The European Resuscitation Council (ERC) First Aid Guidelines 2015 state that when direct pressure cannot control severe bleeding, tourniquets and haemostatic dressings are now advised. ILCOR (International Liaison Committee on Resuscitation) fully supports this
If someone is bleeding extremely heavily from either a major artery or vein, they can quickly lose a lot of blood. The bleeding is likely to pulsate in time with the heart. This is more pronounced with an arterial bleed, but happens within venous bleeds too. With extremely heavy, potentially catastrophic bleeding an adult could easily lose 40% of their blood volume in 3-4 minutes. This could be even quicker when dealing with children.
If a casualty loses a substantial amount of blood – more than 40% of their blood volume, the body is no longer able to compensate for that amount of blood loss. They will develop hypovolaemic shock. Hypovolaemic shock is a low volume of blood causing failure of the circulatory system, if untreated they will die.
Military and civilian research has shown wealth of evidence demonstrating the effectiveness of tourniquets and haemostatic dressings in the treatment of life-threatening bleeding.
Key changes in the new European Resuscitation Guidelines relating to bleeding:
- New guidelines no longer recommend elevation for the control of severe bleeding. Elevation does reduce the flow of blood, but alone it will not stop bleeding. If someone has an arterial bleed, just holding it in the air is not going to stop the bleeding. Applying direct pressure to the source of bleeding is much more likely to stop life-threatening blood flow.
- You should not use indirect pressure points to control severe bleeding. There is more than one artery supplying the blood to each limb. Pressing on pressure points will not be able to stop the blood flow. Finding pressure points can also be very difficult, particularly with the femoral artery.
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Treatment of Bleeding:
- Encourage the casualty to sit or lie down in the most appropriate position for the location of the wound and the amount of blood lost. If they are feeling dizzy and showing early signs of shock, raise their legs.
- Examine the wound (as quickly as possible) to assess:
- The type and extent of bleeding.
- The source of the bleeding.
- Whether there are any foreign objects embedded in the wound – if so, do not remove them as they will be stemming bleeding, but apply direct pressure either side of the object.
- Apply direct pressure to try and control bleeding. If you control the bleeding with this direct pressure, keep holding for 10 minutes as it takes this long for clots to form.
- Once you control bleeding, dress the wound – if the wound bleeds through the first dressing, apply another on top. If the wound bleeds through the second dressing you should consider alternative options to stop the bleeding.
The first step when treating a catastrophic bleed is always to apply direct pressure. It is still likely to be the first and only solution needed for the casualty.
Please note:
Tourniquets and haemostatic dressings have been introduced as additional options to treat severe catastrophic bleeding. However, direct pressure remains the main choice of treatment and it will control bleeding in the vast majority of cases. The European Resuscitation Council 2015 guidelines state that haemostatic dressings and tourniquets should be used when direct pressure is either not possible or ineffective.
In environments where a catastrophic bleed is likely, tourniquets and haemostatic dressings should be an integral part of the first aid kit. All first aiders should be trained in their use.
As a member of the general public you are highly unlikely to need to use a tourniquet. However understanding how to improvise one, and how and when to use one, could save lives if you’re ever involved in a major medical accident or emergency.
Do Improvised Tourniquets Work?
There is ongoing debate around the usefulness of an improvised tourniquet: Stewart SK, Duchesne JC, Khan MA discussed this in their paper – Improvised Tourniquets: obsolete or obligatory: Journal of Trauma Acute Care Surg 2014;78;1. He came to the following conclusion:
“We propose that education on how to expertly construct and apply an improvised tourniquet becomes and integral part of basic life support and pre-hospital emergency care algorithms, for military and civilians alike. In the absence of a commercially produced tourniquet, this simple first aid measure can satisfactorily arrest life-threatening haemorrhage, while minimizing morbidity that other cruder designs may cause.”
How to Use an Improvised Tourniquet
Here is one of the easiest ways to make an improvised tourniquet from the contents of a standard first aid kit. Use a triangular bandage folded into a broad fold bandage and to tighten the tourniquet using scissors as a windlass. If you have access to cutlery, such as a table knife, this would be even better. Otherwise you no longer have your scissors available to use.
Please note: A tourniquet should be at least 4cm wide to prevent localised damage to nerve tissues.
