CONTROL BLEEDING
081-86A-0161
Purpose: This Training Support Package provides the instructor with a standardized lesson plan
for presenting an introduction on the procedures for control bleeding to the ANA Medical
Company.
Collective: Treat Unit Casualties
References Number Title Date Additional Information:
ANA STP 8-86C-E4-5-SM-TG, Soldier's Manual and Trainer's Guide MOS 86C, Mar 2008
ANA 4-02.2, Medical Evacuation, Feb 2009
ANA 4-25.11, First Aid, Jul 2009
STP 8-68W13-SM-TG
STP 8-91W15-SM-TG
Instructor Requirements:
1:20, MoD Defense Personnel, Contractor, ANA Personnel
Instructional Guidance
NOTE: Before presenting this lesson, instructors must thoroughly prepare by studying this lesson
and identified reference material.
Before class- This LESSON PLAN has practical exercises built throughout to check on learning or
generate discussion among the group members. You may add any questions you deem
necessary to bring a point across to the group or expand on any matter discussed.
 You must know the information in this LESSON PLAN well enough to teach from it, not
read from it.
SECTION II. INTRODUCTION
Method of Instruction: Conference / Discussion or Practical/Hands on
Technique of Delivery: Small Group Instruction
Instructor to Student Ratio is: 1:20
Motivator
Your ability to successfully control bleeding under extreme circumstances will result in saving
lives. Basic lifesaving steps include clearing the airway/restoring breathing, stopping the bleeding,
protecting the wound, and treating shock. These are the ABC measures that apply to all injuries.
As a soldier medic, you need to be proficient in applying these basic lifesaving steps. In this
lesson you will require special precautions and procedures for controlling bleeding.
Terminal Learning Objective
NOTE: Inform the students of the following Terminal Learning Objective requirements.
At the completion of this lesson, you [the student] will:
ACTION: Control Bleeding.
CONDITIONS: You have encountered a casualty who is bleeding externally and may also be
bleeding internally. Body substance isolation precautions have been taken, as appropriate.
Necessary materials: field dressings, cravats, gauze pads, gauze roller bandage, and materials
for a tourniquet.
STANDARDS: Controlled bleeding without further harming the casualty.
A. ENABLING LEARNING OBJECTIVE
ACTION: Medic understands how to examine the casualty for life threatening bleeding
CONDITIONS: You have encountered a casualty who is bleeding externally and may also be
bleeding internally. Body substance isolation precautions have been taken, as appropriate.
Necessary materials: field dressings, cravats, gauze pads, gauze roller bandage, and materials
for a tourniquet.
STANDARDS: Treat the injuries using appropriate techniques insuring all open (or penetrating)
wounds are checked for a point of entry and exit and first aid measures applied accordingly.
Learning Step / Activity 1. Medical Personnel.
Method of Instruction: Conference / Discussion
Technique of Delivery: Small Group Instruction
Instructor to Student Ratio: 1:20
Time of Instruction: 2 hr
B. ENABLING LEARNING OBJECTIVE
ACTION: Medic understands how to apply a Field Dressing, pressure dressing and stop external
bleeding using pressure points and or a tourniquet.
CONDITIONS: You have encountered a casualty who is bleeding externally. Body substance
isolation precautions have been taken, as appropriate. Necessary materials: field dressings,
cravats, gauze pads, gauze roller bandage, and materials for a tourniquet.
STANDARDS: Treat the injuries using appropriate techniques and controlled bleeding without
further harming the casualty.
Learning Step / Activity 2. Medical Personnel.
Method of Instruction: Conference / Discussion
Technique of Delivery: Small Group Instruction
Instructor to Student Ratio: 1:20
Time of Instruction: 2 hr
Instructional Lead-In
While administering first aid to a casualty who is bleeding, you must remain calm. The sight of
blood is an emotional event for many, and it often appears severe. However, most bleeding is
less severe than it appears. Most of the major arteries are deep and well protected by tissue and
bone. Although bleeding can be fatal, you will usually have enough time to think and act calmly.
