Severe External Bleeding

Severe External Bleeding
Posted on 05/12/2022

Are You Prepared for Severe External Bleeding

Ian Ramsey 

SkyView Academy

Around 60,000 Americans die each year from uncontrolled hemorrhage.  Approximately 75% of these deaths are due to physical trauma (1).  According to the American College of Surgeons “uncontrolled hemorrhage (severe bleeding) remains the single most preventable cause of death after both military and civilian injuries (2).”  While rare, injuries leading to severe bleeding do happen at sporting events so it is worthwhile to be prepared to deal with this injury.   Uncontrolled hemorrhage can become a life threatening injury in less than five minutes and a rapid response is critical.  Having specialized equipment readily accessible greatly reduces the risk of death from severe bleeding.  Additionally, individuals who attend sporting events should consider acquiring education in the use of this equipment and in the protocols for responding to a case of severe bleeding.

Typical blood volume in the human body is approximately 65-70mL of blood per kilogram of body weight.  An acute blood loss of 20% or more is intolerable to the human body and can lead to hypovolemic shock, a life threatening situation (3).  For a 100lb freshman athlete a loss of 1 pint of blood could be life threatening.  An athlete suffering an open fracture leading to a severed artery could easily lose 1 pint of blood by the time someone arrives at the scene.  Direct pressure may be difficult or impossible to implement in such an injury and more than half of such life threatening injuries lead to death within minutes (4).  An immediate response is critical.  

Tourniquets and hemostatic dressings are necessary for managing uncontrolled hemorrhage.  While tourniquets may have the stigma of causing permanent damage to the affected limb, research has shown that commercial windlass-type tourniquets can be applied for up to 2 hours with minimal risk of creating any permanent damage (2).  Many people trained in first aid are taught to use improvised tourniquets.  However, improvised tourniquets take too long to construct and are much less effective than commercial tourniquets (2).  In addition, the larger the limb the more pressure required to occlude the damaged blood vessel.  Two tourniquets may be required up to 30% of the time (5).  For injuries to the neck or torso a tourniquet is inappropriate.  For these injuries hemostatic gauze is necessary for wound packing.  Individuals trained to treat severe bleeding should have rapid access to the proper equipment to manage this injury.  Proper equipment includes at minimum Personal Protective Equipment, bandages for direct pressure, two commercial windlass-type tourniquets and hemostatic gauze.

In addition to the proper equipment individuals trained in first aid should seek out the proper training in its use. Symptoms of severe bleeding and hypovolemic shock include cool, moist skin that is pale or gray, increased heart and respiratory rate, weak pulse and decreased blood pressure.  The following Prehospital External Hemorrhage Control Protocol (6) can be used as a guideline for the use of tourniquets and hemostatic gauze.   Local EMS protocols can be used as well.  Uncontrolled hemorrhage is a more important situation to manage than airway or breathing and always comes before CPR, especially if there is only one rescuer (3).  Tourniquets are often not used soon enough and over-triage is acceptable, as the risk of permanent damage with commercial tourniquets is low and unneeded tourniquets can be removed at the hospital (2).  The American College of Surgeons has created a program called Stop the Bleed ( that provides education in the use of tourniquets and hemostatic gauze for use against uncontrolled hemorrhage.

Protocol for prehospital external hemorrhage control. | Download Scientific  Diagram

Individuals who attend sporting events should consider reviewing their preparedness for dealing with uncontrolled hemorrhage and how quickly such an injury can become life-threatening.  This review should start with an assessment of her or his equipment and include a review of possible scenarios that could occur in the field.  A review of the techniques required to use this equipment is also in order and Stop the Bleed offers a great starting point for this review.


  1. Cannon, Jeremy W.  Hemorrhagic Shock. New England Journal of Medicine, 2018; 378:370-379.

  2. Holcomb, John B., Butler, Frank K., Rhee, Peter.  Hemorrhage Control Devices: Tourniquets and Hemostatic Dressings.  Hartford Consensus Compendium; American College of Surgeons.  September 2015; Volume 100; Number 1S.

  3. Pollak, Andrew N. Emergency; Care and Transportation of the Sick and Injured. Published by Jones & Bartlett Learning, Burlington MA.  Copyright by the American Academy of Orthopaedic Surgeons, 2021.  Pp. 933-960.

  4. Sobrino, J and Shafi, S.  Timing and Causes of Death After InjuriesProc (Bayl Univ Med Cent). 2013 Apr; 26(2): 120–123.

  5. Shertz, Mike. Tourniquets: One May Not Be Enough. September 10, 2021.  Accessed March 2022.

  6. Bulger, Eileen M. et al. An Evidence-Based Prehospital Guideline For External Hemorrhage Control: American College of Surgeons Committee on Trauma.   Prehospital Emergency Care. Apr-Jun 2014;18(2):163-73.

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