Bleeding control

01 — Direct pressure and wound packing

Direct pressure is the foundation. Wound packing fills the gap where pressure alone cannot reach.

The 2024 AHA and Red Cross Guidelines for First Aid are clear on the priority order for life-threatening bleeding: apply direct pressure immediately, then escalate to a tourniquet or wound packing depending on the wound location. Uncontrolled bleeding is the primary cause of death in 35 percent of trauma patients and can be fatal within minutes. Acting immediately is more important than acting perfectly.

Direct pressure means placing a cloth, gauze, or any clean material directly over the wound and pressing firmly. Do not lift the dressing to check if bleeding has stopped. If blood soaks through, place additional material on top of the original, without removing it. The original dressing helps form a clot; removing it disrupts that process.

Wound packing is used for locations where direct pressure cannot be applied effectively: the scalp, neck, shoulder, armpit, and groin. These junctions cannot be compressed from outside the way a limb wound can. The Red Cross technique for wound packing is to push gauze firmly and directly into the wound cavity, packing it tightly to fill the space, and then maintaining pressure over the packed wound. Continue pressure and call 911. Wound packing requires training to do correctly and carries risk if done improperly, but the risk of uncontrolled bleeding at these sites is greater than the risk of attempting the procedure.

02 — Embedded objects

Do not remove an embedded object. It may be the only thing controlling the bleeding.

The Red Cross and ANZCOR first aid guidelines are consistent on this point: removing an embedded object is contraindicated in field first aid. The object acts as a physical plug at the wound site. Removing it disrupts whatever tamponade effect it is providing and can convert a controlled bleed into a rapidly uncontrolled one.

The correct procedure is to pack material around the object on both sides, not over it, to apply pressure around the wound margins without disturbing the object. Bandage the padding in place around the object to stabilize it and prevent movement. Call 911 or arrange emergency transport immediately. The object should remain in place until removed by medical professionals in a controlled environment where the bleeding can be managed surgically if necessary.

The only exception is an object that is blocking the airway. In that situation, airway takes precedence over bleeding control. In all other cases, leave the object in place.

03 — Nosebleeds

Sit forward, not back. Tilting the head backward sends blood down the throat.

The American Red Cross nosebleed guidance is direct: seat the person upright with their head slightly forward. This keeps blood flowing forward and out of the nose rather than draining into the throat and stomach. Blood in the stomach causes nausea and vomiting, which can worsen the bleeding.

• Seat the person upright. Ask them to lean their head slightly forward, not back.
• Pinch the soft part of the nose, just below the bony bridge, using thumb and forefinger.
• Hold the pinch continuously for 10 to 15 minutes. Do not release to check if bleeding has stopped.
• Ask them to breathe through their mouth and spit out any blood rather than swallowing it.
• After 10 to 15 minutes, release gently and check for bleeding.
• If bleeding continues after 15 minutes, or if it is severe and gushing, seek emergency care. Seek medical attention if the person is on anticoagulants or has a known clotting disorder and the bleeding does not stop.

04 — Internal bleeding

First aiders cannot treat internal bleeding. The only correct response is to call for emergency help and manage shock.

Internal bleeding occurs when blood vessels inside the body rupture and blood accumulates in a body cavity or tissue rather than escaping externally. Common causes include blunt force trauma, falls, and certain medical conditions. The bleeding is not visible from the outside, which makes it easy to underestimate.

Signs that may indicate serious internal bleeding include persistent abdominal pain or rigidity, swelling or bruising over the abdomen or back, dizziness or confusion, pale or clammy skin, rapid or weak pulse, nausea, and blood in urine, vomit, or stool. These are signs that the circulatory system is under stress, even though no external wound is visible.

First aid cannot manage internal bleeding. No amount of pressure, positioning, or field treatment will stop blood loss occurring inside the body. The correct response is to call 911 immediately, keep the person as still and calm as possible, lay them down with legs elevated slightly if they show signs of shock, cover them to maintain warmth, and do not give them anything to eat or drink. Monitor consciousness and breathing, and be prepared to begin CPR if they become unresponsive and stop breathing. Everything else waits for emergency medical personnel.