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HLT-EMT39-02 · Lesson 3 · 29 clock hours · lab

Hemorrhage Control: External Bleeding and Wound Management

Objective. Students will correctly select and apply direct pressure, wound packing with hemostatic gauze, and tourniquet application to simulated extremity and junctional hemorrhage within the time frames specified by TECC and NREMT skill standards.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Hemorrhage Control: External Bleeding and Wound Management

Uncontrolled external hemorrhage is one of the leading preventable causes of death in trauma patients. As an EMT or paramedic, your ability to recognize and rapidly control life-threatening bleeding is among the most critical skills you will ever perform. This lesson covers three core techniques: direct pressure, wound packing with hemostatic gauze, and tourniquet application.

Why Hemorrhage Control Matters

Severe external bleeding can lead to hemorrhagic shock within minutes. The body compensates temporarily by increasing heart rate and constricting blood vessels, but these mechanisms fail as blood loss continues. Your priority is to stop bleeding before shock becomes irreversible. Follow your local protocols and the principles of TECC (Tactical Emergency Casualty Care) or PHTLS (Prehospital Trauma Life Support), which guide civilian EMS hemorrhage management.

Standard Precautions

Before touching any patient, don appropriate personal protective equipment (PPE): gloves at minimum, eye protection if splashing is possible. Blood-borne pathogen exposure is a real occupational hazard. Never delay life-saving intervention to find PPE, but apply it as fast as possible. After care, dispose of contaminated materials per your agency's infection control policy.

Direct Pressure

Direct pressure is the first-line intervention for most external wounds. Place a clean dressing directly over the wound and press firmly with the flat of your hand or fingertips, depending on wound size. Maintain continuous, uninterrupted pressure — lifting the dressing to check the wound allows clot disruption and restarts the bleeding cycle. If the dressing saturates, add more dressings on top and continue pressure. Do not remove the original dressing. Apply pressure for a minimum of several minutes; follow your local protocol for duration. Direct pressure is effective for wounds on surfaces where you can apply adequate force, such as the scalp, limbs, and trunk.

Wound Packing with Hemostatic Gauze

For deep, narrow wounds — such as stab wounds, gunshot wounds, or wounds at the groin, axilla, or neck — direct surface pressure alone cannot reach the bleeding source. Wound packing is required.

Hemostatic gauze contains agents (such as kaolin or chitosan) that accelerate clot formation. When using hemostatic gauze:

1. Expose the wound fully by cutting away clothing.

2. Identify the deepest point of the wound or the visible bleeding source.

3. Pack gauze tightly into the wound, starting at the deepest point and working outward. Use firm, deliberate pressure with your fingers to push each fold of gauze into contact with the wound cavity.

4. Continue packing until the wound is filled.

5. Apply firm, sustained direct pressure over the packed wound with both hands for the time period specified by the gauze manufacturer and your protocol (commonly several minutes).

6. If bleeding continues, do not remove the gauze — add more on top and maintain pressure.

Never pack gauze into a chest wound with a penetrating injury, as this may worsen a tension pneumothorax.

Tourniquet Application

A tourniquet is indicated when direct pressure fails to control extremity hemorrhage, when the wound is too large to pack, or when the situation prevents you from maintaining manual pressure (e.g., multiple casualties, entrapment). Commercial tourniquets such as the CAT (Combat Application Tourniquet) and SOFTT-W (Special Operations Forces Tactical Tourniquet-Wide) are the accepted standard.

Application steps:

1. Expose the limb by cutting clothing if needed.

2. Place the tourniquet proximal to the wound (between the wound and the heart), on the skin or over a single layer of clothing — never over a joint.

3. Route the strap and tighten the self-adhering band until snug.

4. Twist the windlass rod (CAT) or tighten the buckle system (SOFTT-W) until bleeding visibly stops or the distal pulse is eliminated.

