Hemorrhage control.
Uncontrolled bleeding is the leading cause of preventable trauma death. The correct order of interventions — direct pressure, wound packing, tourniquet, hemostatic — can change the outcome.
Step 1
Direct pressure
First line for almost every wound. Use two hands, a firm pad, and hold for several minutes without peeking.
Step 2
Wound packing
For deep, narrow wounds where direct pressure is not enough. Pack gauze tightly to the source.
Step 3
Tourniquet
For extremity bleeding uncontrolled by pressure. High and tight, note the time.
Tourniquet technique
- Apply 2–3 inches above the wound, not over a joint.
- Pull the strap tight and fasten it.
- Twist the windlass until bleeding stops and distal pulses disappear.
- Lock the windlass and mark the time prominently.
- If one tourniquet fails, apply a second one side-by-side above the first.
The modern recommendation is "high and tight" when the wound location is unknown or chaotic, because wasting time finding the exact source can cost the patient's life.
Junctional and non-tourniquet bleeding
For wounds in the groin, axilla, or neck where a tourniquet cannot be applied, use wound packing with hemostatic gauze followed by direct pressure. Pack the gauze deep into the wound cavity, all the way to the bleeding vessel, then hold firm pressure for at least 3 minutes (or per product instructions). Junctional tourniquets exist for some systems but are not universal.
Hemostatic agents
Hemostatic gauze contains kaolin or other agents that accelerate clotting. It works best when packed directly into the bleeding source, not laid on top. After packing, apply direct pressure and reassess. Do not remove the gauze; if bleeding continues, pack more on top.
NREMT tip
If a test stem describes an arm or leg wound with severe bleeding, the correct answer is almost always direct pressure first, then tourniquet if uncontrolled — never start an IV before bleeding control.
FAQ
When do I use a tourniquet instead of direct pressure?
Use a tourniquet for life-threatening extremity bleeding that is not controlled by direct pressure, or when direct pressure is not practical due to multi-casualty or severe wound anatomy. Apply it high and tight on the limb, 2–3 inches above the wound, and note the time.
Can I remove a tourniquet in the field?
Generally no. Once applied, leave it in place until the patient reaches surgical care. Removing it can dislodge a clot and trigger rebleeding. Only loosen under medical direction and only if you can closely monitor for recurrence.
What is wound packing?
Wound packing is tightly stuffing a hemostatic or plain gauze into the wound cavity, especially for deep wounds or junctional areas where a tourniquet cannot be applied. Pack to the top, then hold direct pressure for at least 3 minutes.
Where does a tourniquet not work?
Tourniquets do not work for junctional bleeding (groin, armpit, neck) or torso hemorrhage. For junctional wounds, use direct pressure, hemostatic gauze, wound packing, and a junctional tourniquet if available. Torso bleeding requires surgical control.
How long can a tourniquet stay on?
Modern tourniquets can remain in place for 2 hours with minimal nerve/muscle risk, and up to 6 hours with acceptable risk of amputation. The priority is stopping hemorrhage; don't avoid a tourniquet because of time concerns.