This document provides instructions on wound packing to control hemorrhage. It emphasizes that aggressive hemorrhage control should be the first priority for medical responders. For non-compressible wounds that cannot be controlled with direct pressure alone, such as in the groin or armpit areas, wound packing with gauze is recommended. The steps for wound packing involve applying direct pressure, packing gauze deeply into the wound towards the source of bleeding, maintaining firm pressure for at least 3 minutes, and assessing if bleeding is still occurring. Standard gauze can be used effectively for wound packing. Communicating the wound packing details to hospital staff is also advised.

1. Wound Packing 101
The majority of this presentation is taken from both:
Dr. Peter Taillac’s presentation to the 2016 “Gathering of Eagles”
West Hartford Police Officer Brian Wallace’s hemorrhage control presentation
Thanks to both Peter and Brian – content used with permission

2. Hemorrhage Control
Aggressive Hemorrhage Control should be your first priority
• Remember, 85% of the Potential Preventable Deaths in
Operation Iraqi Freedom (OIF)/ Operation Enduring
Freedom (OEF) were due to Hemorrhage
• Two terms student should understand:
– “Compressible” – think tourniquet / extremities
– 31% Compressible injuries in OIF/OEF
• “Non-compressible” – think armpits, groin
– 69% Non-compressible
From evaluation of 982 casualties, and casualties could have more than 1 cause of death. (Kelly J., J Trauma
64:S21, 2008)

3. Hemorrhage Control
Remember - Aggressive Hemorrhage Control should be
your first priority
Your thought process for treating bleeding should be:
1. Should I be acting to stop the bleeding now?
2. Apply direct pressure while working on better
solution
3. Can I put a tourniquet on?
4. If I can’t, pack the wound & put a dressing on.
5. Is it working?

4. Hemorrhage Severity
• Life Threatening
– Arterial
– Fast venous
– Long term venous
• Non- Life Threatening
– Slow venous
– Capillary
Even slow bleeding may become life-threatening if not controlled with direct pressure

5. Why Wound Packing?
• OLD - Placing dressings on top of a wound:
– Absorbs blood
– Keeps ambulance clean
– Does little to stop bleeding
• NEW - Direct pressure must be applied to source
of bleeding
– Finger on an isolated severed vessel might work
– May require a knee to provide sufficient pressure
– Wound packing helps apply pressure directly to source
of bleeding and may promote clotting

6. But, I Was Told EMR/EMTs Are Not
Allowed to Pack Wounds…
• Nope. Just another EMS myth/dogma.
• This may have arisen from concerns of clot
dislodgement or foreign bodies ending up in
body cavities
• The effectiveness of this bleeding control
technique outweighs potential concerns
• Just another form of direct pressure

7. When Should I Pack a Wound?
• Wound packing is not always necessary
– Direct pressure alone is usually sufficient
– Uncontrolled extremity bleeds may be managed with
a tourniquet
• Severe, uncontrolled junctional hemorrhage may
benefit most from wound packing
– Lower abdomen
– Groin
– Axillae
– Proximal extremities

8. Do I Need to Buy Expensive Gauze to
Pack Wounds?
Nope - Standard gauze may work just as well as hemostatic gauze
Comparison of ChitoFlex®, CELOX™, and QuikClot® in control of hemorrhage. Devlin J, et al. J Emerg Med 2011;41(3):237
CONCLUSION: In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and
promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents.
However, no agents were superior to standard gauze in our model of limited access.

9. Wound Packing 101
OK, So How To Do This?
• Step 1 – Apply direct pressure
– Gloved finger
– Gloved hand
– Knee
– Gauze
– Shirt
– Whatever is needed

10. Wound Packing 101
• Step 2 – Consider putting finger/hand in the
wound (yes, IN the wound) to get to the
source of bleeding and push hard
– May be unsafe if sharp bone or shrapnel
fragments present (injury/location dependent)
• Can wrap finger in gauze/shirt to minimize risk
– Use gloves/PPE
– Mask/eye protection recommended

11. Wound Packing 101
• Step 3 – Pack the gauze in and keep packing, and
packing, and packing
– Pack gauze tightly down and deeply into the wound
toward the source of bleeding
– Keep packing
– You can start backing your finger/hand out while still
applying pressure/packing around it
– Keep packing till you can not pack any more gauze in

12. Wound Packing 101
• Step 3 continued – Keep packing!!
– Pack until you REALLY can’t push any more gauze
in there
– Leave any remaining gauze over the wound to aid
in applying direct pressure

13. Wound Packing 101
• Step 4: Apply very firm pressure for at least 3
minutes
– Think ‘knee’ or two handed palms (just like
pressing for CPR)

14. Wound Packing 101
• Step 5: Assess – Is the wound still bleeding?
– No
• Limit movement (splint, etc.)
• Apply pressure dressing
• Continue supportive care
– Yes (soaking through or around packing)
• Pack some more if possible
• Apply more pressure (e.g. knee)
• Rapid transport

15. Pressure Dressing
• Important to maintain pressure and keep pack
from coming loose
• Any stretchy bandage can work
• Twisting bandage when passing over wound may
focus pressure on wound site

16. Wound Packing 101
• Communicate with hospital providers
– Let the receiving hospital know what/how much
material you crammed into the wound
– Describe the force, duration and color of bleeding
prior to wound packing

17. External Hemorrhage Control
Apply direct pressure
Hemorrhage controlled with
direct pressure?
Yes
No
Extremity wound?Yes
No
Apply
tourniquet(s)
Pack wound with gauze bandage (plain or hemostatic
impregnated) with continued direct pressure
Hemorrhage
controlled?
Yes
Maintain Direct Pressure
Consider Pressure Dressing
Supportive Care

18. Some Videos of Wound Packing
Packing an extremity wound:
https://youtu.be/2KHaXzwdyes
EMS practice with packing a simulated wound:
https://youtu.be/L1JjQZ_aYME

19. Questions?