# Talk to me about pressure point bleeding control...



## attnondeck (May 5, 2011)

1: pressure  (understood)
2: elevate (understood)
3: pressure points (understand the concept, but where and how is it done)
4:tourniquet (yup.... self explanatory)  


just looking for some info on number 3.  thanks


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## FreezerStL (May 5, 2011)

> 1: pressure (understood)
> 2: elevate (understood)
> 3: pressure points (understand the concept, but where and how is it done)
> 4:tourniquet (yup.... self explanatory)



https://www.nremt.org/nremt/downloads/bleedingcontrolshock.pdf

Although I also learned it this way, it is no longer in practice. 

The NREMT removed pressure points from their skills test. Studies have shown its more beneficial to just go straight to tourniquets. 

If you understand the concept it's pretty self explanatory. Find the arterial pressure point above the injury and apply pressure, thus occluding or slowing blood flow enough to allow the clotting cascade to begin.

The brachial and femoral arteries were the go to's in most situations.


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## HotelCo (May 5, 2011)

Just remember... What the NREMT says, and what is actually done aren't usually the same. If granny has a skin tear from a slip and fall, and direct pressure doesn't solve the problem because she's on blood thinners, you don't have to jump to a tourniquet. Be smart.


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## usalsfyre (May 5, 2011)

HotelCo said:


> Just remember... What the NREMT says, and what is actually done aren't usually the same. If granny has a skin tear from a slip and fall, and direct pressure doesn't solve the problem because she's on blood thinners, you don't have to jump to a tourniquet. Be smart.


I don't think pressure points are going to work here either though. I never saw pressure points be effective for more than a couple if seconds. As far as a tourniquet goes, either it's egxangunating hemorrhage or it's not, the type of wound doesn't matter. It doesn't matter if it's a papercut, if there's sufficient blood loss it will get a tourniquet. 

One thing to remember is a B/P cuff is a much gentler and more controllable tourniquet than the gee whiz tactical stuff.


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## Veneficus (May 5, 2011)

usalsfyre said:


> either it's egxangunating hemorrhage or it's not, the type of wound doesn't matter.



I would say that in most cases it is not.

I have noticed that my definition of "a lot" of blood has changed considerably over the years.

An amount it takes to be life threatening is very often more than what it looks like.

That doesn't even begin to touch on the type of bleeding.

I would like to point out that in the EMS curriculum, in first responder texts they refer to 2 types of bleeding, "bleeding you can see and bleeding you can't see." In the paramedic level texts they don't bother to increase the level of understanding, but simply change the words to "external bleeding and internal bleeding."

With this (sarcastic) advanced knowledge, (end sarcasm) they are expecting people to determine what is life threatening or not and what to do about it.

Then many paramedic classes don't have clinical rotations in surgery or major trauma centers, so many students have no idea what life threatening bleeding might look like any more than some guy on the street.

(Except for the two dudes, who know a considerable amount about dealing out injuries  )


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## usalsfyre (May 5, 2011)

Veneficus said:


> I would say that in most cases it is not.
> 
> I have noticed that my definition of "a lot" of blood has changed considerably over the years.



One of my favorite exercises is to take 6 liters of theatrical blood and pour it out on the floor. People are usually shocked at how much it actually is. Granted it doesn't take anywhere near what amounts to your entire blood volume to be life threatening, but it usually causes people to drastically alter their perception.


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## Veneficus (May 5, 2011)

usalsfyre said:


> One of my favorite exercises is to take 6 liters of theatrical blood and pour it out on the floor. People are usually shocked at how much it actually is. Granted it doesn't take anywhere near what amounts to your entire blood volume to be life threatening, but it usually causes people to drastically alter their perception.



I never thought about doing that in an educational setting, that is a great idea! 

Maybe I'll just get a butcher to save me abot 3 units of animal blood though.


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## medtech421 (May 5, 2011)

usalsfyre said:


> One of my favorite exercises is to take 6 liters of theatrical blood and pour it out on the floor. People are usually shocked at how much it actually is. Granted it doesn't take anywhere near what amounts to your entire blood volume to be life threatening, but it usually causes people to drastically alter their perception.



