe bleeding | 18

Available in 2 languages (English, español).

American Red Cross

This brief video outlines the basic First Aid steps to help someone with severebleeding. It also outlines the importance and application of tourniquets.

Available in 1 language (English).

First Aid Reference Centre

First aid video outlining the steps for dealing with a nosebleed.

Available in 2 languages (English, español).

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Explore the guidelines

Published: 15 February 2021

Severe bleeding | 19

International first aid, resuscitation, and education guidelines 2020.https://www.globalfirstaidcentre.org/ Severe bleeding | 19

First aid

Explore the first aid recommendations for more than 50 common illnesses andinjuries. You’ll also find techniques for first aid providers and educators on topicssuch as assessing the scene and good hand hygiene.

Severe bleeding | 20

International first aid, resuscitation, and education guidelines 2020.https://www.globalfirstaidcentre.org/ Severe bleeding | 20

First aid education

Choose from a selection of some common first aid education contexts andmodalities. There are also some education strategy essentials to provide the theorybehind our education approach.

Severe bleeding | 21

International first aid, resuscitation, and education guidelines 2020.https://www.globalfirstaidcentre.org/ Severe bleeding | 21

About the guidelines

Here you can find out about the process for developing these Guidelines, andaccess some tools to help you implement them locally.