SHOW SLIDE 1
CONTROL BLEEDING
081-86A-0161
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A-
REFERENCES:
ANA-STP-8-86
ANA 4-02.2
STP 8-91W15-SM-TG
STP 8-68W13-SM-TG
SHOW SLIDE 2
Briefly detail the action, condition and standard to the students. Explain that this is performance
based and that the students will be tested on this following this block of instruction.
SHOW SLIDE 3, 4
Determine if the bleeding is external or internal.
Serious bleeding (hemorrhage) usually results when an artery or vein is cut or torn (such as being
punctured by shrapnel or the sharp end of a fractured bone) or when the blood vessel is ruptured
due to disease or a blow with a blunt instrument.
External Bleeding - When the bleeding is external, blood can be seen coming from an open (skin
is broken) wound. External bleeding can be from an artery (a blood vessel which carries blood
away from the heart), from a vein (a blood vessel which carries blood back to the heart), or from
capillaries (tiny blood vessels connecting an artery and a vein).
Arterial blood is bright red (rich in oxygen) and is usually expelled from the wound in spurts. The
spurts are caused by the pulse waves resulting from the heart's pumping actions (contractions).
Venous blood is a dark bluish-red (low in oxygen content) and flows at a slower, steady rate.
Venous blood does not escape in spurts because the pulse is not present in the veins.
Capillary blood resembles venous blood in color. The very small size of capillaries causes the
escaping blood to ooze from a wound rather than flow at a more rapid rate.
SHOW SLIDE 5, 6
Internal bleeding occurs when the blood from a damaged blood vessel or organ (such as a
laceration of the liver) flows into a body cavity or is trapped in the surrounding tissue rather than
escaping the body through an open wound. Internal bleeding can be identified by discolored
tissue (bruises), swelling (from blood escaping into surrounding tissue), rigid body cavity (cavity
filled with blood), and/or blood escaping through a body orifice such as the mouth, rectum, or
vagina. The casualty may cough up blood (hemoptysis), vomit blood (hematemesis), or pass
bloody stools (hematochezia). Vomited blood may be bright red or it may be dark and resemble
coffee grounds. The stools may be bright red or dark (melena). Blood loss from internal bleeding
is just as serious as visible blood loss from external bleeding.
Apply direct pressure to the wound with a gauze pad or field dressing. Direct pressure is the first
and most effective method to control bleeding. In many cases, bleeding can be controlled by
applying pressure directly to the wound.
SHOW SLIDE 7, 8
Elevate the affected extremity above the level of the heart. Do not elevate if there are suspected
musculoskeletal injuries, impaled objects in the extremity, or spinal injury. Raising (elevation) of
an injured arm or leg (extremity) above the level of the heart will help control bleeding. Elevation
should be used together with direct pressure. Do not elevate an extremity if you suspect a broken
bone (fracture) until it has been properly splinted and you are certain that elevation will not cause
further injury. Use a stable object to maintain elevation. Placing an extremity on an unstable
object may cause further injury.
Apply additional dressings if the wound continues to bleed.
Never remove a dressing once it has been applied to a wound. Removing the dressing may
destroy any clotting that has begun, thus causing further injury to the site. In some cases, leaving
the blood soaked dressing in place allows more bleeding. In this instance, remove the dressing
and redress once to be sure direct pressure is being placed on the wound.
Once bleeding has been controlled it is important to check a distal pulse to make sure that the
dressing has not been applied too tightly. If a pulse is not palpable, adjust the dressing to
reestablish circulation.
If using gauze pads or similar material to dress a wound, bandage the dressing in place.
SHOW SLIDE 9
Direct Pressure - Place a sterile dressing or clean cloth on the wound, tie a knot or adhere tape
directly over the wound, only tight enough to control bleeding. If bleeding is not controlled, apply
another dressing over the first or apply direct pressure with your hand or fingers over the wound.
