Management of life-threatening bleeding

Rapid response is key when it comes to emergency hemorrhage incidents


By Brandon Griffith and Tim Freund

Hemorrhage from traumatic injuries is a leading cause of preventable death in the United States. The National Trauma Institute estimates hemorrhages account for greater than 35% of pre-hospital hospital admittance deaths. According to the World Health Organization (WHO), approximately 1.75 million lives are lost annually around the globe due to hemorrhages caused by traumatic injury/violence.

With such a high mortality rate, it is vital life-threatening hemorrhages be controlled rapidly.

When properly applied, a tourniquet will stop the flow of blood into an extremity.
When properly applied, a tourniquet will stop the flow of blood into an extremity. (Brandon Griffith)

The importance of hemorrhage control

Our bodies need an uninterrupted supply of oxygenated blood to function effectively. Blood carries oxygen and glucose via the circulatory system to supply the energy needed for the body. It also returns the by-products of normal energy production from our tissues, brain and other vital organs. A “hemorrhage” is the sudden disruption of this closed loop resulting in the loss of blood components from the cardiovascular system. The decrease in circulating blood volume (hypovolemia) decreases oxygenation of the body’s tissues resulting in hemorrhagic shock.

Types of bleeding

Bleeding can be internal (inside the body) and external (outside the body). In many circumstances, injured persons will be bleeding internally and externally at the same time. Within both internal and external hemorrhage, bleeding can be arterial, venous and capillary. Again, it is common for an injured person to have arterial, venous and capillary bleeding simultaneously.

Arterial: Bleeding in the arteries that transport blood from your heart to the rest of your body. Because the arterial system is tasked with pushing blood to areas far from the heart, it is a “high pressure” system. Arterial bleeding is bright red blood that tends to spurt or pulsate. Arterial bleeding is usually life-threatening if not addressed immediately.

Venous: Bleeding that occurs in the veins that carry blood back to your heart. The venous system drains blood from distant parts of the body back to the heart under lower pressure. Venous bleeding is dark red colored and tends to flow continuously. Venous bleeding has the potential of being life-threatening if left untreated.

Capillary: Bleeding that takes place in the tiny blood vessels that connect your arteries to your veins. Capillary is a more common type of bleeding, which tends to ooze from a damaged/injured area, but it is rarely life-threatening by itself. Capillary bleeding tends to be superficial and easy to control with direct pressure.

Police1 resource: How well do you know 'Stop the Bleed'?

Treatment and management of bleeding

Law enforcement has two priorities when they arrive on scene of a person or persons who are bleeding:

  • Render the scene safe before initiating life-saving treatments;
  • Request fire/EMS.

When it comes to controlling hemorrhages, you must factor in the location(s) of the bleeding. Once you locate the source, control the bleeding with direct pressure, tourniquet application, wound packing, and/or a combination of these life-saving applications.

Direct pressure is effective for many instances of external bleeding and requires no special equipment except simple personal protective equipment like nitrile gloves. Direct pressure is commonly performed with one or both gloved hands directly on the source of bleeding. This may require applying most of your body weight on the location of the bleeding for several uninterrupted minutes.

Wound packing may be necessary for deeper or larger wounds that do not respond to direct pressure. Wound packing involves filling the wound with as much cloth, gauze, or hemostatic gauze so the wound stops filling with blood instead. Wound packing is a more precise tactic than direct pressure by pressing the packing material on the bleeding vessel if possible. Packing a wound is usually more effective when paired with several minutes of direct pressure and sometimes a pressure dressing.

Proper wound packing includes stuffing hemostatic gauze or cloth down into the wound where the bleeding is occurring. Pack as much of the gauze into the wound as you can and then apply firm direct pressure.
Proper wound packing includes stuffing hemostatic gauze or cloth down into the wound where the bleeding is occurring. Pack as much of the gauze into the wound as you can and then apply firm direct pressure. (Brandon Griffith)

Tourniquet application involves applying a tourniquet completely around an extremity for the purpose of stopping blood flow through pressure evenly around a limb. Most tourniquets are at least one inch wide and use some sort of mechanical advantage to provide constant pressure. This pressure is focused on pressing arteries against bones to stop bleeding. While tourniquets can be improvised, a CoTCCC-approved device should be used whenever possible.

When applying a tourniquet on an extremity, there are two different methods commonly used. The military has long preached “high & tight,” meaning place the tourniquet as high up the limb as possible. Under fire or in low light/no light situations where you do not want to be seen (illuminated) or are unable to clearly see the source of life-threatening bleeding, this is a great method. It is easy in those situations to place the tourniquet all the way up to the armpit or groin area and tighten down the device to stop blood flow. “Stop the Bleed” instructs students to place a tourniquet 2 to 3 inches above the bleeding wound, avoiding the knee and elbow.

Initially, tourniquets should be placed over clothing, however, you want to ensure you’re not placing the tourniquet over pockets containing items. A wallet, cellphone, keys, holster, etc., can all hinder the proper application of a tourniquet. Elbow and knee joints have bones that prevent the compression of the artery meaning you will be unable to stop the blood flow to the wound. It is important to note, tourniquets should not be applied directly on top of the wound and should always be placed between the wound and the heart.

