My hospital has been promoting the Stop the Bleed Campaign. How was this initiative developed and what does it mean for prehospital and ED personnel?—V.M., MASS.
M. Thomas Quail, MS Ed, RN, LNC, responds: On October 6, 2015, President Obama launched the Stop the Bleed Campaign initiative as part of the National Preparedness System.1 The Campaign's goal is to provide civilian bystanders with the tools and knowledge needed to control hemorrhage and save lives in the immediate aftermath of acts of terrorism and other mass casualty events.2 This initiative was developed with input provided by medical, police, fire, and military experts from the Hartford Consensus Group, which was formed after the Sandy Hook shootings to review life-threatening injuries.3,4
The lessons learned from active shooter, terrorism, and mass casualty incidents have demonstrated that bystanders with little to no medical training will act as civilian first responders and provide first aid before the arrival of emergency medical services (EMS)5,6 Bystander training is essential because EMS personnel are allowed to enter and provide treatment only after all threats have been identified and mitigated by specially trained police teams. The reason? Previous events have shown that secondary threats, including booby traps, additional shooters, and improvised explosive devices, have been used to attack EMS personnel.7-9
The window of opportunity to save a life from a major arterial hemorrhage may be as little as 5 minutes.3,4,6 Kabaroff reports that massive hemorrhage continues to be associated with significant morbidity and mortality during events such as these.10
The Stop the Bleed Campaign's motto is, “If you see something, do something.”3,4 It encourages training the public in methods to control bleeding by learning how to apply direct pressure, pack wounds, and use emergency tourniquets.
Tourniquet use over the years has been controversial due to the fear that severe tissue ischemia could lead to amputation.11 However, the updated 2015 American Heart Association Guidelines for First Aid state that “because the rate of complications is low and the rate of hemostasis is high, first aid providers may consider the use of a tourniquet when standard first aid hemorrhage control does not control severe external limb bleeding. A tourniquet may be considered for initial care when a first aid provider is unable to use standard first aid hemorrhage control, such as during a mass casualty incident, with a person who has multisystem trauma, in an unsafe environment, or with a wound that cannot be accessed.”12 (See Tourniquets:Essential to stop severe bleeding.) The first aid provider should note the time the tourniquet was applied and inform EMS personnel of this when they arrive.12
Stop the Bleed Campaign training teaches current first aid techniques and reinforces bystanders' knowledge to reduce the risk that they'll harm victims or themselves or incur liability when providing first aid. (See Learn more.) The Hartford Consensus Group initiative also recommends installing bleeding control stations placed in plain view in airports, federal buildings, heavily populated public areas, malls, and sports arenas, next to or near the automated external defibrillator.3
Bleeding control kits contain gloves, scissors, emergency tourniquets for single or multiple casualty use, and hemostatic gauze, which is placed over the wound or into the wound cavity.12-14 Commercially manufactured emergency tourniquets consist of a wide band and a device known as a windlass used to tighten the band. The Hartford Consensus Group states that this minimal equipment is all that's needed for civilian first responders to control or stop uncontrolled hemorrhage.1-6,10,11,15
Prehospital and ED personnel must be aware of the Stop the Bleed Campaign initiative and anticipate triaging patients with hemostatic packed wounds and tourniquets applied by civilian first responders assisting victims of a mass casualty event. A tourniquet applied before the patient has reached the hospital should be released only after the patient has arrived at definitive care.3 For more information about preparing for a mass casualty event, see “When Disaster Strikes, Will You Be Ready?” on page 52 of this issue.
Tourniquets: Essential to stop severe bleeding
Orange emergency tourniquets are used for civilian casualties. The bright color alerts EMS and ED personnel to their use. Black emergency tourniquets are used in military and police applications so as not to draw attention. Blue emergency tourniquets are used only for training exercises and won't work in a real emergency.
Check out the U.S. Homeland Security's online resources for the Stop the Bleed Campaign:
1. The White House. Office of the Press Secretary. Fact sheet: Bystander: “Stop the Bleed” broad private sector support for effort to save lives and build resilience. 2015. https://obamawhitehouse.archives.gov/the-press-office/2015/10/06/fact-sheet-bystander-stop-bleed-broad-private-sector-support-effort-save
2. American Academy of Family Physicians. Crawford C. AAFP joins White House Summit on Responding to Medical Emergencies: meeting focuses on empowering emergency scene bystanders. 2015. www.aafp.org/news/health-of-the-public/20150216whitehouseprepmtg.html
3. Hartford Consensus. Strategies to enhance survival in active shooter and intentional mass casualty events: a compendium. American College of Surgeons Bulletin
. 2015;100(1S). https://www.facs.org/~/media/files/publications/bulletin/hartford%20consensus%20compendium.ashx
4. American College of Surgeons. Stop the Bleeding! Hartford Consensus Group issues a call to action. Conference attendees learn about strategies to increase victim survival in their communities. 2013. https://www.facs.org/media/press%20releases/2013/hartford1013
5. Butler FK. Military history of increasing survival: the U.S. military experience with tourniquets and hemostatic dressings in the Afghanistan and Iraq conflicts. J Spec Oper Med
6. Ahern S, DiNoto E, Maloney S, Mynatt J, Peerbolte S, Snider J. Public access bleeding control: an implementation strategy. National Preparedness Leadership Initiative (NPLI Cohort XIII). https://cdn2.sph.harvard.edu/wp-content/uploads/sites/8/2015/10/Team-You-Can-Act-Team-Report.pdf
7. Managing the Emergency Consequences of Terrorist Incidents. Interim planning guide for state and local governments. Federal Emergency Management Agency (FEMA). 2002. https://www.fema.gov/pdf/plan/managingemerconseq.pdf
9. Thompson J, Rehn M, Lossius HM, Lockey D. Risks to emergency medical responders at terrorist incidents: a narrative review of the medical literature. Crit Care
10. Kabaroff A. Stop the Bleeding: understanding how our methods have evolved and how far we need to go. JEMS
. 2013. www.jems.com/articles/2013/11/stop-bleeding.html
11. Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emerg Med J
12. Singletary EM, Charlton NP, Epstein JL, et al. Part 15: First Aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation
. 2015;132(18 suppl 2):S574–S589.
13. Doyle GS, Taillac PP. Tourniquets: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care
14. Markenson D, Ferguson JD, Chameides L, et al. Part 17: first aid: 2010 American Heart Association and American Red Cross Guidelines for First Aid. Circulation
. 2010;122(18 suppl 3):S934–S946.
15. Massachusetts Emergency Management Agency. After Action Report for the Response to the 2013 Boston Marathon Bombings. 2014. www.mass.gov/eopss/docs/mema/after-action-report-for-the-response-to-the-2013-boston-marathon-bombings.pdf