Direct pressure can be applied by the casualty or a bystander. Direct pressure is the quickest
method to control bleeding. Applying pressure directly to the wound usually controls bleeding;
keep in mind that in a tactical environment, the use of temporary tourniquets will be the treatment
of choice for controlling rapid or massive bleeding on the battlefield.
Elevate the Limb - If the injured limb is not fractured (or if a splint has already been applied) and
the limb does not have an impaled (protruding) object, raise the limb above the level of the
casualty's heart. Elevating the limb will help to decrease blood flow to the injured area and,
thereby, reduce bleeding and swelling. Make sure the limb is supported and the limb will not slip
off the support. Elevating the injured limb and applying manual pressure should be done at the
same time when no fracture is involved.
If the wound is on a leg, place a pack, log, rock, or other object under the foot and ankle of the
injured leg.
If the wound is on an arm and the casualty is lying on his back, place the casualty's forearm on
his chest.
If wound is on an arm and the casualty is sitting up, have the casualty place his forearm on top of
his head.
Pressure Dressing - A pressure dressing consists of a wad of material placed over a regular
dressing and secured with a tight bandage. The pressure dressing is used to apply continuous
pressure on the wound in an effort to compress blood vessels and help control bleeding. The
pressure dressing does not stop the flow of blood through arteries and veins. A pressure dressing
is only applied to a wound on a limb (arm or leg).
SHOW SLIDE 10, 11
Locate and apply pressure to the appropriate arterial pressure point, if the wound continues to
bleed.
Pressure points may not be effective if the wound is at the distal end of the limb. Blood
is being sent to these areas from many smaller arteries.
Brachial artery--used to control bleeding from the distal end of an upper extremity.
Hold the casualty's arm out at a right angle to his or her body with the palm facing up.
Do not use force to raise the arm if the movement causes pain.
Locate the groove between the humerus and the biceps muscle.
Hold the upper arm in the palm of your hand with your fingers positioned in the medial groove.
Press your fingers into the groove to compress the artery against the underlying bone. If pressure
is applied properly, the radial pulse will not be palpable.
SHOW SLIDE 12
Femoral artery--used to control bleeding of a lower extremity.
Locate the femoral artery on the medial side of the anterior thigh, just below the groin.
Place the heel of your hand over the site and apply pressure toward the bone.
More pressure is needed to compress the femoral artery than the brachial artery due to the
amount of tissue and muscle in the thigh. Greater force is needed for obese and muscular
individuals. If pressure is applied properly, a distal pulse will not be palpable.
SHOW SLIDE 13
In cases of severe bleeding when direct pressure and elevation are not controlling the bleeding,
indirect pressure must be used. Bleeding from an artery can be controlled by applying pressure to
the appropriate pressure point. Pressure points are areas of the body where the blood flow can
be controlled by pressing the artery against an underlying bone. Pressure is applied with the
fingers, thumb, or heel of the hand.
Pressure points should be used with caution. Indirect pressure can cause damage to the
extremity due to inadequate blood flow. Do not apply pressure to the neck (carotid) pressure
points, it can cause cardiac arrest.
Indirect pressure is used in addition to direct pressure and elevation. Pressure points in the arm
(brachial) and in the groin (femoral) are most often used, and should be thoroughly understood.
The brachial artery is used to control severe bleeding of the lower part of the upper arm and
elbow. It is located above the elbow on the inside of the arm in the groove between the muscles.
Using your fingers or thumb, apply pressure to the inside of the arm over the bone.
The femoral artery is used to control severe bleeding of the thigh and lower leg. It is located on
the front, center part of the crease in the groin. Position the casualty on his or her back, kneel on
the opposite side from the wounded leg, Place the heel of your hand directly on the pressure
point, and lean forward to apply pressure. If the bleeding is not controlled, it may be necessary to
press directly over the artery with the flat surface of the fingertips and to apply additional pressure
on the fingertips with the heel of your other hand.
SHOW SLIDE 14, 15
Consider other conjunctive therapies to control bleeding if necessary.
