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Wound Packing: A Critical Skill for Bleeding Control

Image of a military medic treating an injured soldier, who has obvious junctional bleeding from the groin

Blood belongs inside the body, and when it's rapidly finding its way out through a wound, we all need to have the basic skills to stop it before it's too late. For life-threatening wounds on a limb, we know that getting a tourniquet on quickly is critical. But what about when the wound is in a junctional area where tourniquets cannot be effectively applied? This is where wound packing becomes an essential life-saving skill in your trauma care toolkit.

"The need to control the bleeding is paramount. The risks associated with the first aid use of tourniquets and haemostatic dressings are less than the risk of uncontrolled severe, life-threatening bleeding". ANZCOR

While wound packing has been a fundamental technique in military medicine for decades, its widespread adoption in standard protocols for civilian first responders has been more gradual, including here in Australia. Until recently, this life-saving intervention was only taught to tactical medics and specialised units rather than being part of core training for all emergency medical providers. However, this is changing as updated clinical practice guidelines increasingly recognise the value of wound packing for managing complex bleeding, particularly for junctional wounds where tourniquets cannot be applied.

Understanding Wound Packing

When to Pack a Wound

Wound packing is specifically indicated in these scenarios:

  • Junctional wounds with significant bleeding (groin, axilla, neck*)
  • Deep cavity wounds where direct pressure alone is not sufficient
  • Wounds too proximal for effective tourniquet placement

When NOT to Pack a Wound

Not every bleeding wound should be packed. Avoid packing in these situations:

  • Chest and abdominal wounds with internal bleeding: These injuries require surgical intervention as the bleeding occurs in body cavities where packing cannot reach the source. Patient transport to a trauma centre is the priority here.
  • Wounds with minimal bleeding: Packing is painful and unnecessary when bleeding can be more simply controlled with direct pressure.
  • Wounds with embedded foreign objects that could be dislodged during packing

*Special Consideration: While neck wounds can be packed in certain circumstances, extreme caution must be exercised to avoid compromising the airway. Only pack posterolateral neck wounds when necessary and never wrap circumferential bandages around the neck after packing.

The Wound Packing Technique

Step-by-Step Technique

  1. Ensure scene safety and use PPE if available
  2. Expose the wound fully: Use trauma shears to cut away clothing so you can see the wound in its entirety.
  3. Locate the source of bleeding: This can be challenging in two situations: either you'll find multiple small bleeding points rather than one clear source, or the bleeding might be so heavy that it's difficult to see the exact origin.
  4. Remove excess blood: Wipe the exterior of the wound with gauze and if there is a deep cavity, gently but swiftly scoop out any blood from inside the wound.
  5. Pack tightly with gauze: We refer here to the RTACC Manual, which describes wound packing as "the process of feeding in a long bandage into the wound and gradually filling the cavity up from the bottom of the wound".
    • Place the end of the dressing in the bottom corner/end of the wound
    • Gradually feed in more dressing while maintaining firm pressure on the bandage already in place
    • Continue until the whole wound is filled with firmly packed dressing
  6. Apply direct pressure for at least 5 minutes
  7. Secure with a pressure bandage

Like any critical skill, wound packing requires regular practice to maintain proficiency. We recommend:

  • Using realistic wound trainers that simulate tissue density and wound geometry
  • Practising under stress and time pressure to replicate field conditions
  • Incorporating wound packing into regular trauma management training
  • Training in low-light conditions and with gloved hands to build muscle memory

Ongoing Care

  • Always leave a good length of dressing outside the wound, to demonstrate to the hospital that there is a bandage inside the patient when they arrive to the trauma centre.
  • Never cut the dressing inside the patient, rather bunch it up and place over the wound opening then secure with a bandage.
  • Always remember to document your interventions clearly so the responding paramedics or trauma surgeons know exactly what you have done in the field.

Haemostatic Agents

What are Haemostatic Agents?

Haemostatic dressings are specialised wound care products designed to accelerate blood clotting and stop bleeding faster than standard gauze alone. These dressings are impregnated with agents that promote clot formation when applied directly to a bleeding wound. The two most common active ingredients in modern haemostatic dressings are:

  1. Kaolin (found in QuikClot Combat Gauze): A naturally occurring clay mineral that activates the body's clotting cascade when it contacts blood, speeding up the formation of clots.
  2. Chitosan (found in other products): Derived from shellfish shells, chitosan works by creating a gel-like clot that seals the wound independent of the body's natural clotting mechanisms, making it effective even for patients on blood thinners.

