TTL tips 8: External Haemorrhage control

Keep blood in the patient. Control haemorrhage early.

Most external bleeding will have been addressed prehospital, but not all. Patients may self-present, deteriorate, or require reassessment as resuscitation progresses. Effective haemorrhage control remains a core ED skill.

D – Direct Pressure

First-line treatment for external haemorrhage.

Identify the bleeding point
Apply firm pressure with a finger or hand
Reinforce with a dressing, maintaining focused pressure

This is the most effective and most commonly sufficient intervention.

D – More Direct Pressure

If bleeding persists:

Reassess the source
Reposition your pressure
Replace soaked dressings

Failure of pressure is often failure of technique. Adjust before escalating.

I – Indirect Pressure

If direct pressure is insufficient:

Compress a proximal artery against bone
Examples:
- Femoral artery (groin)
- Axillary artery

This is a temporising measure and requires sustained force.

T – Tourniquet / Topical Haemostatic

Tourniquet (limb haemorrhage)

Apply proximal to the wound
Consider two tourniquets in significant bleeding.
Tight enough to stop arterial flow
Expect pain so prepare opioids ± ketamine

Tourniquets are highly effective but associated with morbidity. Use appropriately, and remove as early as is safe to do so. On this note, tourniquets that have been applied pre-hospitally should be re-assessed early, as they can often be released on arrival to the ED. Get a good history of why they were put on, and make a sensible decision. If they were put on due to what clearly sounds like a major arterial bleed, be very cautious. If put on for less dramatic reasons then maybe consider an early release and reassessment (you can always reapply). There is some really interesting data coming out from the Russian-Ukraine war about the harms of prolonged tourniquet use (see references below), so they are not benign interventions.

Topical haemostatic (non-compressible bleeding)

Indicated for junctional or deep wounds (e.g. groin, axilla)
Use agents such as Celox
Pack the wound firmly and completely
Get someone to hold the ribbon whilst you stuff the material into the wound. Please don’t place it as a pad on top of a bleeding wound and expect it to work.

Not indicated for minor bleeding.

Practical Points

Prehospital teams may escalate early (tourniquet/haemostatics first). In ED, a stepwise approach is usually appropriate.
Reassess frequently, haemorrhage control is dynamic.
Even “minor” bleeding (e.g. scalp wounds) can become clinically significant over time.

Key Messages

Direct pressure is the most important intervention
If it’s not working, adjust before escalating
Use tourniquets and haemostatics appropriately
Blood on the floor is no more – All bleeding matters, control it early

What is important is to manage all bleeding if it is persistent. Even small amounts of flow from something like a scalp wound can add up over time and become clinically important.