Wilderness Medical Series — Module 05

How to Control Bleeding With Proper Dressing and Bandaging

Learn how to control wilderness bleeding with direct pressure, wound packing, and pressure dressings — plus how to recognize and treat hypovolemic shock.

By Joshua Enyart · Founder & Head Instructor, Gray Bearded Green Beret

Former Army Ranger, Green Beret, and full-time survival instructor · three decades of professional instructor experience

Once a bleed has been recognized and classified, the intervention begins. For low-to-moderate volume bleeds that are not immediately life-threatening, the sequence moves through direct pressure, wound packing and pressure dressings in order of escalating need. For high-volume arterial bleeds on the extremities, the tourniquet takes priority — a topic covered in full in the next article.

This article covers the interventions for bleeds that can be addressed without a tourniquet, along with the secondary concern that follows every significant hemorrhage event: hypovolemic shock.

Direct Pressure and Elevation

Direct pressure is the first-line intervention for low-volume, low-pressure bleeds that are not immediately life-threatening. It is exactly what it sounds like: applying consistent manual force directly to the wound, with a clean dressing between the hand and the wound.

Expose the wound before applying pressure. Clothing must come off or be cut away to see and access the injury properly. The exception is clothing that is stuck to a wound — fabric adhered to a wound by dried blood or wound material should not be removed without adequate irrigation, because removal risks reopening the clotting that has begun.

Application steps for direct pressure and elevation:

• Apply manual pressure to the wound using your hand or bodyweight, with a dressing between hand and wound. If you are treating someone else, gloves are on before contact.
• Elevate the wound above the level of the heart where possible. Gravity reduces blood flow to the compromised vessels and assists the body's clotting mechanisms.
• Hold pressure and reassess after ten minutes. If the bleeding has not slowed significantly, escalate to wound packing and pressure dressing. Lifting the dressing to check the wound restarts the clock on clotting — once you commit to ten minutes of pressure, hold it.
• If the bleed has stopped, place a bandage over the dressing to maintain it as cleanly as possible. Continue to reassess the wound regularly for resumption of bleeding.

Direct pressure is not appropriate for high-volume, high-pressure bleeds. A forceful arterial bleed will not be stopped by hand pressure alone — the pressure required to compress an arterial vessel against a bone significantly exceeds what most people can sustain manually. This is a stop gap at best and usually requires an enormous amount of body weight. 

Wound Packing

Wound packing is indicated when an open wound is large and deep enough to pack — typically a significant laceration or a puncture wound with a substantial cavity — and the bleed is medium-to-high volume in a location where a tourniquet cannot be used.

Hemostatic dressings — gauze impregnated with kaolin or chitosan — accelerate clotting beyond what plain gauze achieves. Use hemostatic dressings when available for any wound packing involving significant blood loss.

Wound packing procedure:

• Fill the entire wound cavity with dressing material, packing it tightly. The goal is direct contact between the dressing and the bleeding vessels at the base of the wound — not just coverage of the surface.
• Continue packing until the void is completely filled. Additional material can be placed over the surface to provide superficial pressure on top of the packed wound. The dressing within the wound should feel like a balled-up fist.
• Apply a pressure bandage over the packed wound — an Israeli bandage or elastic bandage works well here. The pressure bandage maintains the force of the packing without requiring constant manual hold.
• Check circulation distal to the dressing after application. You should still be able to locate a pulse or confirm sensation below the dressing site. If circulation is compromised, the dressing may need to be adjusted.

Where not to pack: Do not pack the torso — thoracic, abdominal, or pelvic cavities. Packing a body cavity without knowing its anatomy and extent risks additional injury. Torso wounds are managed differently: direct pressure on the wound surface, shock management, and rapid evacuation.

Applying a Pressure Dressing

A pressure dressing — most commonly an Israeli bandage or elastic bandage — maintains the compression of a packed wound without constant manual pressure. It allows the provider to free up their hands for other tasks while the clotting process continues.

An Israeli bandage includes an integrated pressure bar that allows the user to redirect the wrap and increase pressure with a single device. If one is not available, an elastic bandage wrapped firmly over the packed wound achieves a similar result.