Splinting: Airsplints are effective in controlling venous and capillary bleeding. They are not usually
effective in high pressure arterial bleeds. Airsplints are effective, however, in maintaining
pressure once other manual methods, such as pressure dressings, have been applied
Immobilization is one of the best ways to stop bleeding
Broken bone fragments may continue to grate on blood vessels and increase bleeding if they are
not mobilized
Muscular activity can also increase the rate of blood flow
Pneumatic splints may be used to apply direct circumferential pressure over an extremity, thus
compressing the extremity, its soft tissues, and the bleeding vessels
Splinting using an pneumatic splint gives a double benefit - splinting and direct pressure
Cold application: Cold minimizes swelling and constricts blood vessels. Never apply icepacks
directly to the skin. Always wrap cold packs in cloth before applying to the skin. Do not apply ice
for more than 20 minutes at a time.
SHOW SLIDE 16
Apply a tourniquet if the wound continues to bleed.
A tourniquet is a last resort for life-threatening injuries. Tourniquets cut off blood flow to and from
the extremity and are likely to cause permanent damage to vessels, nerves, and muscles. Never
loosen or remove the tourniquet after it has been applied.
A blood pressure cuff can provide a temporary tourniquet to control bleeding until a pressure
dressing is applied. Place the cuff above the wound and inflate it to 150 mm Hg. Deflate the cuff
slowly once a bandage has been applied.
If the nature of the wound is such that direct pressure or pressure points will not be effective, go
directly to a tourniquet. Traumatic amputation of an extremity is one of those situations. Forceful,
arterial bleeding from an extremity wound may require early use of a tourniquet. Do not waste
time attempting a pressure dressing.
Place the tourniquet between the heart and the wound, leaving at least 2 inches of uninjured skin
between the tourniquet and the wound. Don’t apply the cravat directly over the wound unless you
have no other choice. Don’t apply a tourniquet over a joint.
Place the tourniquet between the heart and the wound. Place a roll or pad over the artery to be
compressed
Wrap the tourniquet around the extremity, and tie a half-knot anteriorly over the padding. Don't
apply the knot directly over the wound unless you have no other choice.
After tying the 1/2-knot, place a stick or similar object on the half-knot, tie a square knot and start
twisting. Twisting will tighten the bandage. Keep twisting until the bleeding stops.
If a stick is not available, use a tent peg or bayonet scabbard. Use whatever materials you have
at hand.
Secure the stick in place so it doesn't unwind, and transport the victim as quickly as possible to a
medical facility
Using a marker, make a "T" on the casualty's forehead. Place the time and date the tourniquet
was applied on a field medical card attached to the casualty.
The task apply a tourniquet will be taught in a later lesson.
Initiate treatment for shock as needed
Assess the need for evacuation.
SHOW SLIDE 17
If the source of bleeding was due to a traumatic amputation-Wrap the amputated part in a sterile dressing.
Wrap or bag the amputated part in plastic.
Label the bag or plastic.
Transport the amputated part in a cool container with the patient.
Do not place the amputated part directly on ice. Do not submerge it directly in water. Do not allow
the part to freeze.
SHOW SLIDE 18, 19
Regardless how severe, all bleeding can be controlled. If left uncontrolled, bleeding may lead to
shock or even death. Most bleeding can be stopped by the medic on site.
The causes of external bleeding can come from numerous sources. Any type of cut, scrape or fall
where blood is coming from an open wound is considered external bleeding.
Internal bleeding occurs when the blood from a damaged blood vessel or organ (such as a
laceration of the liver) flows into a body cavity or is trapped in the surrounding tissue rather than
escaping the body through an open wound.
Bleeding can often be temporarily controlled by applying hand pressure to the appropriate
pressure point. A pressure point is the spot where the main artery to an injured part lies near the
skin surface and over a bone.
Hemorrhage control continues to be the priority in battlefield care. Hemorrhage is the leading
cause of preventable death on the battlefield. The focus of this lesson and our focus as medics
must be on controlling bleeding as we encounter injuries on the battlefield. Questions