The three methods, in order
There are three methods of bleeding control. They sit in a strict order, and the order is the most important thing about them. Direct pressure first. Wound packing when pressure cannot reach the source. Tourniquet when the wound is on a limb and will not close with either.
The order matters because most severe external bleeding stops with the first method. Firm, sustained, two-handed pressure on the wound for three uninterrupted minutes will close the majority of bleeds a civilian will ever see. The other two methods exist for the cases where pressure is not enough, or where pressure cannot be applied at all.
The sequence in one line. Press. If pressure cannot reach the source because of where the wound is, pack. If the wound is on a limb and is still pumping, tourniquet. Each step is faster to start than to describe. The whole sequence, including the decision to escalate, fits inside the time it takes EMS to arrive in most US cities.
Where elevation fits. Elevation is not on this list. The current Stop the Bleed® curriculum does not teach elevation as a primary bleeding control method, because the time and attention it takes to elevate are better spent maintaining pressure. If you are already holding pressure with both hands and have a free moment, raising the limb does not hurt. It is not a method on its own.
Direct pressure: the foundation
Direct pressure is the foundation of bleeding control management. It is the method every other method either supports or escalates from. The technique is simple. Doing it well, for long enough, is the hard part.
The technique. Place a clean cloth, gauze, or your bare hand directly over the wound. Press hard with both hands, one stacked on top of the other. Lean your body weight into it through straight arms. Lock your shoulders over your hands so the pressure comes from your torso, not from your forearm muscles. Forearms tire in under a minute. Body weight does not.
What to use. A clean cloth or sterile gauze is ideal. A torn shirt, a folded towel, a stack of napkins all work. If a hemostatic dressing like Combat Gauze or Celox is in the kit, use that under the pressure: the impregnated material accelerates clotting on contact with blood.
If you have nothing clean, your bare hand on the wound is correct. Infection is a problem for tomorrow. Bleeding is a problem for the next four minutes.
How long. Three uninterrupted minutes is the working number. Most external bleeding will stop in that window if pressure is firm and continuous. Continuous is the operative word. Lifting your hands at sixty seconds to check resets the clock and may flush the early clot out of the wound.
How to know it is working. After three minutes, the blood seeping into the cloth slows or stops. The cloth darkens but does not soak fresh. You can ease your weight slightly without seeing a fresh pulse of red.
If the wound is still actively bleeding through, escalate: pack the wound if it is deep and you can reach into it, or move to a tourniquet if it is on a limb.
Wound packing: when pressure is not enough
Wound packing is the method for the places a tourniquet cannot reach. Junctional injuries at the neck, the armpit, the groin, and deep wounds where the bleeding source is below the surface.
A tourniquet cannot occlude a vessel in the neck or the groin. Surface pressure alone often cannot reach deep enough into the wound channel to close the vessel either. Packing fills the cavity and lets pressure work from inside the wound.
The principle. You are stuffing the wound full of material to compress the bleeding vessel from inside the wound channel, then maintaining hard surface pressure on top. The material can be hemostatic gauze if available, plain rolled gauze, or clean cloth. The goal is to push the dressing into the cavity directly against the bleeding source.
The technique in brief. Find the deepest part of the wound where the bleeding is coming from. Push the dressing into that spot with two fingers. Keep feeding more material in, packing it tight against the bleeding source.
Once the cavity is full, place both hands on top and hold sustained pressure for at least three minutes. Do not remove what you packed in to add more, build on top.
The full technique, with hand positions, depth, and how to know the pack is set, is in our wound packing guide. The summary above is enough to act on. The detailed page is worth reading before you need it.
Test your response
You are first to a deep cut on a coworker's forearm. The wound is soaking through a folded shirt and dripping onto the floor. You have your bare hands, a clean towel from the break room, and a CAT tourniquet in the office trauma kit twenty feet away. What is the first move? What do you do first?
Be honest. No one's watching.
Tourniquet: for the wounds that will not quit
A tourniquet is the third method, used when the wound is on an arm or a leg and pressure and packing have not controlled the bleeding. It is not a precautionary device. It is the answer to blood that is pulsing, soaking through, or pooling on the floor and not slowing under your hands, on a limb.
Primary placement. Two to three inches above the wound, on the bare skin of a single long bone, never over a joint. On an arm, that is the upper arm above the elbow, over the humerus. On a leg, that is the thigh above the knee, over the femur.
Tighten until the bleeding stops, not until it slows. Note the time of application on the device or on the patient's skin.
High and tight. When you cannot see the source of the bleeding, when the limb is amputated, when there is not enough room above the wound for proper placement, or when the scene is unsafe, place the tourniquet as high on the limb as possible: at the groin for a leg, at the armpit for an arm.
You will not damage anything by going higher than strictly necessary.
The full placement, tightening, and improvisation technique is in our tourniquet guide. The line that matters most for this page is the order. Tourniquet is the third method. It is the answer when the first two have not been enough, on a limb. Once it is on, it stays on until a physician releases it in a hospital setting.
MARCH protocol: how the pros think about it
MARCH is the mnemonic the military and trauma medical community use to organize the first minutes of trauma care. It stands for Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia. The order is deliberate. It is a triage of which problem will kill the patient first.
- M, Massive hemorrhage. Stop the bleeding. Direct pressure, packing, tourniquet, in that order. Severe external bleeding can kill in three to five minutes. Nothing else matters if this is not controlled.
- A, Airway. Make sure air can move. Is the mouth clear, is the head positioned so the tongue is not blocking the throat, is there visible obstruction.
- R, Respiration. Check that the chest is rising and falling. Look for sucking chest wounds or asymmetric movement that suggests collapsed lung territory.
- C, Circulation. Reassess for hidden bleeding, check responsiveness and pulse, treat for shock by keeping the patient flat and warm.
- H, Hypothermia. A bleeding trauma patient cools fast, even on a warm day. Cold blood does not clot well. Cover the patient with a blanket, coat, or whatever is at hand. Get them off cold ground.
Why the M is first. Airway problems kill in minutes. Massive hemorrhage kills in minutes too, and faster than airway in most penetrating trauma. That is why the M moved to the front of the protocol when MARCH replaced the older ABC sequence in trauma medicine.
The civilian version of the same thinking is the Hartford Consensus, the 2013 American College of Surgeons document that named uncontrolled hemorrhage as the leading preventable cause of death in trauma and put bleeding control training in the hands of bystanders.
What civilians need from MARCH. The M. The rest of the protocol is the responsibility of paramedics and trauma teams once they arrive. The bystander's job is to control the bleeding in the window before EMS gets there. Press the wound with everything you have, escalate to packing if the source is somewhere your hands cannot reach, and reach for a tourniquet only when a limb keeps pumping through both. That is the whole civilian protocol.
~7 min
Median 911-to-arrival EMS response time in U.S. urban areas. Suburban median is roughly fourteen minutes, rural areas thirty or more (Mell et al., JAMA Surgery, 2017). Severe external bleeding can drop a patient toward shock inside that window. The first person on scene is the patient's chance.