I am calling a few instructors to suggest this.  Even if you use a simple 3 liter bottle you are talking half the volume and things are going to be very interesting.


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## MrBrown (May 5, 2011)

Clotting cascade? Ha! You know every second person is on coumadin for their AF and every other person is on aspirin as part of their post infarct regime 

Man a lot of people seem to be sick these days .... 

It takes a considerable amount of pressure to actually make the "pressure point" theory work and if we think about it, its much easier to apply a tourniquet


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## Veneficus (May 5, 2011)

MrBrown said:


> Clotting cascade? Ha! You know every second person is on coumadin for their AF and every other person is on aspirin as part of their post infarct regime



Platelet disorders and clotting cascade disorders are not the same


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## nwhitney (May 5, 2011)

usalsfyre said:


> One of my favorite exercises is to take 6 liters of theatrical blood and pour it out on the floor. People are usually shocked at how much it actually is. Granted it doesn't take anywhere near what amounts to your entire blood volume to be life threatening, but it usually causes people to drastically alter their perception.



My instructor did a very similar exercise the other day in lab.  He had different items that he soaked in "blood".  He used a tampon, t-shirt, trauma pad, jeans, a maxi pad and a couple of other items.  We had to estimate the amount of blood each one held.  Estimates ranged from 15ml-1000ml.  Turns out it was fairly difficult to determine the amount of blood in each (point of the demonstration) and each item had 60ml of blood.


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## FreezerStL (May 5, 2011)

> Clotting cascade? Ha! You know every second person is on coumadin for their AF and every other person is on aspirin as part of their post infarct regime



Let's not forget about my favorites: liver cirrhosis(alcoholism) and vitamin deficiencies(poor diet/antibiotics)  



> It takes a considerable amount of pressure to actually make the "pressure point" theory work and if we think about it, its much easier to apply a tourniquet



Too true.



> Man a lot of people seem to be sick these days ....


 :wacko:


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## attnondeck (May 10, 2011)

so what im seeing is that its rarely used and a tourniquet is just a better option?  thanks for all the replies guys


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## Akulahawk (May 11, 2011)

It's not that it's rarely used, it's that it's rarely applied effectively, and even if you do manage to stop flow through that particular artery, there will likely be some collateral circulation that will still allow for some blood flow. A tourniquet is a lot easier, and once applied, you have several HOURS before there's irreversible damage from the tourniquet.


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## mycrofft (May 11, 2011)

*Out of order as usual*

Not to undermine your learning (I presume this is in re. a class?), but some comments:
1. ELEVATION: watch to see this officially labelled "ineffective". ARC teaches laypersons it is. I've seen it work on extremites and nosebleeds...or was letting them fall dependent the error, versus elevation being the effective intervention?
2. PRESSURE POINTS: hurt like heck, often ineffective for a number of reasons, but if you don't have a TK handy, or while you're waiting for teh Boy Scout to spin his neckerchief , it might buy you time. Laypersons rarely do them right at all.
3. TK's and PRESSURE POINTS: if you are going to "shut down an artery", make 'em work; if you are only causing venous congestion by failing to close the artery but still closing the vein, the rate of bleeding increases due to the entire tributary (downstream of an open artery and normally drained by the vein you're holding closed) vessel bed to pressurize; ask any phlebotomist.

MANY, many bleeds on extremities are controlled by fast, adequate pressure which is HELD in place and titrated to effect. 
PS: Ever notice in training classes that no one ever has a significant bleed from the head, the torso, the groin, or the face?


