Direct Pressure, Pressure Dressings, Pressure Points

Last Full Review: ILCOR 2020; American Red Cross Scientific Advisory Council 2019
Last Update: 2023

Direct pressure is the traditional first approach recommended for the initial control of bleeding, while pressure dressings have been suggested after the initial control of non-life-threatening bleeding.

What evidence supports the use of direct pressure for bleeding control, and is there a role for use of pressure points, elevating a bleeding extremity or applying an ice pack (i.e., cryotherapy)?

 

 

 

Evidence Summary

A comprehensive systematic review (Charlton et al. 2021, 235; Singletary et al. 2020, S284) by the International Liaison Committee on Resuscitation in 2020 evaluated multiple techniques for control of life-threatening bleeding. No human studies were identified to support the use of proximal pressure points, and no evidence was found for elevation of extremities or cryotherapy as a means for controlling life-threatening bleeding. Indirect evidence from in-hospital studies of patients undergoing endovascular procedures reported a faster time to bleeding cessation with direct manual pressure compared with mechanical compressions or clamp devices.

For the use of pressure dressings, evidence from one case series of 62 individuals with penetrating traumatic wounds in the prehospital, civilian setting reported control of bleeding in 87% of individuals who had a commercial pressure dressing applied, and a reduction in bleeding in another 11% (Naimer et al. 2006, 644).

An American Red Cross Scientific Advisory Council Answer in 2023 (American Red Cross Scientific Advisory Council 2023) evaluated the evidence for the use of additional layers of gauze dressings in the setting of refractory bleeding. Limited evidence was identified evaluating pressure generated at the skin surface with direct manual pressure, pressure with a cloth bandage over a pad, an elastic bandage over a nonadherent pad, and the same setup with an addition of a wooden block under the elastic bandage (Naimer et al. 2006, 644). Direct manual pressure was found to generate the most pressure. A three-phase, randomized controlled crossover trial in 2019 evaluated differences in pressure generated when adding increasing layers of gauze and different techniques of force application (Charlton et al. 2019, e19). Results reported that the greatest force was generated by using a single stack of gauze placed over a wound with direct pressure applied using two stacked hands. Direct manual force was also noted to generate more pressure than compression with pressure dressings.

There are no systematic reviews comparing the effectiveness of different techniques for providing direct manual pressure to control bleeding. However, experimental studies of manual pressure techniques and pressure dressings have been performed by members of the American Red Cross Scientific Advisory Council. One study (Charlton et al. 2019, e19) using 33 volunteer participants with medical training and a bleeding simulator with a flat force sensitive resistor evaluated pressure application using the finger pads of three digits of the right hand, three fingers of the dominant hand with the opposing hand applying counter pressure, or three digits of each of two hands on top of the other. Pressure was held continuously for each application for 10 seconds, using different thickness of 4” x 4” gauze followed by application or an elastic or self-adhesive wrap. The greatest force was generated when a single stack of 10, 4” x 4” gauze pads was used and when two hands were used to apply pressure over the simulated wound. In addition, direct manual pressure generated much higher pressures than a pressure dressing. While indirect and very-low certainty evidence, results of this study support the use of an overlapping two-hand technique for applying manual pressure and avoidance of excess layers of gauze that may decrease the force applied to a wound.

A second study evaluated the application of direct manual pressure using two hands with elbows bent compared with direct pressure with elbows locked (Charlton et al. 2019, 31). The study was performed by volunteers using a hemorrhage control trainer with electronic feedback. Participants (n=30) were asked to hold pressure at or above 3 pounds per square inch (psi) for a 3-minute period. The group applying pressure with both hands overlapping and elbows bent were able to provide pressure at or above 3 psi 63.7% of the time (SD 33.1), while participants using the cardiopulmonary resuscitation (CPR) posture were above 3 psi 100% of the time (SD 0) (MD, 36.27%; 95% CI, 18.7–53.75%). The difference between the two experimental arms remained statistically significant when examined by age, gender or medical experience. While this provides very-low certainty evidence from a manikin study, it suggests that the CPR posture for applying direct manual pressure may be an efficient method for applying direct pressure to bleeding wounds.