5. Secure the windlass with the locking clip.

6. Write the time of application on the tourniquet's time tab or on the patient's skin in a visible location.

7. Do not cover or remove the tourniquet in the field without physician direction.

8. Document tourniquet placement time on the patient care report.

Junctional hemorrhage — bleeding at the groin, axilla, or base of the neck — cannot be managed with a standard limb tourniquet. Wound packing with hemostatic gauze and sustained manual pressure are the primary field interventions. Junctional tourniquets (e.g., SAM-JT, JETT) exist and may be part of advanced protocols; follow your medical director's guidance.

Safety and Scope Considerations

Key terms10

Hemorrhagic shockA life-threatening condition caused by significant blood loss that leads to inadequate oxygen delivery to tissues; a preventable cause of trauma death when bleeding is controlled early.
Direct pressureThe first-line hemorrhage control technique in which firm, continuous manual force is applied over a wound dressing to compress bleeding vessels and promote clot formation.
Wound packingA hemorrhage control technique for deep or cavitary wounds in which gauze is tightly packed into the wound cavity to apply internal pressure directly to the bleeding source.
Hemostatic gauzeGauze impregnated with a clot-promoting agent (such as kaolin or chitosan) used to accelerate hemorrhage control in wounds that cannot be managed by surface pressure alone.
TourniquetA device applied proximal to an extremity wound and tightened until blood flow past the device stops, used when direct pressure cannot control life-threatening limb hemorrhage.
Junctional hemorrhageBleeding at anatomical junctions — groin, axilla, or base of neck — where standard limb tourniquets cannot be placed; managed primarily with wound packing and sustained direct pressure.
ProximalCloser to the point of attachment or the trunk of the body; tourniquets are placed proximal to a wound so that they compress the artery supplying the injured area.
TECCTactical Emergency Casualty Care; a framework adapted from military TCCC for civilian EMS that guides hemorrhage control and trauma care priorities in high-threat environments.
WindlassThe rod mechanism on a CAT tourniquet that is twisted to progressively tighten the band around the limb until hemorrhage is controlled.
PPE (Personal Protective Equipment)Equipment worn by the provider — at minimum, gloves — to protect against exposure to blood and body fluids during patient care.
In class: Instructor-led demonstration on a hemorrhage control task trainer showing direct pressure technique, proper wound packing with hemostatic gauze, and CAT/SOFTT-W tourniquet application; students complete a step-by-step observation checklist. · Repetitive hands-on station rotation: each student performs direct pressure, wound packing, and tourniquet application at least five times each on task trainers, receiving peer and instructor feedback after each attempt. · Simulated high-stress scenario with multiple casualties and limited supplies; students triage, prioritize hemorrhage control interventions, and document decisions on a patient care report form.
Materials: Hemorrhage control task trainers (e.g., bleeding simulators), CAT and SOFTT-W tourniquets, hemostatic gauze (training), wound packing trainers, gloves, stopwatch, NREMT psychomotor skill sheets, PCR forms
Check: NREMT-style hemorrhage control psychomotor checklist; all critical steps (tourniquet placed proximal to wound, tightened until bleeding stops, time written) must be completed correctly; 80% overall checklist score; any critical step failure requires immediate remediation and retest.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Trauma
1. You arrive at a scene where a patient has a deep gunshot wound to the thigh with bright red, pulsatile bleeding. Direct pressure with a dressing does not control the hemorrhage. What is the most appropriate next intervention?
Trauma
2. After applying a CAT tourniquet to a patient's arm, which action is the highest priority before transport?
Trauma
3. A patient has a stab wound to the groin with uncontrolled bleeding. Which technique is most appropriate for field hemorrhage control at this location?
Trauma
4. While performing wound packing on a deep extremity wound, the first piece of hemostatic gauze becomes saturated with blood before the cavity is filled. What should you do?
Trauma
5. During a mass casualty simulation, a patient with a severely bleeding arm wound is found to have a tourniquet applied by a bystander. The tourniquet is in place but the patient states it is painful. What is the correct action?
Trauma
6. When applying a tourniquet to the upper arm, where should it be positioned?
Trauma
7. Which of the following wounds would be LEAST appropriate for wound packing with hemostatic gauze?
Trauma
8. A key principle of direct pressure for hemorrhage control is that the provider should:
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