Severe bleeding and shock

When someone is bleeding badly, the first treatment is your hands on the wound: pressing on it is the first step in every guideline in this lesson. The AHA and American Red Cross's 2024 first aid guideline says that "Uncontrolled bleeding is the most important preventable cause of death in 35% of trauma patients", and that it can happen before the ambulance arrives.¹ The American College of Surgeons, which runs the Stop the Bleed programme, warns that "Bleeding emergencies can claim a life in 3-5 minutes".⁷

What you do in those minutes is simple to say. Press hard. If pressing is not enough on an arm or a leg, a tourniquet. If the wound is where a tourniquet can't go, pack it and press. Then watch for shock, which in first aid means the circulation failing, not a fright; that is the last section. Stop the Bleed teaches the same order as its ABCs: alert (call 911), find the bleeding, compress.⁷ This lesson covers each step, two habits the guidelines leave out, a century in which the tourniquet was taught as the enemy, and the one place where American and British advice lays the person differently.

Which bleeding kills

Most bleeding can be managed with direct pressure, as St John Ambulance puts it, and lesson 10 deals with that kind.⁴ This lesson is about the other kind. The AHA/Red Cross 2024 guideline says life-threatening bleeding can be recognised by "pooling of blood on the ground, blood that is rapidly flowing or spurting from the wound, bleeding that continues despite direct manual pressure, or bleeding that results in systemic symptoms", such as drowsiness, dizziness, chest pain or loss of consciousness.¹

Two public pages make that easier to judge by eye. The American Red Cross gives a yardstick for volume: bleeding may be life-threatening when the blood present comes to "about half of what a soda can contains", and less in a small child or a baby.⁶ St John says a severe bleed is likely to slow with pressure, while a life-threatening one is "extreme bleeding likely to cause death in minutes", with blood pumping from the wound, bleeding that pressure can't stop or slow, and blood soaking "through bandage after bandage".⁴

Call, and keep your hands on

RCUK's 2025 first aid guideline opens its section on life-threatening bleeding with "Call 999."³ The American Red Cross puts calling 911 straight after checking the signs.⁶ St John says to ask a helper to call, and if you're alone to use the speaker so you can treat the person while you talk.⁴ Here the speaker matters twice over, because your hands are needed on the wound.

If you have gloves, use them. If not, the British Red Cross and the American Red Cross both suggest a plastic bag over your hand, or asking the person to press with their own hand, and the British Red Cross says that without a cut of your own you're very unlikely to catch or pass on an infection.⁵⁶

Pressure, first and hardest

Every body in this lesson starts in the same place.

• AHA/Red Cross 2024: "Direct manual pressure should be applied to achieve initial control of external bleeding." (COR 1, LOE C-LD).¹
• ILCOR: direct manual compression rather than compression devices or pressure dressings, for severe life-threatening bleeding from an arm or a leg (2021, carried in its 2025 review, strong recommendation, very low certainty).²
• RCUK 2025: "Apply firm, direct manual pressure to any bleeding injury site."³

The countries agree, and ILCOR with them. Notice ILCOR's grade: strong, on very low certainty evidence, close to the pairing lesson 7 showed you for tensing your legs against a faint. The panel is sure enough of the balance to say "we recommend" while saying plainly that the studies are thin. The AHA calls direct pressure the mainstay of treatment.¹ The only reason any source here gives for why it works is the British Red Cross's: "You are acting as a "plug" to stop the blood escaping. The pressure you apply will help the blood clot and stop the bleeding."⁵ The guidelines give the instruction without the mechanism.

Here's how, in the American Red Cross's steps: find where the blood is coming from, put a dressing on it (a haemostatic one if you have it, which comes below), and press steadily and firmly straight down, with the injured part on a firm, flat surface.⁶ St John says to cut or remove clothing that covers the wound.⁴ Then keep pressing. The American Red Cross's reasons to stop are that the bleeding has stopped, a tourniquet is on and working, someone takes over, you are too exhausted to go on, or the place becomes unsafe.⁶

Once it is controlled, a pressure dressing holds what your hands achieved. The AHA/Red Cross guideline says one may be reasonable (COR 2b, LOE C-LD), and RCUK says it without a grade: "Once bleeding is under control, apply a pressure dressing."¹³ St John adds a check that the bandage is not too tight: press a nail or the skin beyond it for five seconds until it goes pale, let go, and if the colour is not back within two seconds, loosen and redo the bandage.⁴ That check is for a bandage only. A tourniquet is tightened until the bleeding stops, and never loosened.