Properly applied tourniquets may cause pain. Be prepared to have your patient screaming and telling you you’re putting it on “too tight.” Reassure them you’re doing all you can to save them, and it will be painful. You will know the tourniquet is tight enough when the bleeding stops. If you get the tourniquet on as tight as you possibly can and they are still bleeding, consider a second tourniquet, or follow up with wound packing and direct pressure.  

All three bleeding control techniques may be painful to the recipient. However, many people who are experiencing life-threatening bleeding are experiencing pain from their injuries. This pain from injury is usually more significant than life-saving measures. If no response is elicited from the injured person during properly applied bleeding control measures, consider the injured person unconscious and near death.

Police1 resource: New TCCC guidelines provide officers more tourniquet choices

Types of wounds

Extremity wounds (arms and legs): Uncontrolled bleeding from arms and legs are usually controlled with direct pressure and/or the application of tourniquet(s). A tourniquet stops the flow of blood into an extremity. When properly applied, tourniquets will prevent all blood from continuing to flow into the injured arm or leg. Application of a tourniquet to arm and leg wounds allows officers to keep their hands available for other activities.

Torso junctional wounds (neck, shoulder and groin): Uncontrolled junctional bleeds from the neck, shoulders and groin can be difficult to control. Tourniquet application for wounds in these regions is ineffective for bleeding control. Wound packing and direct pressure are the best bleeding control applications for junctional wounds.

Too often in movies or shows when someone has a life-threatening bleed the saver simply places a towel over the wound and presses down on it. In the real world when the wound is large enough you need to “pack” hemostatic gauze, cloth, etc. down into the wound where the bleed is occurring. Stuff as much of the gauze or cloth into the wound as you can and then apply firm direct pressure on top of the packed material to best control the hemorrhage.

Chest/back and abdominal wounds: Wounds located on the chest, back and abdomen are most associated with internal bleeding. It is important to know you cannot control internal bleeding outside of a hospital. If you suspect internal bleeding, the patient must be rapidly transported to a trauma center. If you choose to wait for fire/ EMS, ensure you verbalize your suspicion of internal bleeding. Fire/EMS cannot stop internal bleeding and must provide rapid transportation to a surgeon. Otherwise, consider transporting the injured person to a trauma center in a law enforcement vehicle if state statute or department policy allows. Wound packing and direct pressure are utilized to mitigate and help slow blood loss from the chest, back and abdominal wounds.

Sucking chest wounds: Sometimes penetrating injuries to the chest/ torso create an alternate pathway for airflow during breathing.  Wounds between the top and bottom of the rib cage in a 360 radius around the torso can significantly disrupt breathing. Air exchange from the wound sounds like hissing and sucking when the person inhales and exhales are strong indicators, along with heavy bleeding, pinkish/red foaming blood around the wound and the coughing up of blood.

It should be known that some sucking chest wounds do not make any noise so any wound caused by penetration of the chest should be treated as a sucking chest wound.

Vented chest seals are the preferred method of bleeding control in sucking chest wounds but if you are unequipped, an occlusive dressing or even your gloved hand will work placed over the wound. If possible, ensure the seal has at least one open side to allow the release of air without letting air in.

If any signs of pneumothorax (the buildup of air in the chest) are present like enlarged neck veins, cyanosis (blue colored fingertips and lips), shallow breathing, crackling sounds, short breathes, one side of the chest fails to rise with inspiration, the seal should be immediately removed from the patient. If the patient passes out and/or stops breathing, immediately begin cardio-cerebral resuscitation (“hands-only CPR”).

Bleeding wounds from the head: If an injured person has bleeding wounds from the head and face, allow them to assume a position of comfort, which prevents them from swallowing or choking on their own blood. These wounds may bleed significantly but should not be packed with gauze. Instead, firm direct pressure should be applied for bleeding control unless a skull fracture is suspected. If the skull moves when pressed, use a pressure dressing instead of direct pressure. 

Looking for additional wounds and managing accordingly: It is extremely important to conduct a thorough check of your patient for additional wounds. Particularly with gunshot victims, you will want to look for additional wounds. Cut clothing and expose victims to look for additional wounds regardless of gender or age. There is no dignity in death. Conduct your check and cover your patient back up. Blood loss decreases body temperature due to volume loss. If you have a blanket or clothing, help your victim prevent heat loss. A survival rescue blanket is another simple and compact piece of life-saving equipment.

It’s important to cut/remove clothing to locate life-threatening bleeds. Always look for more than one injury and be mindful of exit wounds with gunshot victims and punctures.
It’s important to cut/remove clothing to locate life-threatening bleeds. Always look for more than one injury and be mindful of exit wounds with gunshot victims and punctures. (Brandon Griffith)

Special circumstances

Impalements: If your patient has been impaled by an object, it is vital you leave it in place and conduct bleeding control methods around it. The object often helps control the patient’s bleeding and removing it will cause further bleeding and should only be done in the hospital by a medical professional. Wound pack, direct pressure, wrap and tourniquet around it. The only exceptions are scene safety or risk of death and further serious injury (like being trapped in a vehicle underwater, under gunfire, the building is on fire, etc).