 

Insights and Implications

Despite the sparse amount and low certainty of evidence evaluating the use of direct pressure for life-threatening bleeding, direct manual pressure has been shown effective for less severe bleeding and is readily available. There is a lack of prehospital and pediatric studies. For non-life-threatening bleeding, there is no evidence to support of the use of pressure dressings compared with direct manual pressure for the initial control of bleeding, and there is no evidence to support the practice of layering additional gauze dressings for ongoing bleeding through the initial dressing. In addition, there is no evidence to support the use of pressure points, limb elevation or cryotherapy for control of bleeding.

 

Tourniquets

Last Full Review: American Red Cross Scientific Advisory Council 2021; ILCOR 2020
Last Update: 2022

Tourniquets were at one time considered a last resort for the control of life-threatening bleeding from an extremity. There were concerns that a tourniquet would cause nerve or additional vascular injury and once applied would obligate the injured person to limb amputation. Battlefield experiences and studies from the military setting have more recently provided evidence of beneficial outcomes with the use of manufactured tourniquets. Since 2015, the Stop the Bleed® campaign has promoted the immediate use of tourniquets for control of life-threatening extremity bleeding.

 

 

 

Evidence Summary

A comprehensive systematic review by the International Liaison Committee on Resuscitation in 2020 evaluated multiple techniques for the control of life-threatening bleeding, including the use of manufactured and improvised tourniquets (Charlton et al. 2021, 235; Singletary et al. 2020, S284). Four cohort studies with 527 prehospital civilians were identified. These studies suggested a reduction in mortality due to bleeding with the prehospital use of tourniquets (range, 0% to 4%) compared with the use of direct pressure alone (range, 0% to 14%). The largest of two prehospital military cohort studies with 70 participants reported a higher rate of bleeding cessation on arrival to the hospital with prehospital tourniquet placement (83.3%) compared with those without tourniquet (60.7%; P=0.033) (Beekley et al. 2008, S28).

Two simulation studies (Guo et al. 2011, 151; Lyles et al. 2015, 21) using healthy volunteers reported a higher rate of occlusion of the distal pulse with the use of manufactured tourniquets compared with improvised tourniquets. A clear benefit was not found in simulation studies for any one tourniquet design (i.e., elastic stretch and wrap, ratcheting) compared with a manufactured windlass tourniquet (Charlton et al. 2021, e14474). A manikin study reported simulated bleeding cessation in 100% of manikins with the use of a manufactured windlass tourniquet, in 40% with use of an improvised bandage tourniquet and in 10% with use of an improvised bandana tourniquet (Guo et al. 2011, 151; Lyles et al. 2015, 21).

A 2021 updated systematic review of tourniquet use by the American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2021) identified 15 new articles—including two random controlled trials, eight observational studies and five review articles or expert guidelines. Evidence continues to indicate that tourniquets are lifesaving for life-threatening bleeding and carry a low risk of adverse events. In these additional studies, manufactured (commercial) tourniquets were more efficacious in simulation studies than improvised tourniquets (Charlton et al. 2021, 235; Cornelissen et al. 2020, 531). Studies vary on the efficacy of different tourniquet mechanisms (Ellis et al. 2020, 276; Glick et al. 2018, 157; Hay-David et al. 2020, e1536; Kragh et al. 2018, 36; Ross et al. 2018, 307). Epidemiological studies suggest that tourniquet overuse can occur, however, even when used in persons determined not to have life-threatening bleeding adverse events are low (Bedri et al. 2022, 246; Wellme, Mill and Montán 2021, 1861). Transient nerve damage or local bruising and hematoma appear to be the most commonly reported adverse effects (Bedri et al. 2022, 246; McNickle et al. 2019, e000267; Smith et al. 2019, 43; Wellme, Mill and Montán 2021, 1861).

Guidelines from the Tactical Field Care Phase of Tactical Combat Casualty Care (TCCC) (Committee on Combat Tactical Casualty Care 2018) for the use of a tourniquet recommend application of a limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation by applying directly to the skin 2 to 3 inches above the bleeding site, and if bleeding is not controlled with the first tourniquet, to apply a second tourniquet side-by-side with the first.