When blood comes through the dressing, the public pages disagree. None of the guidelines (AHA/Red Cross 2024, ILCOR, RCUK 2025) addresses it, and no page gives a reason.

In the US, the American Red Cross: "Do not remove the original gauze pad and do not stack multiple gauze pads", though you may add one pad on top and replace that.⁶

In the UK, St John: "If blood comes through the dressing, remove it and reapply pressure with a new dressing".⁴ The British Red Cross: "Remove the item and replace with a fresh one".⁵

What all three share is the point: firm pressure, on the bleeding, with no long gap. If pressing through a sodden pad is working, keep going. If it is not, the question is whether pressure has failed.

Two habits the guidelines leave out

Pressure points

You may have been taught to press on a pressure point higher up the limb, in the armpit or the groin. The guidelines do not teach it. The AHA doubts it, and ILCOR advises against it.

AHA/Red Cross 2024, section 9.1;¹ ILCOR 2025 First Aid CoSTR.² RCUK's 2025 steps do not mention pressure points.³

The AHA doesn't know that they help; ILCOR says don't. The AHA found no studies in people actually bleeding, only a volunteer study in which pressing on the artery in the upper arm or the thigh cut off flow further down the limb in most people, but not for long. The pulse beyond the pressure point came back "in a median of 40 seconds after brachial artery occlusion and 20 seconds of femoral artery occlusion".¹ (Brachial means the upper arm's, femoral the thigh's; a median is the middle value, so half the volunteers had a pulse back sooner.) ILCOR's 2025 update found seven more studies of pressure points or pressure devices hinting at "some potential benefits" in some settings, which it judged confounded by indirect evidence and possible bias, and it kept its recommendation against.² Neither says why the flow returns. What the volunteer study tells you is enough: in healthy people a pressure point bought seconds.

Raising the limb

Nothing in the AHA/Red Cross 2024 guideline, ILCOR's 2025 review or RCUK 2025 tells you to raise a bleeding arm or leg.¹²³ The NHS "Cuts and grazes" page, last reviewed in April 2026, still says: "If the wound is on your hand or arm, raise it above your head. If the wound is on your lower limb, lie down and raise it above the level of your heart." It gives its reason: "This will help reduce the blood flow."⁹ No source calls it harmful, so this course does not either. It is not among the resuscitation guidelines' steps, and for life-threatening bleeding your hands have a better job. Lesson 10 returns to the page for the small cuts it covers.

When pressure isn't enough: the tourniquet

A tourniquet is a strap that goes round the limb above the wound and is tightened until the bleeding stops. The commercial kind has a rod, the windlass, that you twist to tighten it, and a clip to hold the rod.

• AHA/Red Cross 2024: "For life-threatening extremity bleeding, a tourniquet should be applied and tightened until the bleeding stops." (COR 1, LOE B-NR).¹ Extremity means an arm or a leg.
• ILCOR: "We suggest that first aid providers use a tourniquet in comparison with direct manual pressure alone for severe, life-threatening external bleeding that is amenable to the application of a tourniquet (weak recommendation, very low–certainty evidence)." That dates from 2020, and ILCOR kept it after a 2025 evidence update of 29 new articles.²
• RCUK 2025: "Apply a tourniquet as soon as possible for life-threatening extremity bleeding that is not controlled by direct manual pressure".³

All three put it on a limb: the AHA and RCUK once pressure has failed, ILCOR in preference to pressure alone wherever a tourniquet can go on. The AHA explains the limb: a tourniquet only helps where it can be applied "proximal to the wound", meaning between the wound and the trunk, the body as against the limbs.¹ ILCOR's summary of the evidence found "reduced in-hospital mortality and a lower incidence of shock when tourniquets are used".²

St John's page on life-threatening bleeding, reviewed in April 2025, six months before RCUK's guideline, puts more weight on how rarely it should come to this. It links the tourniquet with catastrophic limb bleeding such as an amputation or a blast injury, or a scene so dangerous that the person has to be moved, and says "most bleeding will be manageable with direct pressure"; if you have tried that and severe bleeding continues, "then a tourniquet may be required".⁴ Its order is the same, pressure first. In the UK, RCUK's "as soon as possible" once pressure fails is the 2025 guideline.

