Severe, uncontrolled bleeding from an extremity is life-threatening, making the rapid application of a tourniquet a life-saving intervention. A correctly applied tourniquet should completely stop the flow of blood. If bright red blood continues to soak through the dressing or clothing, the initial attempt to occlude the artery has failed. This failure requires immediate, decisive action and a systematic approach to troubleshooting and employing alternative hemorrhage control methods.
Immediate Assessment and Readjustment
A tourniquet’s failure often stems from a mechanical error rather than the device being ineffective. The first step involves a quick inspection of the device already in place. The most common reasons for failure are insufficient tightening or placing the device too low on the limb.
The device must be tightened using the windlass mechanism until all bleeding completely ceases. If bleeding persists, check that the tourniquet is not positioned over a joint or a bulky object, which prevents pressure transfer to the artery. If the tourniquet was placed near the injury, it should be moved as high up the limb as possible, known as “high and tight,” to ensure compression above the injury site.
If the tourniquet was applied over clothing, it is recommended to move it directly onto the skin, approximately two to three inches above the injury if possible. However, the priority is to stop the bleeding. If the device is “high and tight” but not working, the first step is to tighten the existing device further. The goal is to eliminate any distal pulse and achieve a complete absence of bleeding from the wound.
Deployment of a Second Tourniquet
If the initial tourniquet has been maximized through tightening and repositioning, and bleeding continues, the next standard intervention is applying a second device. A single tourniquet may not be wide enough to compress the entire artery, particularly on the upper thigh, allowing blood flow to bypass the occlusion.
The second tourniquet should be applied adjacent to the first one, placing it slightly closer to the torso. Positioning the second device immediately next to the first effectively doubles the width of the compression band. This creates a wider pressure wave, which is more effective at collapsing the underlying artery and achieving complete blood flow cessation.
The second device must be fully tightened until the bleeding stops, regardless of the first tourniquet’s status. If the hemorrhage stops, no further limb intervention is required, and the focus shifts to preparing the patient for transport. Both devices must remain in place and should not be loosened or removed.
Direct Pressure and Hemostatic Wound Packing
When bleeding occurs in junctional zones (such as the neck, armpit, or groin) or if two tourniquets have failed, wound packing becomes necessary. This method involves applying direct, sustained pressure to the source of the bleeding deep within the wound cavity.
The most effective material is a hemostatic dressing, which is gauze impregnated with an agent designed to accelerate the body’s natural clotting cascade. Common agents include kaolin, which promotes clotting factor activation, or chitosan, which helps blood cells adhere to the gauze. If hemostatic gauze is unavailable, tightly packed standard gauze or clean cloth can still be effective.
To pack the wound, material must be stuffed directly into the injury cavity, aiming for the deepest point where the bleeding originates. The goal is to completely fill the wound space, pushing the gauze in as tightly as possible to create direct pressure against the damaged blood vessel. Simply placing the gauze on top of the wound is not sufficient; the material must be in firm contact with the vessel itself.
Once the wound is completely filled, firm, continuous pressure must be held over the packed gauze for a minimum of three minutes. This sustained pressure allows the hemostatic agent to interact with the blood and form a stable clot. After three minutes, the pressure can be released, and the wound should be checked for active bleeding. If bleeding continues, more gauze should be packed into the wound, and pressure reapplied.
Post-Intervention Patient Stabilization and Transport
Once severe bleeding is controlled, the priority shifts to managing the patient’s overall condition and preparing for definitive medical care. A patient who has experienced massive blood loss is at high risk of developing hemorrhagic shock, a condition where the body cannot deliver enough oxygen to the organs. Signs of shock include a rapid heart rate, pale or clammy skin, and an altered mental status.
The patient should be kept warm and lying flat to help maintain blood flow to the core organs. Keeping the patient warm is an important step in managing shock, as body temperature can drop quickly following a traumatic injury. It is also important to note the precise time the tourniquet was applied.
This time must be communicated to emergency medical personnel, as the duration of arterial occlusion is a factor in subsequent medical decisions regarding the limb. Tourniquets should not be removed or loosened by non-medical personnel, as this can cause a rapid return of bleeding. The devices must remain in place until the patient reaches a hospital or trauma center where medical professionals can safely manage the next steps.