Section I. CONTROLLING BLEEDING WITHOUT A TOURNIQUET

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4-1. GENERAL

The leading preventable cause of death on the battlefield is bleeding from an extremity. Bleeding (hemorrhaging) from an extremity can usually be controlled by applying a dressing and bandage, applying manual pressure, elevating the injured limb, and applying a pressure dressing. An Emergency Bandage serves as a dressing and bandage. It can also as a pressure dressing. If the casualty is bleeding from a limb and these methods do not control the bleeding, then a tourniquet must be applied to stop the loss of blood from the limb.
a. In an amputation of the arm, forearm, thigh or leg, a tourniquet is applied immediately since the other measures are inadequate to control the bleeding.

b. In combat while under enemy fire, a rapidly applied tourniquet is the initial method used to control life-threatening bleeding from a limb. Once you and the casualty are in a safe location, you can reevaluate the tourniquet.

4-2. EXPOSE THE WOUND

If possible, expose the wound first by pushing or cutting away loose clothing around the casualty’s wound. This will enable you to better view the extent of the injury. Scissors, strap cutter, or a knife can be used to cut clothing. In the care under fire phase, do not take time to expose the wound.

CAUTION: Clothing or anything else stuck to the wound should be left alone to avoid further injury. Cut or tear around the stuck material so that the stuck material remains undisturbed. Do not
attempt to clean the wound.

WARNING: Do not remove protective clothing in a chemical environment. Apply dressings over the protective clothing.

4-3. CHECK FOR ENTRANCE AND EXIT WOUNDS

Before applying the dressing, carefully examine the casualty to determine if there is more than one wound. A missile may have entered at one point and exited at another point. The exit wound
is usually larger than the entrance wound. If there is an entrance
wound and an exit wound, both wounds need to be dressed and bandaged.

CAUTION: If the missile (such as a bullet or shrapnel) lodges in the body (fails to exit), do not attempt to remove the missile or probe the wound.

CAUTION: If there is an object extending from (impaled in) the wound, do not remove the object. Apply a dressing around the object and use additional improvised bulky dressings made from
the cleanest material available to build up the area around the object. This will stabilize the object and help to prevent further injury. Apply a supporting bandage over the bulky
materials to hold them in place.

4-4. EMERGENCY BANDAGE

The Emergency Bandage (figures 4-1 and 1-4) can be used on any bleeding wound. It can be used both as a field dressing and as a pressure dressing. Follow the procedures below when applying the Emergency Bandage to a wound on the casualty’s extremity. Figure 4-2 shows the Emergency Bandage applied to a forearm. Figure 4-3
shows Emergency Bandages applied to various other wounds.

Emergency Bandage packet (opened)

a. Remove the bandage from the pouch and packaging.

NOTE: If possible, put on examination gloves (found in the soldier’s Improved First Aid Kit and in the combat lifesaver aid bag) to reduce contamination. Use the gloves in the casualty’s Improved First Aid Kit, if possible. This also applies to the Combat Gauze and other items found in the IFAK.

b. Place the pad (dressing) directly on the wound.

c. Wrap the elastic bandage around the wounded extremity (figure 4-2A).

d. Insert the elastic bandage completely into the pressure bar (figure 4-2B).

e. Pull the elastic bandage back over the top of the pressure bar (reversing direction forces the bar down onto the pad) (figure 4-2C).

f. Wrap the elastic bandage tightly over the pressure bar.

g. Continue to wrap the elastic bandage around the limb so that all edges of the pad are covered (figure 4-2D).

h. Secure the hooking end of the closing bar into the elastic bandage (figure 4-2E). The bandage is now secure.

Applying an Emergency Bandage to a wound on the forearm

Emergency Bandage applied to other injuries

4-5. COMBAT GAUZE

Combat Gauze (shown previously in figure 1-5 of Lesson 1) is a 3-inch by 4-yard roll of gauze that is impregnated with a hemostatic agent (kaolin). This material is a pro-coagulant and will cause blood to clot when it comes into contact with the blood. This action, along with the pressure of packing it into a bleeding wound and applying manual pressure, causes the wound to stop bleeding. Combat Gauze is used for serious arterial bleeding. Instructions for applying the Combat Gauze are given below. Use the casualty’s Combat Gauze first.

a. Open the clothing around wound.

b. If possible, remove any excess pooled blood from the wound while preserving any clots already formed in the wound.

c. Locate the source of most active bleeding.

d. Pack the Combat Gauze tightly into wound and directly onto the source of the bleeding.

e. More than one Combat Gauze may be required to stem the blood flow.

f. Combat Gauze may be repacked or adjusted into the wound to ensure proper placement.

g. Quickly apply manual pressure until the bleeding stops. It is recommended that you apply continuous pressure for three minutes.

h. Reassess for proper and effective placement.

i. Apply a pressure bandage to the wound to secure the Combat Gauze in the wound.