A 2019 American Red Cross Scientific Advisory Council scientific review  of improvised tourniquets, updated in 2022 (American Red Cross Scientific Advisory Council 2022), concluded that there is limited evidence to compare improvised with manufactured tourniquets and to assess the feasibility of using improvised tourniquets when manufactured tourniquets are not available. Comparative studies were primarily based on health human volunteers or simulation studies. No trials were found that specifically compared the effectiveness of improvised tourniquets and manufactured tourniquets as separate variables to direct manual pressure. These studies generally suggest that manufactured tourniquets are more efficacious than improvised tourniquets. The primary types of improvised tourniquets evaluated were cloth and windlass tourniquets and rubber tubing wrapped multiple times in succession around the extremity. One study (Kue et al. 2015, 399) reported that flexible rubber surgical tubing when used as a tourniquet was successful in controlling prehospital hemorrhage in 94 of 98 cases (95.9%). Two small comparative observational studies in wounded military personnel demonstrated a similar rate of efficacy for improvised tourniquets when compared with manufactured tourniquets (Lakstein et al. 2003, S221; Passos et al. 2014, 573). In one small observational study (Lakstein et al. 2003, S221), improvised cloth and windlass tourniquets were effective in controlling hemorrhage 72% (13/18) of the time (RR, 0.83; 95% CI, 0.34–2.05). In another small study (Passos et al. 2014, 573), improvised tourniquets (cloth, belt type or unknown) had equal survival rates to those of early hospital placed manufactured tourniquets (4/4 compared with 4/4; RR, 1.00; 95% CI, 0.02–41.22).

Overall, in simulation studies, improvised cloth and windlass tourniquet effectiveness averaged 56.2% (range 10 to 100), improvised belt type tourniquet 52.5%, improvised rubber tubing 80.0% (range 60% to 95%) and manufactured windlass 80.3% (range 50% to 100%). This data suggests that while improvised tourniquets generally are less efficacious than manufactured tourniquets, there is variation in success rates of both types. In some studies, improvised tourniquets are 100% efficacious, suggesting that both design and training play a role in tourniquet efficacy.
If a manufactured tourniquet is not available, a provider should consider other options, including an improvised tourniquet per the American Red Cross Scientific Advisory Council guidelines, if they are trained to do so. Improvised tourniquets using a rod and windless have the most data supporting their use. If an improvised tourniquet is attempted, a band and windlass design is preferred. The windless system used should be study enough to avoid breakage during tightening.

 

Insights and Implications

Because there are no studies that delineate the optimal tourniquet type and there is currently no regulating body for approved civilian tourniquets, the American Red Cross Scientific Advisory Council, First Aid Subcouncil, recommends the use of manufactured tourniquets that are approved by the Committee on Tactical Combat Casualty Care (CoTCCC), as described online at https://books.allogy.com/web/tenant/8/books/f94aad5b-78f3-42be-b3de-8e8d63343866/. As of 2023, these include the Combat Application Tourniquet (CAT) Gen 6 and Gen 7, the Ratcheting Medical Tourniquet–Tactical (RMT-T), SAM Extremity Tourniquet (SMA-XT), SOF Tactical Tourniquet–Wide (SOFTT-W, 1.5” wide strap), the Tactical Mechanical Tourniquet (TMT), the TX2” Tourniquet (TX2) and the TX3” Tourniquet (TX3). These tourniquets can all be applied with a single hand.

The only tourniquet that was tested in humans included in the American Red Cross Scientific Advisory Council review was the C-A-T®Gen 7.

 

Pediatric Tourniquets

Last Full Review: American Red Cross Scientific Advisory Council 2019
Last Update: 2022

While tourniquets have become standard therapy for life-threatening bleeding in adults, few studies are available to guide their use in pediatric patients. The principles of bleeding control remain the same in both adult and pediatric patients; however, body size may limit the use of tourniquets in smaller limb circumferences. For instance, some tourniquets employ a rigid mechanical advantage system (e.g., windlass or ratchet) that precludes the ability to fit circumferences that are smaller than that mechanism. As tourniquets rely on the ability to tighten enough to occlude distal blood flow, these circumference limitations may prevent successful use of certain tourniquets on the smaller limbs of pediatric patients.

