• There was prior bleeding, and the patient is now
in shock (unconscious, confused, pale).
When treating an individual who is in obvious
shock from bleeding wounds, hemorrhage control
should be the first priority, before fluid resuscitation.
Effective hemorrhage control does not stop with the
initial tourniquet application. The military experience with tourniquets has provided some key teaching
points about their use:
• Waiting too long to place a tourniquet is a mistake.
• Tourniquets should be applied just proximal to
the site of the severe bleeding and never placed
directly over a joint.
• Tourniquets should be tightened as necessary to
stop bleeding from the distal injury.
•If bleeding is not controlled with one tourniquet,
a second tourniquet should be applied just proximal to the first.
• The need for a second tourniquet is especially applicable when applying tourniquets to generously
sized lower extremities.
• The purpose of tourniquets is to stop arterial bleeding. If a distal pulse is still present, the tourniquet
should be tightened or a second tourniquet applied
just proximal to the first, and the pulse should be
•If a tourniquet is used, it should be an effective
arterial tourniquet and not an ineffective venous
tourniquet, as use of the latter can increase bleeding.
•Casualties with tourniquets in place should be
rechecked periodically to ensure that the tourniquet is still working and that hemorrhage is
•Pulses distal to every tourniquet should be
•Correctly applied tourniquets can cause significant pain, but this pain does not signify that the
tourniquet has been applied incorrectly or that it
should be removed.
• Pain should be managed with analgesics as appropriate, but not for patients in shock.
Mistakes regarding tourniquets include the
•Not having an effective commercial tourniquet
•Not using a tourniquet when one should be used
• Using a tourniquet for minimal or minor bleeding
when one should not be used
•Putting the tourniquet on too proximally
• Not making the tourniquet tight enough to effectively stop the bleeding
•Not using a second tourniquet if needed
• Waiting too long to put the tourniquet on
• Not reevaluating the tourniquet’s effectiveness
•Periodically loosening the tourniquet to allow
blood flow into the injured extremity
The time when a tourniquet is applied should always
be noted on the individual’s body, customarily by writ-
ing the letter T on the person’s forehead, along with
the time that it was tightened. This notation should be
done with an indelible ink marker to ensure that this
important information does not wash or wipe off. The
Commercial windlass-type tourniquets should be used in the
prehospital setting for the control of significant extremity
hemorrhage when direct pressure is ineffective or impractical….