- Tie the bandage around the bare limb on a single bone (i.e. if the lower part of the arm or leg are bleeding, you should tie the tourniquet on the upper part, where there is only one bone rather than two).
- The tourniquet should be at least 5cm above the wound, or 5cm above the joint if the wound is on the lower limb. Never place a tourniquet over a joint.
If there’s a clean cut through an artery, for example in a deep incised wound, the artery can contract back up the arm or leg. This is why you should place the tourniquet at least 5cm (or 2 inches) above the wound.
You may find other guidance on the positioning of a tourniquet, such as applying the first tourniquet mid-point over a single bone. This advice is also acceptable, so long as the tourniquet is positioned proximal to the wound (closer to the trunk of the body).
1. Place the knife or your scissors on top of the knot and tie another knot on top of them.
2. Use the knife or your scissors as a windlass to wind round and tighten the tourniquet.
3. The windlass can be secured either by tying another triangular bandage to stop it unwinding or by wrapping and tying both ends of the triangular bandage around the ends of the windlass to ensure it remains in place.
Time Factor
It is important to note the exact time in which you applied the tourniquet. To arrange for urgent transfer for medical help, ensure you tell them where and when the tourniquet was applied.
Please note it will be extremely painful for the casualty to have a tourniquet. Howewver it is absolutely vital that you apply the tourniquet tight enough to entirely stop the bleeding.
If a tourniquet is not on tight enough it can make things worse as it can occlude the veins. Arteries may be harder to stop as they are less easy to get to. Moreover, if the venous return is stopped by the tourniquet, the only place for blood to come out is from the wound.
NEVER be tempted to loosen or remove a tourniquet. Once applied, tourniquets should only ever be removed by a doctor in a hospital setting.
Unsuitable but Tempting Alternatives for an Improvised Tourniquet:
A tie is likely to be too thin. A leather belt is also unsuitable as it is too tough to use with a windlass; you will be unable to provide sufficient force by hand to tighten it sufficiently to provide enough pressure to stop the blood flow.
A tourniquet should be at least 4cm wide to prevent localised damage to nerves tissues.
A tourniquet must be put on sufficiently tight to stop the bleeding. If it is not tight enough it can actually end up increasing blood loss. It may be necessary to apply more than one tourniquet to completely stop bleeding.
It is important for the doctor treating the casualty to have a good understanding of how long the tourniquet has been applied for. Write the time the tourniquet was applied onto the tourniquet itself or onto the casualty.
Please remember that although tourniquets can save lives, their use should not be taken lightly. They remain a second-line treatment when direct pressure is not possible or insufficient to control bleeding.
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This was extremely helpful and important because of today’s tragedies in life. Watched 60 Minutes tonite 11.4.2018. Thank you
Thank you. Glad you found it so useful. Best wishes Emma
As ex military I have used CAT tourniquet for real. Because of my work in security I am FREC3 trained. After a recent multi casualty incident onboard a ship, involving severed legs I surfed the net for a refresher, so that I can heighten the crews awareness in torniquets, how to use and how to improvise. I found your article to be by far the best but also mirrored FREC3 training.
Releasing the tourniquet is an ancient method and as you stated, for the correct reasons, wrong.
However, I have also seen that if a tourniquet is to be used for more than an hour one can do a test release to see if the bleed has stopped. If not, it’s to be retensioned and left.
You may be able to clarify on this more.
Excellent article.
Thank you for your lovely feedback. This article focuses on immediate first aid, assuming there is back up secondary care, that can be provided pretty quickly. I would suggest it unlikely that a major catastrophic bleed would have stopped in an hour and would feel it is more prudent to keep the tourniquet in place. Research has suggested that major tissue damage is not likely to take place for quite a few hours. You can die very quickly from a catastrophic bleed or from a release of toxins. Tourniquets should only be released by someone qualified to do so, with appropriate resources to stem the bleed.
Thank you Emma, having given my particular situation considerable thought on preparation of my presentation, I had come to exactly the same conclusion you had replied with. I think some of the technical facts and figures out there are too confusing for a life or death situation.