Where it goes, and how tight

ACS Stop the Bleed lay course, version 2.0;⁷ RCUK 2025 First aid;³ St John Ambulance.⁴

On clothing, Richey's 2007 review advised against putting one on over clothes; the Stop the Bleed course allows it, and neither the 2024 nor the 2025 guidelines address it.¹⁰⁷

The numbers are close enough to carry as one picture: a hand's width or less above the wound, never on a joint. That picture is this course's summary, not any guideline's wording, though it is close to the rule of thumb Richey used when teaching, a palm's width above the wound.¹⁰ St John adds that below the elbow or knee is best where the wound allows.⁴ If the spot just above the wound falls on a knee or elbow, this course puts two sourced rules together: between the wound and the trunk (AHA/Red Cross 2024), never on the joint (RCUK 2025; Stop the Bleed; St John), so above the joint. That is this course's reasoning, not a line any source prints, and it puts the band further up than 5 to 7 cm; the call handler can confirm it.

Tighten it until the bleeding stops (AHA/Red Cross 2024, COR 1, LOE B-NR; Stop the Bleed), or in RCUK's words until it "slows and stops" (RCUK 2025).¹⁷³ St John's method: pull the strap tight enough that you "should not be able to get three fingers under the band", then twist the rod until the bleeding stops and clip it.⁴ If one is not enough, RCUK says a second can go on above the first.³ Richey gives the reason tight matters: a band too loose to stop blood flowing into the limb can still stop it draining out, and the wound bleeds more.¹⁰

Then the part people aren't ready for. RCUK: "This may be painful for the person."³ Stop the Bleed: "Tourniquets HURT".⁷ St John says to warn the person before you tighten it.⁴ RCUK, Stop the Bleed and St John all expect the pain, and none of them treats it as a reason to loosen.

Wider is better. The AHA: "Narrow tourniquets cause more pain and tissue damage and are less effective than wider tourniquets."¹ Its supporting text gives the reason: a wider band needs less pressure to shut off the blood flow, and high pressure is linked with nerve injury.¹ That is why its one rule for an improvised tourniquet, below, is about width.

Write the time, and never let it go

RCUK 2025: "Write the time the tourniquet was applied." and "Do not release the tourniquet. It should only be released by a healthcare professional."³ Stop the Bleed: "Do NOT remove the tourniquet".⁷ St John gives the reason: "Once a tourniquet is applied it should not be loosened as the bleeding will start again."⁴ St John also says to record the time on the tourniquet's time tab, the place on it for writing the time, if it has one.⁴

For children, the AHA says commercial windlass tourniquets "appear to be appropriate for use in children as young as 2 years of age", and Stop the Bleed that "In all but the extremely young child, the same tourniquet used for adults can be used in children."¹⁷ For a limb too small for one, ILCOR's good practice statement (2021) is direct pressure, with or without a haemostatic dressing.²

Who may use one

In the US, the AHA/Red Cross 2024 guideline attaches no training condition, though its supporting text says "Some training may be required" for lay people to apply a commercial tourniquet successfully.¹ The American Red Cross's page is narrower: "Apply direct pressure and a tourniquet (if trained) for life-threatening bleeding on a limb."⁶

In the UK, RCUK 2025's tourniquet steps carry no training condition, but its first aid guideline sets one as a general principle: "As a general principle, only use equipment and medications you have been trained to use." It adds the exception that matters here: "There are occasions when a first aider may be directed to use equipment by the emergency services that they may not have previously had in-depth training on."³ The Public Access Trauma (PAcT) kits that the Department of Health and Social Care and the National Counter Terrorism Security Office recommend for public places hold two tourniquets each, and ProtectUK, run by Counter Terrorism Policing, says they are "designed to be used by ANY person, regardless of their level of first aid training".⁸ St John says that if pressure fails and you have no tourniquet or are not trained, the call handler may ask you to improvise one and tell you how.⁴

So each country's text carries a training line: the AHA's "Some training may be required" and the American Red Cross's "(if trained)" in the US, RCUK's general principle in the UK. In the UK, RCUK names the way round it, direction by the emergency services, and St John says the call handler may coach you. No US source here says the same, though the call handler is on the line in either country and will tell you what to do. The "(if trained)" is a good reason to train.

Lesson 1 gave the general picture of the law, from sources written about CPR. This course read no statute or guidance that treats a tourniquet differently from other help given in good faith, and it did not search case law on tourniquets, so that is a gap, not a finding.