These specialised dressings come in various forms, from gauze rolls to pre-packed applicators, all designed to be packed into bleeding wounds to create direct pressure on bleeding vessels. Unlike standard gauze, haemostatic dressings actively participate in the clotting process, rather than just working as a physical barrier.

When to Use Haemostatics

According to the RTACC manual, haemostatic gauze products like QuikClot "are typically only to be used for massive or uncontrollable bleeds and large cavity wounds.” They emphasise effectiveness by stating: "Used correctly, these can control lethal major arterial bleeds very effectively." The key phrase here is "if used correctly" - highlighting that proper technique is critical to success when using these specialised dressings. ANZCOR emphasises that haemostatic dressings must be applied as close as possible to the bleeding point, held with manual pressure initially, then secured with a bandage.

Remember: While haemostatic dressings are valuable tools in controlling severe bleeding, they are not miracle products that work on their own—they cannot simply be packed into a wound and abandoned. For these agents to be effective, proper direct pressure must be applied and maintained for at least 5 minutes. Without this crucial pressure application, the dressing cannot perform its function. A notable advantage, however, is that unlike many conventional treatments, these products remain effective even in challenging scenarios such as hypothermic patients and those taking anticoagulant medications.

Ensuring you have the right supplies immediately available is crucial for effective wound packing:

  • Carry haemostatic gauze in your trauma kit or IFAK if possible. If space is an issue, keep in mind that all Quikclot Combat Gauze is vacuum sealed into an ultra-compact package.
  • Keep your wound packing materials alongside your tourniquets for quick access
  • Have multiple gauze packets available for larger wounds

At TacMed Australia, we offer 4 options for QuikClot haemostatic products. Which one is right for you?

  • QuikClot Combat Gauze: Designed for major bleeding. Vacuum-packed for compact storage and sterility.
  • QuikClot Combat Gauze LE: Same great QuikClot Combat Gauze but also contains an X-ray detectable strip for easy identification.
  • QuikClot EMS Rolled Gauze: A 7.5cm x 1.2m rolled configuration that provides flexibility for different wound sizes and shapes. This format is particularly useful for longer wound tracks or when more gauze is needed.
  • QuikClot EMS 4x4 Dressing: Perfect for smaller wounds or as a supplement to other dressings. These 4x4 dressings provide the haemostatic benefits of kaolin in a convenient size for more minor injuries.

What NOT to Use for Packing

When faced with a critical bleeding emergency, some improvised solutions can be more dangerous than beneficial. Here are four household items that should not be used for wound packing:

  1. Tampons: Bleeding control is about pressure, not absorption! Since tampons are designed to ABSORB blood, not create the PRESSURE needed to stop traumatic bleeding, they should be avoided. Also, they expand outward rather than conforming to wound geometry, have inadequate volume to fill most traumatic wound cavities, and may interfere with proper clot formation.
  2. Cotton Balls or Household Cotton: These materials fragment easily when wet with blood, leaving fibres in the wound that can lead to infection. They also absorb blood without creating sufficient pressure to stop bleeding.
  3. Tissue Paper or Paper Towels: These disintegrate when saturated with blood, making removal difficult and increasing infection risk. They also lack the structural integrity needed to maintain pressure against bleeding vessels.
  4. Standard Adhesive Bandages (Band-Aids): This is obvious, but Band-Aids are designed for minor cuts and scrapes, not deep wounds requiring packing. Despite what your mum might have told you as a kid, Band-Aids do not fix everything and will certainly not help major haemorrhage.

Real-World Application

Scenario: Weekend Forestry Accident

Imagine you're helping a friend clear fallen trees on his property. You've brought your TacMed Tactical IFAK+ as you always do for high-risk activities. Your kit includes a pair of trauma shears, a SOF Tourniquet, a 4" Emergency Bandage, QuikClot Combat Gauze, a Hyfin chest seal, a CPR face shield, casualty card, sharpie, and nitrile gloves.

Suddenly, you hear a scream followed by the chainsaw's engine cutting off. You rush over to find that the saw has kicked back unexpectedly, causing a deep laceration to your mates groin. There's significant blood pulsing from the wound—clearly arterial bleeding.

