The following slide talks about signs of ongoing life-threatening bleeding that may not have been noted or appropriately addressed in Care Under Fire. These include pulsatile blood, steady bleeding from the wound, blood pooling on the ground or soaking overlying clothing or bandages, or blood flowing at the site of a traumatic amputation of an arm or leg. Any obvious ongoing life-threatening bleeding should be addressed immediately.

- Casualties with Major Artery injury can bleed to death in 3 Minutes
- Early tourniquet use prevents late stage of shock
- Limb exsanguination and saves lives. Tourniquets are safe when applied for < 2 hours.
- Nonindicated tourniquet placement is common (even when CUF is included as an indication).
- Morbidity is uncommon when tourniquet use is relatively brief. Prolonged (> 6 hours) use of a tourniquet can potentially result in the loss of a limb.

In combat casualties, early control of significant external hemorrhage is the most important intervention that can be undertaken. During the wars in Afghanistan and Iraq, an estimated 1,000 to 2,000 lives were saved by tourniquet application. Despite the fact that potentially preventable deaths from extremity hemorrhage had dropped from 7.8 percent noted in a study by Kelly study to 2.6 percent in a subsequent study by Eastridge, a decrease of 67 percent, hemorrhage remains the predominant cause of preventable death in combat fatalities.

Research supporting the early control of severe bleeding, whether from the use of tourniquets or from other control measures, has shown a positive impact in multiple military-based and civilian prehospital studies. Overall, the supporting level of evidence is moderate to strong for early control of severe hemorrhage.

The time it takes to lose a significant amount of blood with severe hemorrhage can be measured in minutes and any delays in control can have significant adverse effects. Every effort needs to be made to initiate and control severe bleeding prior to proceeding with the rest of your assessment and treatment plan.