A century of "take it off"

Many people learned that tourniquets cost limbs and are a last resort. Stephen Richey's 2007 review in the World Journal of Emergency Surgery traces where that came from.¹⁰

In the American Civil War, frightened, barely trained soldiers tied tourniquets on tight and wouldn't loosen them, and after the first battle some of the wounded lay on the field for days. Richey describes surgeons, faced with what followed, turning against tourniquets altogether, and argues that the tourniquet "bore more than its fair share of the blame" for outcomes that poor planning, untaught troops and thin medical logistics had caused.¹⁰

In the First World War, Tuffier, a respected French army surgeon, recommended that ambulance crews remove any tourniquet they found, which Richey thinks was more likely to restart the bleeding than to save a limb. The advice was repeated that a tourniquet should never be left on beyond the first stage of care. Richey grants that switching quickly to gentler ways of stopping the bleeding is best, but says such across-the-board advice "is most likely the source of the modern day hesitancy to utilize tourniquets in any manner".¹⁰

In the Second World War, the US Army's review found soldiers often misused tourniquets. The earlier advice to loosen one every 30 minutes was replaced, because it risked the patient slowly bleeding to death, by orders that only a medical officer should remove it. Richey notes that this is still common practice, and it is the rule you have just read from RCUK and St John.¹⁰

So the tourniquet's bad name came from real harm, in armies that left the wounded for days, and from the fixes that followed: taking tourniquets off, then loosening them, both of which let the bleeding start again. Richey himself, in 2007, still advised that first aid training for the public should "continue to deemphasize" tourniquets and focus on direct pressure and early medical help.¹⁰ The guidelines have moved since: the AHA/Red Cross 2024 guideline makes the tourniquet COR 1, and RCUK 2025 says to apply one "as soon as possible" once pressure fails.¹³

Civilian data followed. In Texas, Teixeira and colleagues studied 1,026 people with injuries to the blood vessels of a limb, 181 with a tourniquet before hospital. Before adjustment, the difference in deaths, 5.2% without a tourniquet against 3.9% with one, was not statistically significant; after adjusting for differences between the groups, the odds of survival were 5.86 times higher with one (95% confidence interval 1.41 to 24.47), and later amputation was 1.1% in both groups.¹² In Houston, Scerbo and colleagues found that among 306 patients, a tourniquet placed only at the trauma centre carried 4.5 times the adjusted odds of dying of blood loss (95% confidence interval 1.23 to 16.4).¹³ Both are retrospective, and this course read their abstracts only. The intervals are wide: the Texas figure fits anything from about 1.4 to about twenty-four times the odds. On safety, the AHA reports two observational studies of 255 people given tourniquets before hospital by "police, EMS personnel, and laypeople", in which "no person had decreased limb function attributed to tourniquet use", and a systematic review with no sign of more amputations.¹

What the evidence still cannot show is cause. Every number above is observational; none comes from a randomised trial. ILCOR rates the certainty very low, and the AHA's level is B-NR, non-randomised.²¹ The AHA's COR 1 makes the tourniquet standard teaching, and the evidence under it is a consistent pattern of associations. What stays contested is the improvised tourniquet, which comes up again in the lane case below.

Packing, and dressings that help blood clot

Some wounds can't take a tourniquet, because there is nowhere between the wound and the trunk for one to go: the neck, an armpit, the groin.¹ Stop the Bleed's course says "For large wounds, superficial pressure is not effective", and its packing slide shows arms and legs, the neck, armpits and groin, and the body. Its method: "If bleeding is from a deep wound, pack gauze tightly into the wound until it stops the bleeding; hold pressure until help arrives".⁷ RCUK 2025 builds packing into its first step: "Apply a standard or ideally a haemostatic dressing directly to the bleeding injury, then apply firm direct pressure, which may require at some sites the dressing to be packed into the wound. In the absence of any first aid dressings, any clean material can be utilised in this way".³

A haemostatic dressing contains a material that helps blood clot, in the AHA's description.¹

AHA/Red Cross 2024;¹ American Red Cross;⁶ RCUK 2025;³ St John Ambulance.⁴

ILCOR suggests a haemostatic dressing with pressure over pressure alone (2020, weak recommendation, very low certainty), and a tourniquet instead where one can go on.² The AHA cites an emergency-department trial: in 160 people with stab wounds to the limbs, bleeding stopped within 5 minutes in 51.2% with a haemostatic dressing plus pressure and 32.5% with pressure alone.¹ It was done in hospital, not by bystanders, so it tells you about the dressing more than about a first aider.

