Indications
- Catastrophic external haemorrhage — from a limb wound, junctional site, or scalp — with visible active bleeding or a large blood loss on scene/handover.
- Suspected pelvic fracture with haemodynamic instability, especially after high-energy blunt trauma.
- Major trauma with actual or anticipated massive transfusion requirement — penetrating or blunt injury with signs of class III/IV haemorrhagic shock.
- Anticoagulated patients with major bleeding of any cause needing urgent reversal.
Principles & cautions
Tourniquet use
- Use for compressible limb haemorrhage not controlled by direct pressure, or when direct pressure is not feasible (multiple casualties, ongoing threat).
- A properly applied tourniquet is painful — expect to give analgesia once other priorities are addressed.
- Do not remove or loosen a pre-hospital tourniquet to "check" bleeding without a plan to control it if bleeding recurs.
Pelvic binder use
- Apply empirically in blunt trauma with suspected pelvic injury and haemodynamic compromise — do not wait for imaging if clinically indicated.
- Avoid repeated manual pelvic "springing" once a binder is being considered — it risks dislodging clot and is unreliable.
- Remove or loosen only when directed by the trauma/orthopaedic team, once imaging and stability allow.
Equipment
Tourniquet and pelvic binder placement
Step-by-step management sequence
Direct pressure first
Apply firm, sustained direct pressure to any external bleeding point as the immediate first action, while preparing further measures.
Pack the wound if pressure alone fails
For deep or junctional wounds, pack the wound cavity tightly with gauze (haemostatic gauze if available), maintaining direct pressure over the packed wound.
Apply a tourniquet for uncontrolled limb haemorrhage
Place 5–7 cm proximal to the wound (not over a joint), tighten the windlass by twisting until bleeding stops and the distal pulse is no longer palpable, then lock the windlass and secure it. Write the application time clearly on the tourniquet/patient — this drives later decisions on conversion or surgery.
Apply a pelvic binder for suspected pelvic fracture
Centre the binder over the greater trochanters (not the iliac crests) and tighten firmly but not so tight as to cause skin injury; log-roll minimally and avoid repeated pelvic springing once applied.
Activate the major haemorrhage protocol
Call it early on clinical grounds (do not wait for a falling haemoglobin) — this triggers rapid release of red cells and initiates balanced component transfusion (working towards a balanced ratio of red cells to plasma and platelets, per local protocol) and involves the blood bank, haematology and senior clinicians.
Give tranexamic acid early
In line with the CRASH-2 and CRASH-3 protocols: 1 g IV over 10 minutes, followed by a further 1 g IV infusion over 8 hours, given as early as possible and only if within 3 hours of injury — benefit diminishes and later administration may be harmful.
Permissive hypotension where appropriate
In penetrating trauma with uncontrolled haemorrhage before definitive control, a lower target blood pressure (avoiding aggressive crystalloid resuscitation that dilutes clotting factors and dislodges clot) may be used pending surgery — follow local trauma network protocols, and this does not apply once definitive haemorrhage control is achieved or in traumatic brain injury.
Reverse anticoagulation
For warfarin- or DOAC-associated major bleeding, give prothrombin complex concentrate (typically 25–50 units/kg four-factor PCC) per local policy, with IV vitamin K for warfarin; consider specific reversal agents (idarucizumab for dabigatran; andexanet alfa where available for factor Xa inhibitors) if accessible.
Escalate for definitive control
Involve surgery, interventional radiology and/or the major trauma team early — damage-control principles (control haemorrhage, restore physiology, definitive repair later) guide ongoing management.
Complications & pitfalls
Tourniquet-related
- Nerve and soft tissue injury with prolonged application — reassess regularly and aim for surgical/definitive control as soon as possible.
- Inadequate tightening leaves venous congestion without arterial control, worsening bleeding.
- Losing track of application time delays limb-viability decisions.
Systemic
- Over-resuscitation with crystalloid causing dilutional coagulopathy and clot disruption.
- Hypothermia and acidosis compounding coagulopathy ("lethal triad" with bleeding).
- Delayed major haemorrhage protocol activation losing critical time.
Documentation
- Time and site of tourniquet/binder application; time and dose of TXA and reversal agents given.
- Major haemorrhage protocol activation time and blood products given.
- Neurovascular status distal to any tourniquet before and after application.
- Handover to receiving team with all timings — tourniquet time in particular must travel with the patient.
Pitfalls & pearls
- Activate the major haemorrhage protocol on clinical judgement — do not wait for confirmatory blood results.
- Give TXA as early as possible within the 3-hour window; it is not a substitute for haemorrhage control, only an adjunct.
- Pelvic binders go over the greater trochanters, not the belt line — a common misplacement that reduces effectiveness.
- Mark the tourniquet time visibly — a hidden or forgotten time costs the limb team critical decision-making information.
- Permissive hypotension is not appropriate once bleeding is controlled, or in traumatic brain injury where adequate cerebral perfusion pressure is the priority.
DOPS pointers
RCEM curriculum: Intermediate/Higher Procedural Skill. What assessors look for at each entrustment level:
| 1 | Observed only — can describe the <C>ABCDE approach and major haemorrhage protocol pathway. |
| 2a | Performs with the supervisor present: correct tourniquet/binder application and TXA administration. |
| 2b | Performs with supervisor in the department: coordinates the full sequence including protocol activation and reassessment. |
| 3 | Indirect supervision: leads the resuscitation team through catastrophic haemorrhage, escalates appropriately to surgery/IR. |
| 4 | Independent; can teach and supervise others, including complex or multi-casualty haemorrhage scenarios. |
References
- CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients. Lancet 2010;376:23–32.
- CRASH-3 Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events in traumatic brain injury. Lancet 2019;394:1713–1723.
- Joint Royal Colleges Ambulance Liaison Committee / Faculty of Prehospital Care. Consensus statement on major haemorrhage and tourniquet use.
- National guidance on prothrombin complex concentrate for warfarin/DOAC-associated major bleeding, local trust major haemorrhage policy.
- RCEM Curriculum 2021 — Emergency Medicine Specialty Learning Outcomes: higher procedural skills (DOPS).