Amputations: Amputations can be difficult to control on scene with exposed tendons, muscle tissue and blood pooling. After the application of a tourniquet, try to keep the exposed tissue of the limb (“stump”) clean and wrapped with gauze. Secure the amputated portion of the limb and ensure it is transported with the patient. If you have a red biohazard bag or garbage bag to secure it and keep it clean, try to do so. However, don’t delay the transport of an injured person to locate a severed part.

Wraps can be used to maintain pressure on a packed wound during patient transport.
Wraps can be used to maintain pressure on a packed wound during patient transport. (Brandon Griffith)

Scene safety after the fact        

Disease transmission

Personal protective equipment should always be carried and worn by officers. This begins with nitrile gloves, which should be readily available in any number of locations in or on their uniform. Life-threatening bleeding can spurt and spray onto your exposed skin potentially into open wounds, mouth, and eyes. If exposure occurs, finish providing life-saving interventions and conduct in-depth washing of the exposed area with soap and water. Avoid hand sanitizer as it causes your blood vessels to dilate and open. This may allow more infectious material to enter your body and cause disease transmission. Follow up this potential exposure by reporting to your chain of command or following your department’s policy on hazardous body fluid exposure.

How important is it for police officers to carry bleeding control equipment like tourniquets, hemostatic gauze and chest seals?

The law enforcement profession has a greater risk of injury than most careers. Because law enforcement officers are sworn to “protect and serve” their communities, it is imperative they are trained and equipped to save lives, beginning with their own. With the prevalence of officer ambushes, it is vital for officers to be prepared to care for themselves (self-aid) when seconds matter and fire/EMS aren’t available. Officers need to have regular training and preparation in self-aid so they can save their own lives, and buddy aid, caring for others, when they’re on a scene without backup. A good tourniquet (or two), gloves, gauze and chest seals kept on their person can be the difference between life and death. A bleeding control kit in the patrol vehicle or a “go bag” will not help an officer who is bleeding out in a critical incident and cannot get to their vehicle or bag.

Another important reason for officers to carry simple medical equipment as part of their uniform and in their vehicle is officers regularly respond first to emergencies to secure the scene before fire/EMS can continue the chain of survival. Law enforcement is usually called first to incidents like suicide attempts, stabbings, shootings, motor vehicle accidents and explosions where guardians are needed first prior to medical care to avoid further victims/patients. Having bleeding control equipment on their persons allows officers up to provide rapid first aid and preserve life.

Police1 resource: What you should carry in a GO bag

Gear set up considerations

Ensure officers carry their kits on their person where they can access them with either hand. Most kits come with the equipment individually wrapped and/or vacuum-sealed. Keep in mind that under stress loss of fine motor skills can occur. When adrenaline is pumping, your heart rate is elevated, and you’re sweating, it can be difficult to open these packages especially if you have been wounded and are bleeding out. Tourniquets don’t need to stay in the plastic wrappers for “sterility” or even cleanliness. It is recommended to train to open and apply your gear with either hand, from a variety of positions (prone, seated, kneeling). Trauma shears, a seatbelt cutter and/or a knife should be a part of your kit. Tourniquets should be stored ready for quick one-handed applications.

Keep in mind massive hemorrhages can take primary and secondary applications of gear to control. Sometimes, a second tourniquet needs to be placed or you need to follow up with additional wound packing and direct pressure. Have contingency plans in place for when a singular method fails to control the bleed.

Police1 resource: What cops need to know about purchasing, applying tourniquets

Isn’t medical care the responsibility of fire/EMS?

Fire/EMS are critical components of the chain of survival and the providers of basic and advanced life support in medical emergencies. However, fire/EMS are not our fastest first responders. Rapid response and bleeding control are everything when it comes to emergency hemorrhage incidents.

The Committee on Tactical Combat Casualty Care reports a person can bleed to death in 3-5 minutes from a significant arterial bleed. Municipal police agencies tend to have 1-4 ½ minute response times to their highest priority calls for service, making law enforcement ideal for responding to uncontrolled bleeding emergencies.

Medical care of time-sensitive emergencies like uncontrolled bleeding is the responsibility of EVERYONE.

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About the authors

Brandon Griffith is the President/CEO of Griffith Blue Heart, a nonprofit specializing in preparing, training and equipping law enforcement for resuscitation emergencies. Brandon is an Arizona police officer, former EMT, advanced multi-disciplined instructor and out-of-hospital sudden cardiac arrest survivor.

Tim Freund is the Director of Training for Griffith Blue Heart. He works full-time as a flight paramedic and part-time as a SWAT paramedic with over a dozen years in both fields. He teaches a broad spectrum of medical classes from civilian courses to military medical and Advanced Tactical Emergency Medical courses.

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