In the UK, the standard PAcT kit as ProtectUK specifies it holds four large trauma dressings and two tourniquets, with no haemostatic dressing, though the British Red Cross says kits vary and some carry dressings that help blood clot.⁸⁵ So you may be packing with a trauma dressing or clean cloth, which RCUK allows.³ The British Red Cross says the kits are appearing in more public places, often beside a defibrillator, and that the 999 operator will tell you how to use one: "it's very important you follow these instructions exactly to prevent causing more harm".⁵ The US equivalent is the Stop the Bleed kit. Stop the Bleed itself was started by "a federal interagency workgroup convened by the National Security Council Staff, The White House", led by the American College of Surgeons, and the "3-5 minutes" line at the top of this lesson is the College's reason for placing kits where nobody has far to go.⁷

Something stuck in the wound

Leave it in. St John says it may be acting as a plug, the British Red Cross that it's helping plug the hole, and the American Red Cross that removing it can make the bleeding much worse.⁴⁵⁶ Press around it, not on it: St John says press either side to push the wound edges together, and the American Red Cross says pad dressings around the object and bandage them in place.⁴⁶ If a limb needs a tourniquet, the American Red Cross puts it "above the embedded object".⁶

The back door

It's early evening in Plymouth. Marcus, seventeen, a friend of your son's who is staying for tea, slips on the back step and puts his arm through the glass panel of the kitchen door. He's on the floor holding his forearm, and blood is running fast between his fingers onto the tiles. Nothing is stuck in the wound.

1. Danger. Broken glass. You push the big pieces aside with a shoe and kneel where it's clear.

2. The call. 999 on speaker, the phone on the floor. RCUK's bleeding section starts with the call, and your hands are about to be busy.³

3. Pressure. A clean tea towel folded into a pad, pressed straight onto the wound with your weight behind it, his arm resting on the floor (RCUK 2025; AHA/Red Cross 2024, COR 1, LOE C-LD).³¹

4. It holds. After several minutes of hard pressure the flow stops. You keep your hand there while someone fetches the first aid box, then bind a pad on firmly (RCUK 2025; AHA/Red Cross 2024, COR 2b).³¹ You press a fingernail beyond the bandage and the colour comes straight back, so it isn't too tight.⁴

5. Watch him. He's pale and says he feels sick. That could be the sight of his own blood, or the start of shock, which is the last section of this lesson. The call handler stays on the line.

In the US the kitchen goes the same way, with 911.

The lane at night

A car has hit a motorcyclist on a country lane after dark. The driver has pulled over and is on the phone to the emergency services, and a second car has stopped behind with hazard lights on. The rider is on the verge, awake and talking, with a deep wound in the front of his thigh well above the knee, and blood soaking the grass. You and a friend both press on it with a folded jumper, as hard as you can. It keeps coming. There's no kit. You have a leather belt; your friend has a pen.

First, lesson 2's danger check: the cars have stopped, the lights are on, and he's off the road. Car Basics, later this term, teaches the roadside itself.

The course hands the decision over here because the improvised tourniquet is genuinely contested. For: limb bleeding can kill in minutes, and nothing manufactured may be to hand; the AHA's background text says both commercial and improvised tourniquets can be used, and St John says a belt pulled tight can work.¹⁴ Against, or not lightly: simulation studies in volunteers and on manikins found commercial tourniquets shut off the flow more often than improvised ones, and narrow bands hurt more and work less well.¹ And, this course would add, building one is time your hands aren't pressing. No source ranks those, and neither does this course.

So: pressure, hard, with both pairs of hands; the call handler told it's failing; a belt only if the call handler, or your training, puts it there. If it goes on, St John's steps are: tell him it will hurt, twist the rod until the bleeding stops, secure it, and don't loosen it.⁴ Where it goes and writing the time are RCUK's and Stop the Bleed's rules for tourniquets in general, and the call handler will say whether they apply.³⁷

You tell the call handler it's still coming. They talk your friend through the belt and the pen while you keep pressing, and you don't stop until the crew take over. The bleeding stops. The rider is shaking, pale and clammy, and says he's thirsty.

