Prehospital Guideline for External Hemorrhage Control

Publication Date: March 1, 2014



We recommend the use of tourniquets in the prehospital setting for the control of significant extremity hemorrhage if direct pressure is ineffective or impractical. (Moderate, Strong)
We suggest using commercially produced windlass, pneumatic, or ratcheting devices that have been demonstrated to occlude arterial flow. (Low, Weak)
We suggest against the use of narrow, elastic, or bungee-type devices. (Low, Weak)
We suggest that improvised tourniquets be applied only if no commercial device is available. (Low, Weak)
We suggest against releasing a tourniquet that has been properly applied in the prehospital setting until the patient has reached definitive care. (Low, Weak)

Junctional Hemorrhage Devices

We suggest the use of topical hemostatic agents, in combination with direct pressure, for the control of significant hemorrhage in the prehospital setting in anatomic areas where tourniquets cannot be applied and where sustained direct pressure alone is ineffective or impractical. (Low, Weak)
We suggest that topical hemostatic agents be delivered in a gauze format that supports wound packing. (Low, Weak)
Only products determined effective and safe in a standardized laboratory injury model should be used. (Low, Weak)

Additional Training Recommendations

  • We advise that tourniquets and topical hemostatic agents be used under clinical practice guidelines and following product specific training.
  • We advise that hemostatic agent training for prehospital personnel include proper wound packing and pressure application techniques.
  • We advise that tourniquets and topical hemostatic agents use be expanded to include all prehospital personnel, including emergency medical responders (in concordance with the Hartford Consensus Statement)
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Recommendation Grading




Prehospital Guideline for External Hemorrhage Control

Authoring Organizations

Publication Month/Year

March 1, 2014

Document Type


External Publication Status


Country of Publication


Document Objectives

This report describes the development of an evidence-based guideline for external hemorrhage control in the prehospital setting. 

Target Patient Population

Patients with external hemorrhage

Inclusion Criteria

Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Management, Treatment

Diseases/Conditions (MeSH)

D006470 - Hemorrhage, D014194 - Traumatology, D014111 - Tourniquets, D006490 - Hemostatics, D006489 - Hemostatic Techniques


hemorrhage, trauma, external hemorrhage, hemostatic

Source Citation

Eileen M. Bulger, David Snyder, Karen Schoelles, Cathy Gotschall, Drew Dawson, Eddy Lang, Nels D. Sanddal, Frank K. Butler, Mary Fallat, Peter Taillac, Lynn White, Jeffrey P. Salomone, William Seifarth, Michael J. Betzner, Jay Johannigman & Norman McSwain Jr. (2014) An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma, Prehospital Emergency Care, 18:2, 163-173, DOI: 10.3109/10903127.2014.896962