Interactive lesson · Chapter 29.1
Direct pressure and the bleeding ladder
Part 1 of 7
Why this matters
A cook has slipped with a knife and opened a deep cut on his forearm. Dark red blood flows steadily onto the floor. His coworker has already pressed three paper towels onto it and is about to peel them off to see how it looks.
Most external bleeding stops with one thing done well: firm pressure, held, and left alone. This lesson is how to do that, and how to tell when it is not enough.
Part 2 of 7
What you find, and what you do
- You findYou look at the blood: bright red and spurting, dark red and flowing steadily, or a dark ooze.You doThat tells you the vessel. Arterial bleeding (bright red, spurting with the pulse) is the hardest to control and the fastest to kill; venous bleeding flows steadily; capillary bleeding oozes and often stops on its own.
- You findThe bleeding is severe or spurting and you have no dressing in your hand.You doPut a gloved hand straight on the wound. Do not spend time looking for a dressing first.
- You findYour hand or a dressing is on the wound.You doPress firmly, toward a bone where there is one, and hold the pressure without letting up. Do not lift it to check; for massive bleeding, keep it on all the way to the hospital.
- You findBlood keeps coming through what you placed.You doDo not peel the dressing off to look. If the bleeding continues, escalate rather than relying on more layers: wound packing with a hemostatic agent where protocol allows, or a tourniquet for a wound on a limb.
- You findThe bleeding has stopped.You doConvert to a pressure dressing: bandage the dressing firmly so the pressure holds without your hands, and keep checking for bleed-through.
Part 3 of 7
Key ideas
- Pressure works by squeezing the tissue around the wound, slowing the flow through the damaged vessels and giving the body time to clot.
- Don't peel a dressing off to look. Lifting it tears away the clot forming under it.
- More layers are not the fix. Gauze soaks up blood without stopping it, and a thick pile cushions your hand away from the wound. Continued bleeding means escalate.
- Volume depends on size. An adult holds about 5 to 6 liters of blood. A sudden loss of about 1 liter is serious in an adult, about 500 mL in a child and 100 to 200 mL in an infant.
- Elevation and pressure points are no longer recommended for bleeding control.
- Life-threatening bleeding from a limb does not climb this ladder: it gets a tourniquet straight away (the next lesson).
- Nosebleeds are managed by sitting the patient up, leaning forward, and pinching the soft part of the nostrils. Leaning back sends blood into the stomach and causes vomiting.
Part 4 of 7
A common mistake
The wrong idea: When a dressing soaks through, take it off and put on a fresh, dry one so you can see the wound.
What is actually true: Leave the dressing where it is: lifting it disrupts the clot. Continued bleeding is the signal to escalate to packing with a hemostatic agent where protocol allows or, on a limb, a tourniquet.
Part 5 of 7
Check yourself
1Blood is bright red and spurting from a wound in time with the patient's pulse. Which vessel is most likely open?
Arterial blood is bright red because it is fully oxygenated, and it spurts because it is under the pressure the heart generates. It is the hardest bleeding to control and the fastest to kill.
2You have held firm, uninterrupted pressure on a heavily bleeding leg wound, and blood keeps soaking through the gauze. What is the next step?
Pressure has failed on a severe limb bleed, so escalate: a tourniquet on a limb, or packing for a wound that cannot take one. Don't peel the gauze off, easing off lets it bleed more, and elevation and pressure points are no longer recommended.
3A patient has a steady nosebleed that started on its own. How should you position them?
Upright, leaning forward, with the soft part of the nostrils pinched. Tilting the head back sends the blood down the throat into the stomach, which causes vomiting.
4Which sudden blood loss is serious for a child, according to the usual rule of thumb?
A sudden loss of about 500 mL is serious in a child, about 1 liter in an adult, and as little as 100 to 200 mL in an infant.
5A patient's forearm is bleeding heavily and you have no dressing in reach. What do you do?
For severe or spurting bleeding, a gloved hand goes straight onto the wound. Time spent hunting for a dressing is blood the patient does not get back.
Part 6 of 7
Summary
Direct pressure controls most external bleeding: compress the wound (a gloved hand at once if it is severe), hold firm pressure without lifting it to check, leave what you placed undisturbed, and escalate if it fails. Continued bleeding means packing with a hemostatic agent where protocol allows or, on a limb, a tourniquet, not more layers and not removing the dressing. Once bleeding stops, a pressure dressing holds it. Life-threatening limb bleeding skips straight to a tourniquet.
Part 7 of 7
What comes next
For exam study only. Follow your local protocols and medical direction.