Many Thanks
Very effective. Most individuals do not know anything about tourniquet use or severe blood loss.proper use is very important.Also stating time applied. I really enjoyed reading the information.Job well done. Thanks Mike
For an American audience–an inch and a half wide. In an emergency situation we don’t want someone scratching his head . . . uh, let’s see. Divide the number of centimeters by . . . what is it? Oh, yeah 2.54. So, 4 divided by 2.54 equals . . . uh 1.67?
Thank you
Great TY! I had Cortana figure that out for me. ?
Emma:
Why is a tourniquet placed 3-4 inches above the venipuncture site when doing a routine blood draw? Why 3-4 inches?
Thanks,
Dan
Dear Daniel, in venapuncture you are trying to engorge the vein, not cut off the blood supply to the entire limb. I am unaware of the precise 3-4 inches stipulation, but it makes sense to apply the tourniquet to the single bone above the venapuncture site.
how long should the tournique be allowed to stay on ?
Once the decision has been made to apply a tourniquet it must only be removed in a hospital environment by a qualified clinician. Once a tourniquet has been applied, toxins will begin to build up and if the tourniquet is removed, they will flood the bloodstream and this can prove fatal.
There are many studies as to how long a tourniquet can remain in situ before irreversible damage occurs to the limb – however the bottom line is that it is only applied for catastrophic bleeding which cannot be controlled by direct pressure. Once the decision is made to apply it, it is not removed until the casualty is treated in hospital by a qualified doctor – they are transported to hospital as quickly as possible
Emma, thank you for the article, very useful as a refresher. Can you add your comments about the reason why it shouldn’t be removed (i.e. because of the build up of toxins) to the main article? I think it is important that people know a tourniquet should not be removed for this reason and is not a ‘fix’ for when you have an issue at home – if you apply it, that person is going to hospital regardless and you do not remove it.
this shit is shameful. so much misinformation in this tutuorial. this needs to be taken down immediatly. using a tournequet should only ever be used on a lost limb or if the wound is soo bad it would be appropriate to sacrifice the limb to stop the blood flow. unless ur a doctor or a first responder you should never ever tournequet some one as you will probably find ur self in a law suit because of complications with the tournequet. it only takes a small amout of time to completely kill the limb u used it on. so this shit should get taken down or give the proper warning tht this should only ever be done on life threatening wounds. please just take this info down for everybodies sake. all i know if i got a gunshot in the arm and passed out and woke up with a tournequet on my arm. there would be hell to pay. apply pressure on the wound and wait for medical proffesionals to show up is the proper way to do things.
Hardly true. The information you’re talking about is severely outdated; a tourniquet can be left on for up to 4 hours before risking permanent damage, if removed in a hospital setting. Regardless, ALL uncontrolled bleeds, especially arterial bleeds, are life-threatening. If you apply direct pressure as hard as you can and the bleeding doesn’t stop (i.e. it seeps through or around your fingers), there is nothing to be lost by applying a tourniquet. Therefore, the article is correct.
I think if you get shot, you won’t be doing much complaining anyway.
Yes, this is incorrect. I have heard from more than one credible source—one such source being a retired military line medic with 15 years of emergency medical experience—not to remove or loosen a tourniquet, even for a minute, until you reach the hospital. The theory that using a tourniquet is a choice between losing a life or losing a limb is outdated and incorrect. Tourniquets have been used for hours at a time without loss of limb.
This was helpful as did one first aid course where I was taught that if using a tourniquet to clamp a vein or artery it should be released every couple of minutes and then re applied to prevent blood poisoning
Dear Alan, please never release a tourniquet once it has been applied as that is extremely dangerous. Best wishes Emma
Hi
I’ve become curious on the use of tourniquets and catastrophic bleeding. I have a basic knowledge on first aid and own a CAT tourniquet but still have a few questions on the use of tourniquets.
Firstly, do you require some sort of qualification to carry and use a pre-made tourniquet? I’m not a medical professional and haven’t taken an actual training course on tourniquets however I do already have a detailed knowledge on when to use it, how to put it on and its potential dangers (courtesy from tourniquet training video courses online).
Also if the time comes and I do have to apply it, would I be penalised or be “told-off” by medical professionals if I were to somehow do it incorrectly or without the proper training?
