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Nov 22, 2017


Aggressive control of massive external hemorrhage is always a priority. Tourniquet application is rarely a failure of the device, and more so of the provider applying it.

Amenable vs Non-Amenable Hemorrhage

Amenable: Limb hemorrhage that will facilitate tourniquet use
Non-Amenable: Junctional or internal hemorrhage that tourniquet use will have little to no effect on.

Tourniquet Pearls & and Pitfalls


1) Place the tourniquet on an amendable site.
3) Turn the windlass until the distal pulse is OBLITERATED, if the anatomy of the injury allows. If not, tighten at least one turn past when hemorrhage stops.
4) Secure the TQ and mark the time.
5) If steps one through 4 fail, apply a second TQ until you’ve controlled the bleed. Some extremities and body habitus will require an additional TQ for adequate control.


1) Failure to properly tighten the band
2) Failure to apply rapidly
3) Failure to apply a second TQ
4) Fear of causing additional pain to the patient
5) Periodically loosening the TQ to allow distal bloodflow.

Wound Packing:

PRESSURE - hold pressure over the wound area or on an applicable pressure point.

EXPOSE - Expose the wound margins as best possible.

IDENTIFY - Identify the major bleeding point within the wound. This may require some probing, but you need to evaluate where to best apply the gauze.

PACK - Using one finger to hold pressure on the ruptured vessel, take the other finger and ball bit of gauze around it. Then, while maintaining pressure with the other finger, direct that gauze right into the bleeding area.

PRESSURE - Maintain pressure the ENTIRE time you’ve packed the wound. PILE gauze into and above the wound. If you need another roll, use it.

EVALUATE - While packing and following packing, ensure that blood isn’t leaking through or around the gauze. If blood continues to arise from around the gauze, you will need to repack - the broken vessel isn’t adequately occluded.

PRESSURE (Again) - Once you have the wound packed, take a compressive wrap or pressure dressing and hold pressure on that wound. If you’re using a hemostatic agent, most will require you to hold manual direct pressure on the wound for three minutes.

MARCH Algorithm for Trauma Management

M – Massive Hemorrhage
Control all massive, external bleeding
A – Airway
Rapidly recognize and address airway concerns
R – Respiration
Treat immediately threatening respiratory compromise
C – Circulation
Establish IV/IO access, initiate blood or fluid resus, admin TXA PRN; optimize end organ perfusion
H – Head/ Hypothermia
Manage and prevent secondary injury from TBI; prophylactically address hypothermia management