Tourniquets and Catastrophic Bleeding

Tourniquets- their Life-Saving Role in Civilian First Aid (and First Aid Training)

This tourniquets blog post is aimed at RYA and HSE First Aid Instructors but may be of interest to the wider training, maritime and first aid community.

Introduction

In an emergency, bleeding control can mean the difference between life and death. When seconds matter, a tourniquet—once reserved for battlefield trauma—has become an essential tool in civilian first aid. Whether you’re teaching sailors, seafarers, outdoor enthusiasts, or professional responders, their understanding of how and when to use a tourniquet can save lives.

This article explores the history of tourniquets, explains how and when to use them, reviews common types, and clears up some myths and misconceptions—with a focus on best practice for Instructors and those delivering First Aid training.

A Brief History of Tourniquets in First Aid & First Aid Training

The use of tight bandages to control bleeding dates back to at least 1517, when European military surgeons applied them above wounds destined for amputation. The modern concept of the tourniquet is generally attributed to French army surgeon Étienne Morel (1674). The term comes from the French word tourner—meaning “to turn”—a reference to the windlass mechanism.

Over the centuries, tourniquets became common in battlefield medicine, though not always with success and often with some controversy. As late as 1916, the Royal Army Medical Corps Journal described them as “an invention of the Evil One,” and they fell from favour in different countries at different different in the 20th century.

Post Vietnam War analysis revealed that up to 7% of combat deaths might have been preventable with proper tourniquet use. While the military world gathered data and refined techniques, civilian use remained limited and controversial.

Previous Civilian Protocols

In the late 20th century, best practice in civilian First Aid, taught that tourniquets should only be placed:

At the top of the limb
On long bones (upper arm or thigh)
Over known pressure points

Tourniquets were also to be routinely loosened—every 15 minutes or so—to prevent tissue death. While well-intended, this approach often resulted in avoidable limb loss or re-bleeding, sometimes leading to death.

While some lives were saved other were lost. Victims often lost an entire limb and some casualties were initially saved by the tourniquet and then killed when it was released. Tourniquets fell from vogue for the second time and by the early noughties had fallen from most First Aid Training. As is always the case with training it takes some time for every organisation, every instructor and every publication to be updated so there is no exact date when everyone stopped teaching and using tourniquets.

As evidence improved and battlefield data grew, the tide began to turn. By 2015, catastrophic bleeding was identified as a high cause of death and once again became a priority in civilian first aid. National and International Organisations revisited guidance on direct pressure, wound packing, haemostatic dressings, and tourniquet use.

Around this time the UK military began teaching that bleeding control comes before airway and CPR—a concept now adopted by many first aid providers. I have to agree this is a compelling argument. After all, there’s little point performing CPR if every compression spurts out more blood. While this theory has been adopted by many First Aid Training organisations it continues to be a point of difference between some leading publications on Emergency First Aid in the wider First Aid industry. Many respected authors have chosen to simply ignore it and deal with Cat Bleeding and CPR as two entirely separate subjects. Speaking realistically if someone requires lifesaving cat bleed treatment and CPR their chance of survival is very minimal, but we would of course do our best.

military-tourniquet

From 2015 the First Aid training world begun to accept once again, that uncontrolled bleeding was a leading cause of preventable death in trauma cases. Injuries from car accidents, machinery, severe falls, shootings, and even natural disasters can cause life-threatening limb haemorrhage. If pressure doesn’t stop the bleeding, a tourniquet may be the lifesaving tool you need. Prior to 2017 there was several myths and contradicting theories as to what should be done, many spread by well-meaning FAW instructors trying to interpret the scant advice out there.

The 2017 Turning Point: A New Civilian Standard

In 2017, the Royal College of Surgeons of Edinburgh (RCSEd) a well-respected body of expert medical opinion published a definitive position statement, finally giving clarity on civilian tourniquet use:

Their position was (and still is) that in civilian (non-miliary) First Aid the use of tourniquets is rare but sometime required
A tourniquet must be used correctly or not at all
While there are several tourniquets on the market, the design of any tourniquets (improvised or otherwise) must have a broad band
The previous advice that applying a tourniquet on only a single bone (upper arm or upper leg) was incorrect as it had been derived from testing on pigs which have a different anatomy to humans. A tourniquet should be applied as far from the heart as possible (i.e. just above the wound).
4 steps were identified
1. Apply the tourniquet as rapidly as possible
2. Apply directly to the skin to reduce slippage
3. Place as distally (as far from the heart) as possible, above the wound including over the lower leg and arm, to preserve the amount of salvageable tissue
4. Apply tightly enough to arrest haemorrhage (if it is ineffective, tighten or reposition). The use of a second tourniquet may be required, slight oozing at the wound site may still occur
The tourniquet should be left in place, (with the time of application noted), until access to higher medical capability is available (in the marine world this will either be once ashore or by TMAS (Tele Medical Assistance Service / Radio Medical Advice)

When Should a Civilian Use a Tourniquet?