4-6. MANUAL PRESSURE

If practical, apply direct pressure over the wound with your hand after you have applied the Emergency Bandage or other dressing. This pressure will help to compress the damaged blood vessels and control the bleeding. Maintain this pressure for 5 to 10 minutes.

NOTE: If the casualty is conscious and can follow instructions, you can have him apply the manual pressure himself.

4-7. PRESSURE DRESSING

If blood continues to seep from the dressing after you have applied manual pressure, apply a pressure dressing. If an Emergency Bandage has been applied, tighten the bandage to form a pressure dressing. Otherwise, apply an improvised pressure dressing. The following instructions assume that an improvised pressure dressing is being applied after the lower limbs have been elevated to help prevent shock.

NOTE: The Emergency Bandage (paragraph 4-4) can be used both as a field dressing and as a pressure dressing.

a. Place a wad of padding on top of the dressing and directly over the wound (figure 4-4A). The wad can be made from a folded muslin bandage (cravat) from your aid bag, a rag, material torn from clothing, or other material that can be folded several times.

b. Place a cravat over the wad of padding (figure 4-4B) and wrap the cravat tightly around the limb over the dressing (figure 4-4C).

(1) The cravat can be made from a muslin bandage from your aid bag or other material torn and folded into a cravat (see figure 4-10 in Section II). Other materials, such as a handkerchief, sock, or strip of cloth torn from a shirt, can also be used.

(2) Wire and narrow material, such as a shoestring, should not be used since they are likely to damage blood vessels and nerve tissue.

c. Tie the ends of the cravat in a nonslip knot to secure the wad of padding (figure 4-4D). Tie the nonslip knot directly over the wound. The cravat should be tight enough so only the tip of one finger can be inserted under the cravat. Do not tie the cravat so tight that it cuts off blood circulation. The pressure on the wad of dressing helps to restrict the blood vessels and control the bleeding.

d. Check the circulation below the pressure dressing. If the skin below the pressure dressing becomes cool to the touch, bluish, or numb, or if the pulse below the pressure dressing is no longer present, the pressure dressing may be too tight. If circulation is impaired, loosen and retie the cravat. If circulation is not restored, evacuate the casualty as soon as possible.

NOTE: The pressure dressing can be loosened and retied without disturbing the blood clot forming under the dressing pad.

Applying an im provised pressure dressing A & BApplying an improvised pressure dressing C & D

e. Apply manual pressure over the pressure dressing.

(1) If the pressure dressing controls the bleeding, proceed to check the casualty for other injuries.

(2) If the wound continues to bleed, apply digital pressure, if possible. If applying digital pressure is not possible or does not control the bleeding, apply a tourniquet as described in Section II.

CAUTION: If the bleeding appears to be controlled, continue to check the distal end of wounded extremity (fingers or toes) periodically to ensure that adequate blood circulation is maintained. If the area below the dressing becomes cool, blue, or numb, loosen and reapply the pressure dressing. If this does not restore circulation, evacuate the casualty as soon as possible.

4-8. DIGITAL PRESSURE

Applying digital pressure to “pressure points” is another method of controlling bleeding. This method uses pressure from the fingers, thumbs, heel of the hand, or knee to press at the site or point where a main artery supplying the wounded area lies near the skin surface or over bone (see figure 4-5). This pressure may help shut off or slow down the flow of blood from the heart to the wound. Two pressure points are discussed below.

a. Arm (Brachial Artery). Digital pressure is used to control severe bleeding of the lower part of the arm and elbow.

(1) The pressure point is located above the elbow on the inside of the arm in the groove between the muscles.

(2) Using your fingers or thumb, apply pressure to the inside of the arm over the bone.

b. Groin (Femoral Artery). Digital pressure is used to control severe bleeding of the thigh and lower leg.

(1) The pressure point is located on the front, center part of the crease in the groin.

(2) Using the heel of your hand or your knee, apply pressure to press the artery against the bone. Lean forward to apply pressure.

pressure points