What type of tourniquet should lifeguards or aquatic personnel use on children or infants with life-threatening bleeding from an extremity?

 

 

 

Evidence Summary

A 2022 American Red Cross Scientific Advisory Council scientific review (American Red Cross Scientific Advisory Council 2022) and an International Liaison Committee on Resuscitation systematic review (Charlton 2021, e14474) assessed the use of tourniquets in the pediatric population. The literature search identified seven studies, including an observational trial in volunteers ages 6 years to 16 years, one observational trial in pediatric patients ages 2 years to 7 years undergoing elective orthopedic surgery, two models of pediatric limb circumferences, two epidemiological studies of tourniquet use in children in conflict zones, and one case report.

One study (Harcke et al. 2019, e20183447) using human volunteers demonstrated consistently successful tourniquet application in both upper arms and upper legs of children 6 years of age or older. A second study (Kelly et al. 2020, 644) demonstrated successful application in human participants 2 years to 7 years of age with a minimal limb circumference of 13 cm. Studies in manikin and polyvinyl chloride (PVC) models generally demonstrate that some windlass and ratcheting tourniquets have increasing failure rates as model circumference decreases. Model circumference size for tourniquet failure corresponds to the size of the upper extremity of children under 5 years of age (El-Sherif et al. 2019, 361). It is postulated that the pliability of human tissue made the mechanism less of a factor than with the less pliable materials used in the two model studies. No study in this review specifically evaluated ease of use or lay provider use in the pediatric population.

 

Insights and Implications

Human studies suggest a windless type of tourniquet (specifically C-A-T® Gen 7) can abolish distal pulses in both the upper and lower extremities, if applied appropriately, to a child as young as 2 years old (in this case with a limb circumference of 13 cm). In manikins and PVC pipe models, the overall trend was that the smaller the circumference of the model, the less likely the tourniquet was to be successfully applied; however, the overall results were inconsistent. In this review, position statements from the Pediatric Trauma Society and the Committee for Tactical Emergency Casualty Care Pediatric Working Group were strongly considered, both of which advocate for the use of tourniquets for life-threatening extremity hemorrhage in the pediatric population (Committee on Combat Tactical Casualty Care 2018; Cunningham et al. 2018, 665).

There is variability in the sizes of children, and tourniquets that are not specifically designed for children may not tighten sufficiently to achieve bleeding control on younger and smaller children or infants. Older and large children may be of sufficient size for tourniquets designed for adults to be effective. A good indication that a tourniquet will be able to successfully occlude distal blood flow and stop bleeding from a wound in a child is the ability to tighten a tourniquet on the extremity prior to twisting the windlass rod or using the ratcheting mechanism.

 

Hemostatic Dressings

Last Full Review: American Red Cross Scientific Advisory Council 2019; ILCOR 2020
Last Update: 2023

A hemostatic dressing is a type of dressing, usually gauze, that is treated with an agent that promotes clotting and cessation of bleeding when applied to the source of bleeding. Hemostatic agents are chemicals or compounds that promote clotting, such as chitosan. Used extensively in the military setting, hemostatic dressings are now sold over the counter in pharmacies.

When and how should a hemostatic dressing be used?

 

 

 

Evidence Summary

A 2020 International Liaison Committee on Resuscitation (ILCOR) systematic review (Charlton et al. 2021, 235; Singletary et al. 2020, S284) of methods for control of life-threatening bleeding identified one randomized controlled study (Hatamabadi et al. 2015, e23862) of 160 patients with stab wounds to the extremity which were treated with either a chitosan-coated hemostatic dressing plus direct pressure or with a pressure dressing. The study reported cessation of bleeding in less than 5 minutes with the use of the chitosan-coated hemostatic dressing plus direct pressure in 51% of patients compared to 32.5% of patients who received pressure dressings (RR, 1.58; 96% CI, 1.08–2.31) (Hatamabadi et al. 2015, e23862). A more recent systematic review (Welch et al. 2020, 194) included 10 case reports, case series or retrospective reviews of hemostatic dressings from the battlefield and prehospital civilian setting. Survival rates with use of hemostatic agents or dressings was reported in this review to range between 79% to 93%, and no serious adverse effects were reported.

