Interactive lesson · Chapter 29.2
Tourniquets and wound packing
Part 1 of 7
Why this matters
A worker's lower leg was caught by machinery. Bright red blood is pumping from a wound below the knee and pooling fast. Hand pressure is not slowing it.
For years a tourniquet was taught as the last thing you tried. Military experience changed that: a correctly applied tourniquet rarely costs the limb, and waiting costs lives. Life-threatening bleeding from a limb gets a tourniquet right away.
Part 2 of 7
What you find, and what you do
- You findThe bleeding from a limb is life-threatening (spurting, pooling, an amputation) or is not controlled by direct pressure.You doApply a commercial windlass tourniquet now, not after a long series of other measures. Improvised tourniquets often fail: without a windlass they cannot be tightened enough, and they are usually too narrow to close the artery.
- You findYou can see where the bleeding is coming from.You doPlace the tourniquet 2 to 3 inches above the wound, between the wound and the heart, and never over the elbow, wrist, knee or ankle. If you cannot find the source, or there are several wounds on the limb, go high and tight on the limb.
- You findYou are tightening the windlass.You doKeep turning until the bleeding stops and the pulse below the tourniquet is gone. Both endpoints matter: closing the veins but not the artery traps blood in the limb and makes the bleeding worse.
- You findThe tourniquet is on and the patient is in severe pain.You doTell the patient beforehand that it will hurt; pain is not a reason to loosen it. Write the time it was applied on the tourniquet and in your report, say it at handoff, leave it visible, and never loosen it in the field.
- You findOne tourniquet, fully tightened, has not stopped the bleeding.You doApply a second tourniquet just above the first instead of forcing the first past its limit.
- You findThe wound is in the groin, the armpit or the base of the neck, where no tourniquet fits.You doIn the groin or armpit, pack gauze (plain, or hemostatic where protocol allows) into the wound down to the source of the bleeding, fill the cavity tightly, and hold firm pressure for at least 3 minutes. A neck wound gets an occlusive dressing, to keep air out of the veins (air embolism), and direct pressure that does not compress the airway or both carotid arteries; pack it only with caution and per protocol.
Part 3 of 7
Key ideas
- Not a last resort. Current civilian practice, including the American College of Surgeons' Stop the Bleed program, puts a tourniquet on life-threatening limb bleeding immediately.
- Placement: 2 to 3 inches above the wound and never over the elbow, wrist, knee or ankle. The joint's structure stops the artery from being compressed, and the nerves there can be injured.
- Endpoint: the bleeding stops and the distal pulse is gone.
- After it is on: record the time, keep it visible, do not loosen or remove it in the field.
- Junctional areas (groin, armpit, base of the neck) take wound packing or a junctional device, not a tourniquet.
- Never pack the chest or abdomen. There is nothing to pack against, and the gauze goes where you cannot control it.
Part 4 of 7
A common mistake
The wrong idea: A tourniquet is the last resort, because it will almost certainly cost the patient the limb.
What is actually true: A correctly applied tourniquet left in place for a prehospital transport rarely costs the limb. Life-threatening limb bleeding gets one immediately; hesitating is what costs lives.
Part 5 of 7
Check yourself
1A patient's arm is bleeding heavily from a wound just below the elbow. Where does the tourniquet go?
The tourniquet goes 2 to 3 inches above the wound and never over a joint. Here that would land on the elbow, so it goes above the elbow, on the upper arm. Over a joint, the joint's structure stops the artery from being compressed, and the nerves there can be injured.
2You tighten a thigh tourniquet. The bleeding slows, but you can still feel a pulse in the foot and the leg below looks swollen and dark. What do you do?
A tourniquet that closes the veins but not the artery lets blood in but not out, which makes bleeding worse. The endpoint is both: no bleeding and no distal pulse.
3One tourniquet is fully tightened on a leg and the wound is still bleeding. What is the next step?
If one tourniquet does not control the bleeding, a second one goes just above the first. Forcing the first past its limit can break it, and loosening it restarts the bleeding.
4A patient has a deep, heavily bleeding wound in the groin. What is the right approach?
The groin is a junctional area where a tourniquet will not fit. Gauze is packed into the wound down to the bleeding source and held under firm pressure for at least 3 minutes. Gauze laid on top is a dressing, not packing.
5Two minutes after you apply a tourniquet, the patient begs you to loosen it because of the pain. What do you do?
A working tourniquet hurts, often badly, and pain is not a reason to loosen it. Warn the patient beforehand and never loosen or remove it in the field once the bleeding is controlled.
Part 6 of 7
Summary
Life-threatening bleeding from a limb, or limb bleeding that pressure does not control, gets a commercial windlass tourniquet: 2 to 3 inches above the wound and never over the elbow, wrist, knee or ankle, or high and tight when the source is unclear or there are several wounds. Tighten until the bleeding stops and the distal pulse is gone, expect pain, record the time, keep it visible and never loosen it in the field; add a second one above the first if needed. Groin and armpit wounds are packed and held for at least 3 minutes; the neck gets an occlusive dressing and careful pressure; the chest and abdomen are never packed.
Part 7 of 7
What comes next
For exam study only. Follow your local protocols and medical direction.