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## Akulahawk (May 11, 2011)

mycrofft said:


> Not to undermine your learning (I presume this is in re. a class?), but some comments:
> 1. ELEVATION: watch to see this officially labelled "ineffective". ARC teaches laypersons it is. I've seen it work on extremites and nosebleeds...or was letting them fall dependent the error, versus elevation being the effective intervention?
> 2. PRESSURE POINTS: hurt like heck, often ineffective for a number of reasons, but if you don't have a TK handy, or while you're waiting for teh Boy Scout to spin his neckerchief , it might buy you time. Laypersons rarely do them right at all.
> 3. TK's and PRESSURE POINTS: if you are going to "shut down an artery", make 'em work; if you are only causing venous congestion by failing to close the artery but still closing the vein, the rate of bleeding increases due to the entire tributary (downstream of an open artery and normally drained by the vein you're holding closed) vessel bed to pressurize; ask any phlebotomist.
> ...


Direct Pressure on the wound works wonders! If that doesn't work, TK.


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## usalsfyre (May 11, 2011)

mycrofft said:


> PS: Ever notice in training classes that no one ever has a significant bleed from the head, the torso, the groin, or the face?


Yeah, and the patient is never laying face down either.

This morning however, I had a patient who had avulsed a portion of her nose (with resultant 500ml or so estimated blood loss) after falling off the toilet through a glass shower door, and was still laying on her face on arrival. D@mn real life...


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## mycrofft (May 12, 2011)

*So how did you stop the bleeding?*

Everything I think of looks like something from an 1880's patent medicine ad for snoring relief.


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## usafmedic45 (May 13, 2011)

attnondeck said:


> 1: pressure  (understood)
> 2: elevate (understood)
> 3: pressure points (understand the concept, but where and how is it done)
> 4:tourniquet (yup.... self explanatory)
> ...



My personal practice is more like:
1. Pressure/pack the wound.
2. If it's still bleeding, push harder/make sure I'm pushing in the right spot. 
Note: If they are still bleeding and I'm not using my entire body weight, then it's never a matter of "sufficient pressure".  More than once, I've ridden to the hospital kneeling on someone's groin.  A couple of those times it was actually medically indicated. 
3. Tourniquet.  The tourniquet would have been proactively placed but not tightened while I was making sure I was pushing hard enough.


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## usafmedic45 (May 13, 2011)

attnondeck said:


> so what im seeing is that its rarely used and a tourniquet is just a better option?  thanks for all the replies guys


Pretty much.  Here's a good reference on tourniquets: http://www.wjes.org/content/2/1/28


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## Bullets (May 13, 2011)

we carry CATs and I have used them on serious limb injuries and I think they worked great, I liked it way more then using a triangle bandage and some improvised windlass. the combat tk was great, secure and completely occluded the artery


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## AnthonyM83 (May 13, 2011)

You original post asked for an explanation of the concept (where and how). The most common points are the common pulse points on long bones (femoral and brachial). The idea is that you pinch off the blood vessel by pressing it against a bone. 

One problem is the amount of pressure it takes to actually accomplish this in many people. I don't believe most providers press hard enough (and pressure is often too "wide"...so the "pinching off" doesn't actually happen).

The other problem is that you tire out pretty darn quickly.


Since tourniquets don't have as many risks as previously thought, it's preferred you just stop the bleeding with one, than fumble around with pressure points. They're good to know. They can come in handy (as someone constructs/applies a tourniquet), but shouldn't be part of your routine bleeding control algorithm. 


Direct pressure stops vast majority of bleeds. The best advice I can give of when to move on to a TQ is when you get the sense that direct pressure isn't helping. The direct pressure you have isn't significantly slowing the major bleed.

As far as elevation, I just blend that step with direct pressure. If I'm putting pressure on an extremity, I'm also elevating it if feasible. But it shouldn't be a step in itself (oh, bleeding is bad, let me now decide to elevate and wait to see if it helps, no didn't help, okay now I can tourniquet...as he continues to lose blood..).


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## systemet (May 13, 2011)

usafmedic45 said:


> Pretty much.  Here's a good reference on tourniquets: http://www.wjes.org/content/2/1/28



Great reference.  Thanks!


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## mycrofft (May 13, 2011)

*TK risks...and quick and dirty OP pressure point note*

In combat, and also under urban controlled circumstances, a proper tourniquet (not a piece of lamp cord) if properly applied and promptly delivered to definitive care, is not as injurious as we were told they were.

