The myth explained: Every major first aid resource says to apply a dressing on any uncontrolled haemorrhage, and if it soaks with blood to add more dressings on top of the original but not remove the blood-soaked dressing. The claim is the removal of the original dressing may disrupt clots that are forming, causing the patient to continue to bleed.
Never Remove a Dressing from a Bleeding Wound; When It Bleeds Through Just Add on More Dressings!
To start addressing this myth it’s important to understand the basics of hemostasis, the process through which clots form. When an injury to a blood vessel occurs, collagen and von Willebrand factors (vWF) are exposed and promote platelets to attach to the wounded surface. As platelet aggregation occurs, a plug develops which stops the bleeding. Platelet aggregation occurs along with human tissue. Once a platelet plug occurs and haemorrhage stops, a fibrin mesh begins to form that stabilises the clot and strengthens it.
When a dressing is applied to a wound, the goal is to stop the bleeding. This is successfully completed the majority of the time with well-aimed direct pressure directly into the injured tissue. The key to well-aimed direct pressure is to apply adequate pressure into the injured tissue and on the injured vessel. When pressure is applied generally around the wound there is typically inadequate pressure to stop the haemorrhage. Well-aimed direct pressure means targeting the pressure directly into the haemorrhaging tissue.
There is not one clinical trial that demonstrates removing a blood-soaked dressing will cause clot removal or cause the clotting process to start over.
When large bulky dressings are applied over haemorrhage sites it becomes very difficult to apply well-aimed direct pressure into the wound and as a result, more generalised pressure around the injury occurs. At this point, the dressing becomes a source for collecting the lost blood and is actually doing very little to control haemorrhage.
Dressings that quickly become saturated with blood are an indication adequate pressure has not been applied to the bleeding site. Simply adding more dressings on top of the injury will do little more than absorb more blood; it will not help control bleeding or support clot formation.
When a dressing becomes soaked with blood, remove it and apply better-aimed pressure with a clean dressing.
ANZCOR Guideline 9.1.1
1.2 Direct Pressure Method
Where the bleeding point is identified, the rescuer, a bystander or the victim themselves should control
- Applying firm, direct pressure sufficient to stop the bleeding. Pressure can be applied using hands or a pad over the bleeding point.
- If bleeding continues, apply a second pad and a tighter bandage over the wound. If bleeding still continues, check that the pad and bandage are correctly applied, directly over the bleeding. If not, it may be necessary to remove the pad(s) to ensure that a specific bleeding point has not been missed. Applying firmer pressure, only using 1-2 pads over a small area, will achieve greater pressure over the bleeding point than continuing to layer up further pads.
The current ANZCOR Guideline 9.1.1 for major bleeding control is:
The application of an arterial tourniquet and/or Haemostatic dressing requires the provider to be trained in its use.
For the leading STOP the BLEED workshop in Australia;
In 2014, the American College of Surgeons released a position paper on prehospital haemorrhage management strategies. In this paper, they identify that well-aimed direct pressure is likely to control haemorrhage in most instances. When haemorrhage cannot be controlled with well-aimed direct pressure, they recommend the next step be tourniquet placement for extremity injuries. In instances when a tourniquet cannot be applied they recommend a haemostatic agent be added to a pressure dressing. Haemostatic dressings must be applied directly to the source of the bleeding in order to work.
The Bottom Line
If initial direct pressure fails to control haemorrhage, remove the dressing and apply well-aimed direct pressure onto the haemorrhage location. When this fails, a tourniquet or hemostatic agent should be used.
*** Part of this article has been reproduced with approval from EMS World (thank you).
Kevin T. Collopy – Sean M. Kivlehan – Scott R. Snyder
 – Bulger E, et al. An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 2014; 18: 163–173.