Bleeding (hemorrhage) is the escape of blood from capillaries, veins, and arteries. Capillaries
are very small blood vessels that carry blood to all parts of the body. Veins are
blood vessels that carry blood to the heart. Arteries are large blood vessels that
carry blood away from the heart. Bleeding can occur inside the body (internal), outside
the body (external) or both. Blood is a fluid that consists of a pale yellow liquid
(plasma), red blood cells (erythrocytes), white blood cells (leukocytes), and platelets
(thrombocytes). Plasma is the fluid portion of the blood that carries nutrients. Red blood
cells give color to the blood and carry oxygen. White blood cells defend the body against
infection and attack foreign particles. Platelets are disk shaped and assist in clotting
the blood, the mechanism that stops bleeding. There are three types of bleeding. Capillary
bleeding is slow, the blood "oozes" from the (wound) cut. Venous bleeding is
dark red or maroon, the blood flows in a steady stream. Arterial bleeding is bright red,
the blood "spurts" from the wound. Arterial bleeding is life threatening and
difficult to control.
In small wounds, only the capillaries are damaged. Deeper wounds result in damage to
the veins and arteries. Damage to the capillaries is usually not serious and can easily be
controlled with a Band-Aid. Damage to the veins and arteries are more serious and can be
life threatening. The adult body contains approximately 5 to 6 quarts of blood (10 to 12
pints). The body can normally lose 1 pint of blood (usual amount given by donors) without
harmful effects. A loss of 2 pints may cause shock, a loss of 5 to 6 pints usually results
in death. During certain situations it will be difficult to decide whether the bleeding is
arterial or venous. The distinction is not important. The most important thing to remember
is that all bleeding must be controlled as soon as possible.
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. There are four methods to control bleeding: direct pressure,
elevation, indirect pressure, and the use of a tourniquet.
Direct pressure is the first and most effective method to control bleeding. In many
cases, bleeding can be controlled by applying pressure directly (Fig. 3-1) to the wound.
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. Under no
circumstances is a dressing removed once it has been applied.
Raising (elevation) of an injured arm or leg (extremity) above the level of the heart
will help control bleeding.
Figure 3-1 Direct Pressure
Figure 3-2 Pressure Points for Control of 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.
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 (Fig. 3-2) 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 (Fig. 3-2E) 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 (Fig. 3-2H )
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.
A tourniquet should be used only as a last resort to control severe bleeding
after all other methods have failed and is used only on the extremities. Before
use, you must thoroughly understand its dangers and limitations. Tourniquets cause tissue
damage and loss of extremities when used by untrained individuals. Tourniquets are rarely
required and should only be used when an arm or leg has been partially or completely
severed and when bleeding is uncontrollable.
The standard tourniquet is normally a piece of cloth folded until it is 3 or more
inches wide and 6 or 7 layers thick. A tourniquet can be a strap, belt, neckerchief,
towel, or other similar item. A folded triangular bandage makes a great tourniquet. Never
use wire, cord, or any material that will cut the skin.
To apply a tourniquet (Fig. 3-3), do the following:
1. While maintaining the proper pressure point, place the tourniquet between the heart
and the wound, leaving at least 2 inches of uninjured skin between the tourniquet and
2. Place a pad (roll) over the artery.
3. Wrap the tourniquet around the extremity twice, and tie a half-knot on the upper
4. Place a short stick or similar object on the half-knot, and tie a square knot.
5. Twist the stick to tighten, until bleeding is controlled.
6. Secure the stick in place.
7. Never cover a tourniquet.
Figure 3-3 Applying a Tourniquet
8. Using lipstick or marker, make a 'T" on the casualty's forehead and the time
tourniquet was applied.
9. Never loosen or remove a tourniquet once it has been applied. The loosening
of a tourniquet may dislodge clots and result in enough blood loss to cause shock and
Do not touch open wounds with your fingers unless absolutely necessary. Place a
barrier between you and the casualty's blood or body fluids, using plastic wrap, gloves,
or a clean, folded cloth. Wash your hands with soap and warm water immediately after
providing care, even if you wore gloves or used another barrier.
Internal bleeding, although not usually visible, can result in serious blood loss. A
casualty with internal bleeding can develop shock before you realize the extent of their
injuries. Bleeding from the mouth, ears, nose, rectum, or other body opening (orifice) is
considered serious and normally indicates internal bleeding.
The most common sign of internal bleeding is a simple bruise (contusion), it indicates
bleeding into the skin (soft tissues). Severe internal bleeding occurs in injuries caused
by a violent force (automobile accident), puncture wounds (knife), and broken bones.
Signs of internal bleeding include:
1. Anxiety and restlessness.
2. Excessive thirst (polydipsia).
3. Nausea and vomiting.
4. Cool, moist, and pale skin (cold and clammy).
5. Rapid breathing (tachypnea).
6. Rapid, weak pulse (tachycardia).
7. Bruising or discoloration at site of injury (contusion).
If you suspect internal bleeding, do the following:
1. Bruise (contusion) - Apply ice or cold pack, with cloth to prevent damage to the
skin, to reduce pain and (edema) swelling.
2. Severe internal bleeding:
a. Call local emergency number or medical personnel.
b. Monitor airway, breathing, and circulation (ABCs).
c. Treat for shock.
d. Place casualty in most comfortable position.
e. Maintain normal body temperature.
f. Reassure casualty
Nosebleeds (epistaxis) can be caused by an injury, disease, the environment, high blood
pressure, and changes in altitude. They frighten the casualty and may bleed enough to
cause shock. If a fractured skull is suspected as the cause, do not stop the bleeding.
Cover the nose with a loose, dry, sterile dressing and call the local emergency number or
medical personnel. If the casualty has a nosebleed due to other causes, do the
1. Keep the casualty quiet, sitting with head tilted forward.
2. Pinch the nose shut (if there is no fracture), place ice or cold packs to the bridge
of the nose, or put pressure on the upper lip just below the nose. Inform the casualty not
to rub, blow, or pick his or her nose. Seek medical assistance if the nosebleed continues,
bleeding starts again, or bleeding is because of high blood pressure. If the casualty
loses consciousness, place them on their side to allow blood to drain from the nose and
call the local emergency number or medical personnel.
Foreign bodies in the nose usually occur among children. First aid consists of seeking
professional medical attention. Nasal damage and the possibility of pushing the object
farther up the nose can result from searching and attempts at removal by unqualified
Casualties with severe external bleeding and suspected internal bleeding must be
seen by medical personnel as soon as possible. All casualties with external and internal
bleeding should be treated for shock.
1. Karren, K. J. and Hafen, B.Q.: First Responder A Skills Approach, edition 3, Morton
2. American Red Cross Standard First Aid Workbook, edition 1991, American Red Cross
3. NAVEDTRA 10669-C, Hospital Corpsman 3 & 2
Department of the Navy
Bureau of Medicine and Surgery
2300 E Street, NW
Washington, DC 20372-5300
Approved for public release; Distribution is unlimited.
The listing of any non-Federal product in this CD is not an
endorsement of the product itself, but simply an acknowledgement of the source.
Operational Medicine 2001
Health Care in Military Settings
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January 1, 2001
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