Apply a tourniquet when any of the following occur

Bleeding is severe and from a limb
Blood is spurting or pulsing and bright red (likely arterial)
Direct pressure is ineffective or unsafe
There is no time to apply or maintain pressure
The casualty must be moved urgently

**Do not use a tourniquet for:**

🚫 Bleeding from the head, neck, or torso
🚫 Minor wounds or cuts controllable with dressings
🚫 Snake bites or crush injuries—these require different management

How to Apply a Tourniquet (Step-by-Step)

📞 Call 999/112 immediately
🩹 Apply direct pressure first
✂️ Expose the limb and wound
📍 Place the tourniquet 2–3 inches above the wound (if this places you on a knee or elbow joint then go just above the joint)
🔄 Tighten until bleeding stops completely (pain is expected)
🔐 Secure using the windlass and fastener
🕒 Note the time of application
🚫 Do not loosen unless instructed by TMAS or a medical professional

🔁 Apply a second tourniquet above the first if needed.

Choosing the Right Tourniquet

Not all tourniquets are created equal. In fact, many improvised ones (like belts or bandanas) can fail under pressure. Most students will have seen a tourniquet used by a hospital nurse when carrying out blood tests. These are often thin and elastic. Their job is to make a vein appear so the nurse can draw blood.

In the case of catastrophic bleeding We are not interested in making a vein appear, we need to completely stop the flow of blood through another vessel, the artery. There are four common tourniquets described below.

Common Types:

CAT (Combat Application Tourniquet): Our preferred choice—robust, affordable, and taught on our First Aid courses.

cat-tourniquet-combat-action

SWAT-T (Stretch Wrap And Tuck): Better for smaller limbs/children. We introduce this on relevant courses.

SOF-T: A rugged alternative to CAT, more expensive and widely used in the USA.

sof-tactical-tourniquet-special operations-forces

RATS (Rapid Application Tourniquet): Does not meet RCSEd guidelines due to its narrow band so we consider it to be ineffective for cat bleeds

RATS-tourniquet

🧭 Keep at least one (ideally two) tourniquet in your:

First aid kit
Boat
Car
Outdoor bag
Workplace cabinet

Common Myths (Debunked)

🧠 MYTH: “Tourniquets will cause limb loss.”
✅ FACT: Modern use shows minimal risk within 2 hours. The priority is saving life. Amputation may become necessary after 6+ hours, but survival comes first, even at the expense of a limb.

🧠 MYTH: “Loosen every 15 minutes.”
✅ FACT: Never loosen a tourniquet outside hospital or TMAS advice. Doing so risks massive re-bleeding and shock.

🧠 MYTH: “Only professionals should use them.”
✅ FACT: With basic training, anyone can save a life with a tourniquet.

🧠 MYTH: “It should be comfortable.”
✅ FACT: A working tourniquet is painful. If it doesn’t hurt, it probably isn’t tight enough to stop bleeding. Pain medication may also be required.

🧠 MYTH: “They don’t work on lower limbs.”
✅ FACT: Placing a tourniquet low on the limb can be more effective due to the narrower limb diameter. The further the tourniquet is from the heart the less pressure it requires.

Where to Learn More

For a detailed clinical review:
📄 RCSEd Position Statement (PDF)

Conclusion: Be Prepared

Tourniquets are no longer niche or controversial—they are evidence-based, first-line tools in trauma care. From lifeboats and cruise ships to schools and slipways, knowing how to stop catastrophic bleeding is a critical skill for first aiders.

Don’t wait for tragedy to strike. Get trained. Get equipped. Be ready.

🧑‍🏫 Tourniquet Training at Chieftain Training

We teach the correct use of tourniquets on the following courses:

Courses available in Hamble, London, and on-board commercial vessels throughout the UK.

DOUG INNES

RYA First Aid Trainer and STCW Medical Care Assessor