At this point in the assessment and management of a casualty, attention can be directed toward a more comprehensive evaluation of all hemorrhage. This includes both potential life-threatening internal hemorrhage, as well as a reassessment of prior interventions in external hemorrhage. Before talking about the specifics, it is useful to look at a progressive strategy for external hemorrhage control.1

Although massive external hemorrhage should have already been addressed, the initial action in this phase should be to ensure that there are no untreated sources of massive bleeding. If there are, they should be addressed with the methods previously described.

If no evidence of persistent massive external hemorrhage is found, the potential for massive internal hemorrhage should be evaluated. In recent conflicts, a common cause of this has been bleeding from pelvic fractures. So, a review of the risk factors for pelvic fracture should be performed, and a PCD placed, if indicated.

The next step is to expose any wounds, and reassess all previously applied tourniquets and dressings with pressure bandages to ensure bleeding is still being controlled. If there is still bleeding, this may be controlled by tightening a previously placed tourniquet or may require a second tourniquet be applied side-by-side. At this point, you can also determine if the bleeding from the wound requires continued use of a tourniquet to maintain control.

If the wound appears to require a tourniquet to control bleeding, and the current tourniquet was placed above the uniform (for example, a high and tight tourniquet), apply a second tourniquet directly on the skin 2-3 inches above the wound to replace the original tourniquet, ensuring bleeding is still controlled.

Occasionally, a tourniquet is placed principally because of the tactical situation and the need to ensure bleeding was rapidly addressed, but the bleeding might be controlled without a tourniquet. In those cases, consider converting bleeding control from a tourniquet to wound packing and pressure bandages, if the tourniquet has been on for less than 2 hours. Continue to reassess tourniquets for potential conversion to hemostatic dressings and pressure bandages at least every two hours, unless there has been an amputation; however, do not attempt tourniquet conversion if the tourniquet has been on for six or more hours.

After these measures, continue the casualty assessment by addressing the rest of the circulation phase objectives: assessing and managing shock, to include establishment of intravenous access and fluid resuscitation.