Why were we told this? Historically in real life, TK use has been with improvised cords, twisted with a windlass, often misplaced, often out in the sticks or the boonies (delayed transport), and were mis-applied, sometimes to pt's with injuries not calling for them. The resultant injuries and unnecessary use was a backlash against teaching or using TK's. Now we are swinging the other way, and are about to go past the point of approriate use and into the "DANGER, Will Robinson!" zone of free-for-all use.

To stop life threatening bleeding, or buy time when they are both bleeding and have other pressing injuries, use a proper TK properly. Usually, you can stop the bleeding by properly bandaging and compressing the site. A pressure point application can buy you the time for the TK, or slow bleeding where a TK or pressure dressing is not going to work (i.e., groin GSW with Hail Mary attempt to compress the descending aorta with your knee). In cases of delayed transport or long transport time, know your protocols, but generically realize that the pt will be experiencing injury from your TK, which was balanced by potential loss of life.

OP, pressure points: usually on flexor surface of joints, running next to a nerve usually ("painful and pulsating"). Don' try that aorta deal, it probably  doesn't work.


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## usafmedic45 (May 14, 2011)

> The resultant injuries and unnecessary use was a backlash against teaching or using TK's.



Actually if you read the article I posted, you'll see that the injuries attributed to tourniquets had nothing to do with their use directly, but with leaving people on the battlefield for extremely protracted periods of time (>12 hours, 18 hours, days, etc).

Actual serious complications of tourniquet use in the field are so rare as to be almost worthy of a case report in a medical journal.


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## mycrofft (May 14, 2011)

*Yes and no...I was not speaking only of battlefield. We're in agreement.*

Civilians in the comfort of their own homes, bars, and turnpikes use belts, lamp cord, bailng wire, fan belts, etc., everything short of a chainsaw chain. THEN they stick a pencil in as a windlass twister and it snaps, or they use a tire iron and the TK acts like a cheesecutter. They also tend to place the TK right on the edge of the wound, or right on a joint, or, rarely, DISTAL to the wound. 

Among the medical veterans of the Vietnam Conflict I served with and spoke to (interestingly, three were at Pleiku but at different time frames), they saw cruddy TK admin mostly due to not having the materials (applied  by a buddy or just ran out of them) or insufficient opportunity (dustoff was leaving, under fire, or such), or the wound just didn't require a TK but it was applied for expedience or out of ignorance. Stuff happens under fire.

Great article, though!


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## usafmedic45 (May 14, 2011)

> Yes and no...I was not speaking only of battlefield.



Neither was I.  The only major complication that comes from improvised tourniquets with any frequency is insufficient pressure to stop bleeding which is why they have been discouraged for some time now in favor of commercially available tourniquets.


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## mycrofft (May 14, 2011)

*Agreed*

get it got it good.B)


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## AnthonyM83 (May 14, 2011)

While, I can't cite the frequency, one may also consider possible nerve damage as a complication, since that is one of the complications taught in phlebotomy when applying a tourniquet...and an arterial tourniquet would be much tighter than one used for venous blood draw (of course a proper tourniquet to stop bleeding would be wider than most venous tourniquets in order to reduce chance for tissue/nerve damage).


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## crazycajun (May 14, 2011)

AnthonyM83 said:


> While, I can't cite the frequency, one may also consider possible nerve damage as a complication, since that is one of the complications taught in phlebotomy when applying a tourniquet...and an arterial tourniquet would be much tighter than one used for venous blood draw (of course a proper tourniquet to stop bleeding would be wider than most venous tourniquets in order to reduce chance for tissue/nerve damage).



Nerve and/or tissue damage mainly occurs after extended use. In most EMS situations the tourniquet will only be in place for a short amount of time.


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## usafmedic45 (May 15, 2011)

crazycajun said:


> Nerve and/or tissue damage mainly occurs after extended use. In most EMS situations the tourniquet will only be in place for a short amount of time.



What he said.


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## EMTswag (Jun 7, 2011)

they're about to take it out of the NJ basic curriculum though. Soon its just going to be direct pressure, and if that fails to control it, then tourniquet.


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