Shock

What it is

Shock, in first aid, is not a fright. St John says it happens when the body isn't getting enough oxygen to the brain and vital organs, and is not the same as emotional shock.⁴ The American Red Cross calls it a progressive, life-threatening condition in which the circulation fails to deliver enough oxygen-rich blood to the tissues and organs, which begin to fail.⁶ St John's causes include severe bleeding inside or out, heart problems, fluid loss, severe allergic reactions and overwhelming infection.⁴ This lesson's cause is blood loss.

What you'd see

Between them, St John and the American Red Cross list pale, cold, clammy skin; sweating; a fast, weak pulse; fast, shallow breathing; grey-blue lips; nausea; restlessness or confusion; and thirst. St John adds yawning and gasping for air, and warns that the person could become unresponsive.⁴⁶ The AHA/Red Cross guideline adds dizziness, difficulty breathing, chest pain and mottled, blotchy skin.¹ The pages list the pulse, but neither tells you how to take one, and lesson 2 showed how often lay rescuers misjudge one, so go by what you can see and hear.

What you do

St John's first step is the one you've already taken: treat any cause you can see, such as severe bleeding.⁴ Then, in both countries:

• Lay them down. The AHA/Red Cross 2024 guideline says a person with signs of shock and a normal level of alertness can reasonably be placed or kept on their back (COR 2a, LOE C-LD); St John and the British Red Cross lie them down too.¹⁴⁵ The American Red Cross adds "unless they prefer a different position for their comfort and breathing".⁶
• Keep their temperature right, with a coat or blanket over them and something under them on cold ground (St John; British Red Cross). The American Red Cross's line is "Maintain the person's body temperature", which includes taking a layer off someone who is hot.⁴⁵⁶
• Nothing to eat or drink. "Do not give the person anything to eat or drink" (American Red Cross), because it raises the risk of vomiting and of breathing the vomit in.⁶ Thirst is one of the signs, not something to fix with a drink.
• Reassure them. St John and the American Red Cross both say fear or anxiety, and pain, can make shock worse.⁴⁶

The legs: the one real difference

The AHA/Red Cross 2024 line reads: "If there is no evidence of trauma or injury (eg, simple fainting, shock from nontraumatic bleeding, sepsis, dehydration), raising the feet about 6 to 12 in (≈30°–45°) from supine position may be reasonable while awaiting the arrival of EMS." (COR 2b, LOE C-LD).¹ Six to 12 in is about 15 to 30 cm.

AHA/Red Cross 2024, section 5.2 and Table 15;¹ St John Ambulance, "Shock", "Severe bleeding" and "Fractures", reviewed April 2025;⁴ British Red Cross, "Bleeding heavily".⁵

Both sides give the same aim. The UK pages raise the legs to help blood reach the vital organs; the AHA positions a person in shock "to optimize circulation to vital organs such as the brain".⁴⁵¹ Where they part is how far to trust the effect, and in whom. The AHA says its evidence comes from outside first aid, the gains were temporary and inconsistent, and heart rhythm problems and low oxygen developed in unstable patients moved into the feet-up position.¹ Its shock section does not say why it limits the leg raise to people without trauma, so this course offers no reason.

Two facts put it in proportion. RCUK's 2025 first aid guideline has no section on the position for shock, so the UK column comes from public pages: St John's, reviewed in April 2025, before RCUK's guidelines appeared, and the British Red Cross's, which carries no date.³⁴⁵ And ILCOR's 2025 review lists "Optimal position for shock" under "Topics Not Included in the 2025 Review".² It is a contested empirical question, graded weak where it is graded at all. Follow your country's guidance and the call handler, who can hear what you describe. Lesson 7 showed you the faint on the same AHA/Red Cross table, where the feet do go up because there is no trauma; the people in this lesson's cases are on the other side of that line.

If they get drowsy or stop responding

In the US, the AHA/Red Cross shock table adds that a person with signs of shock who is at risk of airway obstruction, from decreased alertness or active vomiting, or who can't be continuously watched, may reasonably be put in the recovery position (AHA/Red Cross 2024, COR 2a, LOE C-LD).¹ The same guideline's positioning section says the recovery position may not be ideal with an injury to the spine, hip or pelvis, and that an injured person who is responsive and breathing normally, whose injury suggests a neck, back, hip or pelvic injury, should be left in the position in which they were found unless the area is unsafe (AHA/Red Cross 2024, COR 1, LOE C-EO).¹ For someone drowsy after being hit by a car, those lines pull different ways.

