American College of Surgeons Stop the Bleed Campaign

Campaign Overview

• The “Stop the Bleed” campaign is a global public health initiative led by the ACS to train, equip, and empower civilian bystanders to recognize and respond to life-threatening hemorrhage after trauma.
  • Significance: Uncontrolled bleeding is the leading preventable cause of death following traumatic injury. Victims can lose their entire circulating blood volume in under five minutes.¹
  • Philosophy: The campaign reframes the “bystander” from a helpless observer to a vital link in the chain of survival, on the premise that the person nearest the victim is most likely to save their life.²
  • Public/Private Partnership: The US Department of Defense retains ownership of the Stop the Bleed trademark and partners with the ACS and other non-governmental organizations to deliver training and distribute equipment.³

Origins and History

• Military Roots: Hemorrhage control techniques developed during the wars in Iraq and Afghanistan evolved into the Tactical Combat Casualty Care (TCCC) guidelines.²
  • TCCC prioritized controlling massive hemorrhage before treating other injuries.
  • A key change was requiring widespread tourniquet use, which led to a 67% decrease in death from uncontrolled extremity hemorrhage.
• Civilian Catalyst: The 2012 Sandy Hook Elementary School shooting prompted a national revelation of mass casualty responses.²
  • Local trauma surgeon Dr. Lenworth M. Jacobs, Jr., noted many victims succumbed to survivable hemorrhage before medical arrival.
• The Hartford Consensus: A panel of experts convened in Hartford, Connecticut to develop recommendations, resulting in the launch of the “Stop the Bleed” campaign in October 2015.²
• Guideline Integration: Recommendations have been incorporated into AHA/Red Cross First Aid guidelines and the 11th edition of Advanced Trauma and Life Support (ATLS), which now places eXsanguinating hemorrhage control before airway management as the first step of the primary survey (xABCDE).^4,5

Curriculum

The Stop the Bleed campaign primarily focuses on teaching response to bleeding based upon a simple mnemonic: the ABCs of bleeding control.^2,6,7

1. Alert: Call or direct someone else to call 911 and provide the emergency response with the location, nature of the incident (stabbing, shooting, car crash, etc.), number of victims, and bleeding control plan.
2. Bleeding Identification: Look for continuous bleeding, large-volume bleeding, or pooling of blood. Because clothing can conceal visual evidence of bleeding, this will likely require removing or opening clothing to expose the wound.
3.  Compress: Apply pressure to stop the bleeding. Use one of three techniques.
   1. Direct Pressure: Apply steady, firm pressure directly on the bleeding wound using any absorbent cloth or your hands if nothing else is available.
      1. If the bleeding is controlled, continue applying pressure until Emergency Medical Services (EMS) arrives. If not, proceed to the next step.
   2. Wound Packing: If bleeding is from a deep wound or a “junctional” area where a tourniquet cannot be applied (i.e., neck, shoulder, groin, axilla), the wound must be packed. A hemostatic dressing (such as QuikClot or Celox) is preferred, though gauze or any available cloth will function in an emergency.
      1. Use fingers to pack the cloth deep into the wound. Pack as tightly as possible until the wound is completely full.
      2. Once packed, apply firm, direct pressure with both hands to the packing. Once bleeding has stopped, cover the packing with a trauma bandage and wrap tightly around the extremity if available. If not, continue to hold pressure until EMS arrives
   3.  Tourniquet Application: The primary tool for life-threatening bleeding on an arm or a leg. Stop the Bleed advocates the use of commercially available windlass-style tourniquets (e.g., combat application tourniquet) rather than improvised tourniquets such as belts and bandannas.
      1. Apply the tourniquet 2-3 inches proximal to the wound. Do not place it on a joint (e.g., elbow or knee).
      2. Tighten the tourniquet until the bleeding stops completely.
         1. This will be extremely painful for the victim, and students are taught to expect this and not stop due to pain.
         2. If the first tourniquet fails to stop the bleeding, apply a second just above it.
      3. Document the time of tourniquet application, ideally by writing directly on the tourniquet.

Program Logistics and Equipment

• Course Format: In-person sessions last 60-90 minutes and combine lecture with hands-on skills training using mannequins, tourniquets, and packing materials.
  • A self-directed virtual course is available online.⁷

• Instructors: Certified healthcare professionals (doctor of medicine, registered nurse, emergency medical technician). These instructors are trained and certified by the ACS.
• Cost: Most courses are free via grants, though some providers may charge a small fee.
• Accessibility: The 3rd edition curriculum (March 2025) prioritizes images over text to improve accessibility.
• Standard Bleeding Control Kits: Include a windlass tourniquet, gauze, pressure dressing, shears, gloves, and a marker.⁸
  • More advanced kits are available that add hemostatic dressings and there are also commercially sized options suitable for placement in public areas or workplaces
  • An individual, basic kit currently costs $41 though there are many grants and public organizations that distribute free kits.

Efficacy and Future Directions

• As of April 2025, nearly 5 million individuals have been trained across 168 countries and continue to grow globally.⁷
• Outcomes: One study found that 8.4% of trainees applied skills in real-world emergencies within one year, and 93.5% reported successful outcomes.⁹
  • Broader epidemiological data reflect a general increase in tourniquet use in the community, but it is difficult to attribute this directly to the Stop the Bleed effort.³
• Skill Decay: A major limitation of this training is the loss of technical proficiency; one study showed only 54.5% of trainees retain tourniquet skills after nine months. Future development priorities include “just-in-time” training aids and refresher courses.¹⁰
• Legislation: At least 17 states in the US now require bleeding control kits in public spaces (e.g., schools, airports), with active legislation pending in many other jurisdictions.⁷
  • There are no standardized regulations governing the composition, accessibility, and maintenance standards for these kits in public spaces.