After applying the pressure dressing, check CMS — circulation, motor function, and sensory function — below the dressing site. Circulation check: can you locate a pulse? Is the skin color and temperature normal below the site? Motor: can the patient move the extremity below the dressing? Sensory: can they feel normal sensation? Changes in any of these after dressing application signal that pressure may be too high and adjustment is needed.

Recognizing Hypovolemic Shock

Once the bleed is controlled, the secondary concern becomes hypovolemic shock. Shock develops when blood volume loss is significant enough that the cardiovascular system can no longer maintain adequate perfusion of the organs and tissues. It can develop after a controlled bleed if the total volume lost before control was achieved was significant.

Six signs and symptoms of hypovolemic shock to monitor for:

• Increased heart rate: Greater than 120 beats per minute. Check by locating the radial pulse at the wrist and counting for fifteen seconds, then multiplying by four.
• Decreased blood pressure: You will not have a blood pressure cuff in the field. Use indirect indicators — a weak or thready radial pulse suggests low blood pressure.
• Rapid breathing: Greater than 30 breaths per minute. Count chest rises for fifteen seconds and multiply by four.
• Pale, cool, clammy skin: The body shunts blood away from the skin and extremities toward the core organs in shock. Cold, pale, moist skin is a reliable early indicator.
• Cyanosis: Bluish coloring around the lips and mouth indicating poor circulation and reduced oxygen delivery to peripheral tissues.
• Altered mental status: Any deviation from the patient's baseline — confusion, delayed responses, agitation, or uncharacteristic behavior — is a shock indicator. Know what the patient's normal is before the injury so you have a baseline to assess against.

Treating Shock in the Field

If signs of hypovolemic shock are present, take action immediately. Field treatment for shock focuses on four priorities.

• Protect the ABCs: Airway, Breathing, Circulation. Ensure the airway is open and unobstructed. Confirm the patient is breathing. The bleed should already be controlled, but verify nothing has resumed.
• Maintain core body temperature: A patient in shock who becomes hypothermic is harder to stabilize and more likely to deteriorate. Build or deploy shelter, insulate from the ground, apply a mylar blanket, and keep them dry. This is not comfort management — it is a clinical priority.
• Maintain hydration: Blood volume loss reduces overall fluid volume. Keep the patient hydrated with water if they are conscious and can swallow. Hydration supports blood volume and assists the body's compensatory response.
• Elevate the feet: Raise the feet eight to twelve inches off the ground while the patient lies flat. This shifts blood volume toward the core and brain, supporting blood pressure and cerebral perfusion.

Shock treatment in the field is supportive — it does not reverse blood volume loss, but it slows deterioration and buys time for evacuation. Get the signal out early. Treatment is buying time; evacuation is the intervention.

When to Escalate to a Tourniquet

Direct pressure and wound packing are appropriate interventions for bleeds that can be controlled with those techniques. A wound that continues to bleed through wound packing, or a bleed that is clearly high-volume and arterial from the first assessment, should not be managed with repeated attempts at direct pressure. Escalate to tourniquet immediately.

The decision to tourniquet is not a failure of wound management technique. It is a recognition that the bleed category — arterial or high-volume venous on the extremity — requires a more definitive intervention than a pressure dressing can provide. Time spent on repeated wound packing attempts during an uncontrolled arterial bleed is time the patient cannot afford.

A helpful framework: if you apply a wound packing and pressure dressing, check it after two to three minutes. If the dressing is already saturated through and bleeding has not slowed, the tourniquet is the next step. Do not wait for the full ten-minute reassessment cycle if the bleed rate is telling you the current intervention is not working.

Both techniques — wound packing and tourniquets — have their specific applications. Knowing which bleed category belongs to which intervention, and being willing to escalate without hesitation, is the critical skill. The technique is the easy part. The decision-making under stress is what formal wilderness medical training develops.

Documentation and Communication

Document the time hemorrhage control was achieved and the method used. If a tourniquet was applied at any point, record the time on the patient's skin or on the tourniquet. When evacuation arrives, the receiving medical team needs this information — tourniquet time is a critical variable in decisions about limb salvage. Field notes written at the time of injury are more reliable than memory under stress.

If a pressure dressing is in place, note what is under it before handing the patient off. Describe the wound location, the packing material used, whether hemostatic gauze was applied, and the current status of the dressing. Clear handoff reduces re-injury from unnecessary dressing removal at first-contact medical care.

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