In the UK, RCUK says: "In cases of agonal breathing or trauma, do NOT move the person into the recovery position" (RCUK 2025), and the ERC that a person with known trauma is kept on their back (ERC 2025).³¹⁶

For an injured person going drowsy, the two countries' texts do not give one answer, and the call handler, who can hear what you describe, makes that call.

If they stop responding but are breathing normally, quietly and regularly at an ordinary pace, lesson 7's rule for an injured person holds in the UK: don't roll them, leave them on their back and keep checking their breathing (ERC 2025; RCUK 2025).¹⁶³ In the US, lesson 7 found no graded line written for an injured person who won't respond: the shock line above leans towards the side, the positioning caution and the leave-as-found line lean against moving them, and the call handler decides.

If their breathing isn't normal, you're back at lesson 2. RCUK 2025: "Slow, laboured breathing, as well as other abnormal patterns such as agonal gasping or panting, must be recognised as signs of cardiac arrest."¹⁴ Gasping in a person who won't respond is no longer St John's sign of shock; it's the arrest. Not breathing normally, or you aren't sure: onto their back, CPR, and tell the call handler. "If there is any doubt, assume cardiac arrest and start CPR."¹⁴ A tourniquet that's on stays on.

What people get wrong

"Press on the pressure point." Uncertain use in the AHA/Red Cross 2024 guideline (COR 2b); ILCOR recommends against (2021, strong recommendation, very low certainty).¹² Press on the wound.

"Loosen a tourniquet now and then to save the limb." RCUK 2025: "Do not release the tourniquet."³ The loosening habit is the one the Second World War review replaced.¹⁰

"A tourniquet costs the limb." "No amputations resulted solely from tourniquet use" in Kragh's combat series, and later amputations were 1.1% with and without in Teixeira's.¹¹¹² Both are observational, and both point the same way.

"You mustn't touch a tourniquet unless you're trained." RCUK 2025's general principle is to use only equipment you've been trained to use, and it says the emergency services may direct you to use it anyway; the UK's public kits are "designed to be used by ANY person"; the AHA/Red Cross 2024 guideline sets no training condition, though its text says "Some training may be required", and the American Red Cross page says "(if trained)".³⁸¹⁶ If you're untrained and one is needed, tell the call handler and do what they say.

"Raise the legs of anyone in shock." The US guideline offers the leg raise only where there's no trauma or injury (AHA/Red Cross 2024, COR 2b), so not after an injury.¹ UK charity pages raise them, and St John's makes an exception for a possibly broken leg or an injured hip or pelvis.⁴⁵ It depends on your country.

"Give someone in shock a drink." Nothing to eat or drink (American Red Cross).⁶

"Pull it out so you can see the wound." Leave it in and press around it.⁴⁵⁶

Practice

Where to learn with your hands

The American College of Surgeons' Stop the Bleed interactive course is a free online version of its classroom lecture on the "three methods of bleeding control"; the certificate needs an in-person skills session too.¹⁵ The classroom courses include hands-on practice of "applying direct pressure, packing a wound, and using a tourniquet".⁷ That is what a page can't give you: how tight is tight enough, what the windlass feels like, how hard to push a pad into a wound. Lesson 16 has the full list of where to train. This course hasn't watched the American College of Surgeons' or the British Red Cross's bleeding videos against the 2025 guidance, so it links the pages instead of showing the videos.

Connections

Lesson 1 took apart the fear of making things worse in cardiac arrest, and this lesson met a sharper form of it, where the person is alive and the tourniquet hurts, taught for a century as the thing that costs the limb. Lesson 2's danger check and the call opened both cases, and its breathing check is where you go if a shocked person stops responding. Lesson 4's reading of a grade was needed twice, for ILCOR's strong recommendation on very low certainty evidence and for COR 1 beside "weak" on the same tourniquet. Lesson 7's positioning table came back, with the trauma line drawn through it, and so did its rule for an injured person who won't respond.

Lesson 10 takes the small cut, the graze and the nosebleed, where pressure is still first and the NHS cuts page comes back. Lesson 11 covers the open fracture that bleeds and the injured neck or back. Personal Safety, later this term, can assume you can control severe bleeding, and owns the violence and threat behind some of it.