Assessment

As you rush to his side, you quickly assess the situation:

  • The chainsaw has stalled and is not a threat to either of you
  • Your mate is conscious and breathing
  • There is a deep junctional wound in the groin area
  • Bright red blood is pulsing from the wound

First Aid Steps

  1. Personal Protection: ANZCOR recommends to “use standard precautions (e.g. gloves, protective glasses) if readily available”.
  2. Expose the wound completely: Use the trauma shears from your kit to cut away his pants, fully exposing the injury.
  3. Apply initial direct pressure: Your mate is in agony, but his hands are free. Calmly help him to hold pressure on the wound while you get your supplies.
  4. “Hey Siri, call 000 on speaker”: Call for help on speaker so you can provide immediate first aid to your mate without delaying ambulance response.
  5. Why not use a tourniquet? A tourniquet would be your first choice for extremity bleeding, but in this case, the wound is too high on the leg—in the crease where the leg meets the pelvis. There simply isn't enough space to place the tourniquet proximal to the wound.
  6. Why not just use the pressure bandage alone? For a wound this deep with arterial bleeding, an external pressure bandage alone would be insufficient. The bleeding vessel is deep in the tissue, and external pressure won't reach it effectively.
  7. Prepare the QuikClot Combat Gauze: Open the package at the tear line, being careful not to contaminate the gauze with dirt. If possible, keep the majority of the z-fold gauze in a clean pocket so you have 2 free hands for packing.
  8. Pack the wound per the step-by-step technique described in this blog.
  9. Monitor and prepare for evacuation: Wait for the ambulance to arrive and prepare him for transport, while continuously maintaining pressure and monitoring his condition.

Why This Approach Works

In this scenario, several factors made wound packing the optimal choice:

  1. Location: The junctional nature of the wound made tourniquet use impossible.
  2. Depth: The deep cavity with arterial bleeding required internal pressure directly on the vessel.
  3. Haemostatic advantage: The QuikClot gauze provides both the physical structure for effective packing and the haemostatic agent to speed up the clot formation.
  4. Proper technique: The methodical packing from deep to superficial, combined with adequate pressure time, gives the haemostatic agent time to work and buys time for your mate until the ambulance arrives.

What Happens Next?

In a perfect world, the bleeding remains controlled during the 25 minute wait for an ambulance. The paramedics arrive to find your friend pale but stable, with the wound packing maintaining haemostasis. They transport him to hospital where vascular surgeons repair the partially severed femoral artery. The surgeon later comments that the proper wound packing likely saved your friend's life by preventing catastrophic blood loss during those critical 10 minutes after trauma.

While fictional, this scenario illustrates why wound packing skills and proper equipment can be lifesaving in situations where other haemorrhage control methods aren't feasible. We also hope it demonstrates why having the right supplies and knowing how to use them properly is essential for anyone who regularly engages in higher-risk activities (like operating chainsaws!).

Developing Your Skills

This blog serves as an introduction to wound packing only. For anyone working or adventuring in high risk environments who is interested in taking their emergency preparedness to the next level, we strongly recommend the following:

TacMed Training

TacMed Training Public Programs are designed with a clear mission: to empower first responders to save lives in critical moments. Developed and delivered by experienced clinicians, many of our courses feature comprehensive wound packing demonstration. We provide the highest standard of practical training specifically for those operating in high-threat and complex environments, ensuring you can confidently apply these life-saving techniques.

Stay Current

Medical protocols evolve as new research emerges, and maintaining awareness of current ANZCOR best practices ensures you're delivering evidence-based care in every situation.

YouTube Learning

Visit our TacMed Australia YouTube channel where we provide detailed video demonstrations, expert tips, and step-by-step guides for managing many complex emergency situations. Our videos offer valuable visual instruction that complements hands-on training. Subscribe today to access our growing library of emergency medical response content!

Connect With Us

Your experiences matter. Have you used wound packing in a real-world scenario? Share your experiences, challenges, and lessons learned with our community in the comments below. These real-world insights help all of us improve our response capabilities.

Need advice on selecting the right wound packing materials for your role? Reach out to us via phone 1300-862-633 or email info@tacmedaustralia.com.au and stay in touch on socials @tacmedaustralia.

 

Stay safe,

Team TacMed

Note: Always follow current ANZCOR guidelines and seek immediate emergency medical care in any trauma situation. This information supplements but does not replace proper first aid training.

 

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