Thanks
Dear Geoffrey, the same rules apply as with first aid training. You operate according to recognised practice and to your skills and experience. You are only using a tourniquet for a life-threatening bleed if direct pressure has not worked and so your intervention should be life-saving and welcomed. Best wishes Emma
Great article! I applied a tourniquet to my thigh after I was accidentally shot. The paramedics asked exactly when it was applied if I had loosened it at any time. There was no exit wound and not much blood coming out of the entrance wound. There was however massive swelling which I assumed was internal bleeding. Direct pressure would have been ineffective since my femur was shattered. I decided to make use of a tennis ball and a nylon strap with a slide buckle on my inner thigh. The trauma surgeon said it worked! Some creativity and first aid knowledge kept me from loosing my leg! Again, great article!
Sounds like you did a great job
sounds to me like your lucky af you didnt lose your leg. the only time u should ever apply a tournequet is if the wound is so bad nothing else can be done. from my knowledge unless your a medical professional ur not allowed to tie a tournequet unless u dont mind losing ur leg possibly. never use a tournequet on some one else unless ur a medical professional. normal ppl are not trained to tie tournequets. and will most likely find them selves ina lawsuit if any conplications occur. the rules may be different in the uk but i think this article is badly written for not excerising the dangers of tournequets.
To again counter Justin’s comment, I am so glad you’re here today, Greg. Good job knowing what to do, and good thinking—and improvising! What an example for the rest of us. As previously explained, Justin’s concern is outdated and entirely incorrect; Greg did exactly the right thing, with more presence of mind than most of us, and I am so glad. From the sound of it, the bleeding produced by such a wound probably was “so bad nothing else can be done,” difficult if not impossible to stop by pressure alone, and definitely life threatening. This is a difficult area to compress adequately even with a tourniquet. As a notable aside, fracture of the femur is often associated with profound shock, so the person administering first aid should be very aware of this complication.
Did I miss something or did it not say how long a tourniquet should remain on for? if you are hours away from help then as a lad in the scouts we were taught to release the tourniquet every 20 mins and then reapply, also to write the time applied on the forehead of the patient.
Dear Kenneth. Thank you for your message. Please never release a tourniquet once it has been applied as this could be fatal for the casualty. Once the decision has been made to apply a tourniquet it should ONLY be removed by a doctor in a controlled hospital environment. Most definitely write the time when the tourniquet has been applied but do not release it, even if you are hours away from help. You are only using a tourniquet for catastrophic bleeds – most bleeding can be controlled with direct pressure and that is always first line treatment.
Hi.
While I am not a doctor with in-depth knowledge, I am a health professional who has knowledge of anatomy and have done multiple refresher courses on CPR and choking.
It has however been many years since I did a general first aid course that covers all the other aspects and am lacking more knowledge here.
In saying this, I have a curly question to ask:
what would be the most effective and efficient way to stop a life-threatening arterial bleed due to external severing on *yourself* (with no bystanders to help)?
For example, if you got stabbed, as is rather prevalent in the UK.
Is there much you could do in this situation on your own to increase your chances of survival (apart from using your phone to ring 999, provided you could maintain consciousness long enough)?
Would it be handy to have a proper tourniquet on you if you knew how to use it?
And apply it hastily *before* ringing emergency services?
Could you improvise with a torn shirt like in the movies if you didn’t have scissors?
Or would you just have to hope that you still have the strength to apply pressure without passing out from an early onset of shock?
How much time would you have?
Thank you for your message. If you are experiencing a catastrophic bleed you could have as little as 3 minutes. With a manufactured tourniquet, they are designed for military use to be applied on oneself if necessary. I do not think you would be able to apply an improvised tourniquet to your own arm on your own – however, you could apply one to your leg if necessary
I practiced applying a SOF tourniquet with one hand on my opposite arm during a first aid class. It’s not quite intuitive, and not exactly easy, so I definitely recommend practicing—it’s NOT something you want to have to figure out when using it for real. Apply it as high up as you can, if you can clench it under your armpit for purchase, and pull it as tight as you can before twisting the windlass. I think being able to deploy it one-handed on yourself is one of the major advantages of commercial tourniquets (as opposed to improvised ones).
Thank you for this information Emma, I refer people to this page often when it comes to tourniquet question clarifications. I’ve used them in military service and they are invaluable. It’s so important to keep updated on the information and techniques too. Lot’s has changed since I first trained in the forces. Thank you again.
When and how the tourniquet is used in venipuncture?