A 2022 American Red Cross Scientific Advisory Council advisory (American Red Cross Scientific Advisory Council 2022a) of hemostatic dressings identified two additional articles, including a systematic review (Welch et al. 2020, 194) and a retrospective database review of hemostatic dressing use during combat operations (Winstanley, Smith and Wright 2019, 405). The database review compared different types of hemostatic dressings versus no hemostatic dressing, with a reported 7% improvement in survival from injuries due to blasts and gunshots (P<0.001) with any hemostatic dressing compared with no hemostatic dressing.

A scientific review by the American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2022b) focused on the ability of lay first aid responder use of hemostatic gauze for control of bleeding. One randomized controlled trial (Goolsby et al. 2019, 795) demonstrated the ability of lay responders to successfully apply hemostatic gauze and multiple retrospective studies reported effective bleeding control with hemostatic gauze, particularly to the scalp and face. The lay responder study reported that participants were most successful with the use of an injectable mini sponge delivery system designed for cavitary wounds.

The 2023 Tactical Combat Casualty Care (TCCC) guidelines for medical personnel recommends that for compressible external hemorrhage not amenable to a limb tourniquet, a hemostatic dressing (i.e., combat gauze) should be used with at least 3 minutes of direct pressure (Anonymous 2022, 11). They note that each brand of their recommended hemostatic dressing works differently, so if one fails to control bleeding, it may be removed and a fresh dressing of the same or another type applied.

 

Insights and Implications

Most studies continue to be conducted in the military population and therefore include younger individuals. Little data is available on socioeconomic factors. Hemostatic dressings would add an increased cost to hemorrhage control which should be considered when implemented at an individual or population level. The overall evidence does suggest that hemostatic dressings could be beneficial in the civilian setting to augment direct manual pressure whenever direct manual pressure is being used. This includes instances such as before a tourniquet is available if a tourniquet fails to stop life threatening hemorrhage or if the area of bleeding in not amenable to a tourniquet.

 

Bleeding Control Kits

Last Full Review: American Red Cross Scientific Advisory Council 2020

Bleeding control kits were designed with the Stop the Bleed® campaign (U.S. Department of Homeland Security 2022) and are intended to provide the necessary supplies and equipment to control serious or life-threatening extremity bleeding following a traumatic injury. Multiple varieties of bleeding control kits are available commercially. Is there any evidence to support what should be included in a personal or public bleeding control kit?

 

 

Evidence Summary

A 2020 American Red Cross Scientific Advisory Council Answer, reaffirmed in 2023 (American Red Cross Scientific Advisory Council 2023), reviewed evidence and existing guidance for contents of bleeding control kits for personal use, public use and for stocking at public events and venues. Evidence for determining the number of personal bleeding control kits in a public access kit is sparse. One study (Goolsby et al. 2019, 236) suggests that supplies for 20 bleeding adults and children should be available in any location servicing more than 50 people at once. Including a hemostatic dressing in personal or multiuse kits is potentially beneficial, since they have been shown to be more effective at stopping bleeding than direct pressure alone (with or without gauze), and it has been shown that laypersons are able to use them (Goolsby et al. 2019, 795). While hemostatic dressings are more expensive than traditional gauze, they more effectively stop bleeding and are possible for laypeople to use. It is also reasonable to consider including them in a personal kit.

 

Insights and Implications

Stop the Bleed® kits are now found and displayed prominently in many public areas, such as public airports and major sports arenas. They may be located inside an automated external defibrillator case or adjacent to the case in a separate but highly visible box. The minimum recommended contents for a Red Cross bleeding kit for personal use align with those from the Stop the Bleed® personal bleeding control kit. The addition of a hemostatic dressing to a personal bleeding control kit may increase the cost of a bleeding control kit, but is beneficial for serious bleeding from compressible areas. Additional personal protective equipment, such as face masks and eye protection, should also be considered when choosing or stocking a Stop the Bleed® kit.