Go deeper

• American College of Surgeons, Stop the Bleed interactive course. Free, online, and the recommended practice for this lesson, then an in-person skills session. This course read the course's web page, not the course.
• Resuscitation Council UK, 2025 Resuscitation Guidelines: First aid, "Control of life-threatening bleeding". A handful of short lines carrying the whole UK sequence, from the call to the second tourniquet. Read in full here.
• Stephen Richey, "Tourniquets for the control of traumatic hemorrhage: a review of the literature", World Journal of Emergency Surgery, 2007, free. Read in full here, used for its history; its 2007 conclusions for public first aid have since been overtaken by the guidelines.
• Hewett Brumberg and colleagues, 2024 AHA and American Red Cross Guidelines for First Aid, Circulation, 2024, free. Sections 9.1 (bleeding) and 5.2 (position for shock) are short, and the supporting text is where the volunteer study, the tourniquet safety data and the leg-raise evidence are. Read in full here from an Internet Archive capture.

Sources

1. E. K. Hewett Brumberg, M. J. Douma, K. Alibertis and colleagues, "2024 American Heart Association and American Red Cross Guidelines for First Aid", Circulation 150, 2024, e519 to e579. **Read level: full, direct, from the Internet Archive capture 20260502024223**, with Table 15 (shock position) read from the publisher's image; sections 5.2 and 9.1 re-read from the same capture on 2026-09-25. Every AHA/Red Cross recommendation on bleeding and shock position with its grade, and the supporting text cited.
2. T. Djärv, M. J. Douma and colleagues for the ILCOR First Aid Task Force, "2025 International Consensus on First Aid Science With Treatment Recommendations", Circulation 152, 2025, typeset text. **Read level: full, direct, from the accepted manuscript on ilcor.org; the direct pressure, pressure point, tourniquet and haemostatic dressing recommendations, their years (2020 and 2021) and the 2025 pressure-point evidence update checked word for word against the typeset text.**
3. Resuscitation Council UK, 2025 Resuscitation Guidelines: First aid, 27 October 2025 . Read level: full, direct; the bleeding section and the "Expectations of a first aid provider" lines re-read on 2026-09-25.
4. St John Ambulance, Life-threatening bleed, Severe bleeding, Shock and Fractures and broken bones, clinically reviewed 28 April 2025 . Read level: full, direct; all four re-read on 2026-09-25.
5. British Red Cross, Bleeding heavily, undated . Read level: full, direct; re-read on 2026-09-25.
6. American Red Cross, Life-threatening external bleeding and Shock, undated. **Read level: full, direct**; both re-read on 2026-09-25 from Internet Archive captures (bleeding 20260921015638, shock 20260609233831), because the live site showed a maintenance page that day.
7. American College of Surgeons, Stop the Bleed: home, about, FAQ and get-trained pages, and the "STOP THE BLEED® Course" lay presentation, version 2.0 (2019). **Read level: full, direct.**
8. ProtectUK (Counter Terrorism Policing), "Standards for Public Access Trauma (PAcT) First aid kits: equipment" and "First aid provisions", publication date 1 June 2026 . Read level: full, direct.
9. NHS, Cuts and grazes, last reviewed 2 April 2026. **Read level: full, direct.**
10. S. L. Richey, "Tourniquets for the control of traumatic hemorrhage: a review of the literature", World Journal of Emergency Surgery 2, 2007, 28, PMC2151059. **Read level: full, direct**; the historical section and the conclusions used, re-read on 2026-09-25.
11. J. F. Kragh Jr, T. J. Walters, D. G. Baer and colleagues, "Survival with emergency tourniquet use to stop bleeding in major limb trauma", Annals of Surgery 249, 2009, 1 to 7 . Read level: abstract only.
12. P. G. R. Teixeira, C. V. R. Brown, B. Emigh and colleagues, "Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury", Journal of the American College of Surgeons 226, 2018, 769 to 776 . Read level: abstract only.
13. M. H. Scerbo, J. B. Holcomb, E. Taub and colleagues, "The trauma center is too late", Journal of Trauma and Acute Care Surgery 83, 2017, 1165 to 1172 . Read level: abstract only.
14. Resuscitation Council UK, 2025 Resuscitation Guidelines: Adult basic life support, 27 October 2025 . Read level: full, direct.
15. American College of Surgeons, Stop the Bleed interactive course. **Read level: page full, direct**; the course itself not taken.
16. T. Djärv, J. Rogers, F. Semeraro and colleagues, "European Resuscitation Council Guidelines 2025 First Aid", Resuscitation 215 (suppl 1), 2025, 110752 . Read level: full, direct, on the publisher's page; used here only for its sentence that a person with known trauma is kept on their back, as lesson 7 read it.