Wound Packing Technique: Gauze Tamponade for Deep Wounds

Why Wound Packing Works

A tourniquet works by compressing the artery proximal to the wound, cutting off blood supply to the entire limb. That is not possible in the neck, groin, or torso.

Wound packing works differently. You fill the wound cavity completely with absorbent material, then apply sustained external pressure. The packed gauze transmits pressure down the wound tract to the bleeding source, mechanically compressing the vessel. Combined with the clot-activating properties of hemostatic gauze (or simply the surface area contact of plain gauze), this creates a tamponade effect.

The physics require two things: the cavity must be filled so there is nowhere for blood to pool instead of clotting, and the pressure must be sustained long enough for a clot to form and stabilize.

Anatomy of a Packable Wound

Wound packing is effective for:

Junctional wounds: Groin (femoral artery and vein run here), axilla (axillary vessels), and lateral neck. These anatomic zones are where major vessels are closest to the surface and where tourniquets cannot create proximal compression.

Deep lacerations: Wounds with significant depth that cannot be controlled with direct surface pressure.

Scalp wounds: Dense scalp vasculature bleeds heavily. Packing is effective before transfer.

Open chest wounds / sucking chest wounds: Special case — see below.

Wound packing is less effective for:

• Internal abdominal bleeding from hollow organ or major vessel injury — requires surgery
• Bleeding from multiple diffuse small vessels across a large wound bed
• Arterial bleeding from a vessel larger than the femoral — cannot achieve enough pressure

Materials

Ideal: QuikClot Combat Gauze or another CoTCCC-recommended hemostatic dressing. Contains kaolin which activates the clotting cascade on contact with blood.

Acceptable: Plain rolled gauze (4-inch or 3-inch). The mechanical tamponade effect works without hemostatic agents. Hemostatic gauze improves outcomes for severe arterial bleeding, but good packing technique with plain gauze is vastly better than poor technique with hemostatic gauze.

Not acceptable: Cotton balls, paper towels, clothing. These are too absorbent, too compressible, and will not transmit pressure effectively down the wound tract. Use gauze.

To secure: Elastic bandage, Israeli pressure bandage, or improvised pressure dressing.

Technique: Step by Step

Preparation

1. Expose the wound fully. Cut or tear away clothing. You cannot pack a wound you cannot see.

2. Identify the bleeding source if possible. Is the bleeding coming from the wound entrance? From a specific depth? From visible vessels? This guides where to focus packing pressure.

3. Put on gloves. Blood-borne pathogen protection. Do not delay critical care for gloves, but use them if seconds allow.

4. Open the gauze package. Unfold the beginning of the gauze roll. For QuikClot Combat Gauze, the gauze is in a Z-fold configuration — locate the end.

Packing

5. Begin at the deepest point of the wound. Take the end of the gauze roll and push it firmly into the wound cavity to the maximum depth you can reach with your fingers. This is the critical step. Surface application does not create tamponade. You must get gauze to the wound's depth.

6. Begin packing tightly. Fold and press the gauze into the wound cavity in tight layers. Use one or two fingers to drive gauze in and against the wound walls. Pack tightly — compressed gauze maintains more contact area than loosely laid gauze.

7. Continue adding gauze until the wound is full. You may need to use the entire package, or multiple packages for large wounds. The wound cavity should be completely filled. When you can no longer add gauze without it falling out, the wound is packed.

8. If using multiple packages: Continue packing from the deep end outward with subsequent packages. Connect the end of one roll to the beginning of the next so you can remove it later as a single unit.

Pressure

9. Apply immediate, firm, direct pressure. Use both hands. Place the heel of your hand directly over the packed wound. Lean your body weight into it.

10. Maintain pressure for a minimum of 3 minutes without interruption. This is the hardest part. The impulse to check if it is working is strong. Do not lift your hands. Lifting before the clot is stable destroys it. Set a mental timer. Count if you have to.

11. The pressure should be substantial. For arterial junctional bleeding: you need to apply enough force to feel significant resistance from the underlying tissue. For a groin wound with femoral artery involvement, this means pressing hard enough that your own hands are fatiguing.

Securing

12. After 3 minutes, maintain pressure while applying a pressure dressing. With one hand maintaining pressure, use the other to begin wrapping an elastic or Israeli bandage over the wound packing.

13. Wrap firmly enough to maintain the packing in compression. The dressing does the work your hands were doing. Wrap tight enough to maintain pressure without cutting off distal circulation.

14. Check distal circulation. Pulse and sensation in the extremity beyond the wound (if applicable).

15. Mark the time. Write "WP" (wound packed) and the time on the patient's forehead or the dressing.

Special Application: Sucking Chest Wound

A sucking chest wound (open pneumothorax) is a penetrating wound to the chest through which air enters the pleural space with each breath. You can hear and sometimes see air moving through the wound.

Wound packing for sucking chest wounds is controversial and has changed with evolving guidelines. Current approach:

1. Apply a vented chest seal (commercial device with a one-way valve) as first choice. This seals the wound while allowing air to escape from the pleural space.

2. If no chest seal is available, a non-occlusive dressing applied and taped on three sides creates an improvised one-way valve effect. Air can escape on the unsealed side but cannot enter.

3. Do not pack a sucking chest wound with gauze and seal it completely — this may cause a tension pneumothorax (dangerous pressure buildup in the chest). The lung needs to be able to vent air.

Junctional Wounds: Specific Considerations

Groin (Femoral Vessels)

The femoral artery and vein exit the pelvis under the inguinal ligament and travel along the inner thigh. Wounds in the upper inner thigh or groin that involve these structures cause rapid, life-threatening hemorrhage.

Packing pressure point: the femoral artery exits at the midpoint of the inguinal ligament (the crease of the hip). Direct pressure here, even above the wound, compresses the femoral artery against the underlying pelvic bone. Maintain this manual compression while your assistant packs the wound.

Junctional Emergency Treatments (JET): Commercial devices (SAM Junctional Tourniquet, JETT) apply direct pressure to the inguinal region with a mechanical advantage. These are now carried by military medics specifically for femoral junction wounds.

Axilla (Armpit)

The axillary artery is the proximate blood supply to the arm. Pack tightly into the axillary wound with the arm elevated slightly if the patient's condition allows.

Neck

Neck wound packing requires careful technique. The concern is compressing the trachea (airway). Pack the lateral neck firmly — the carotid and jugular are the targets. Avoid packing tightly across the anterior midline (trachea).

For neck wounds, ongoing manual pressure by an assistant is often preferable to a circumferential pressure dressing, which can compress the airway.

Removing Wound Packing

Do not remove wound packing in the field unless you have complete supplies to repack and control re-bleeding. The clot forms within the packed wound and is disrupted by removal. Removing packing without surgical backup causes re-bleeding.

Inform medical personnel receiving the patient that wound packing is in place: what type of gauze, how much, time of application.

Surgical removal requires careful, controlled technique and is typically done under direct visualization in the operating room.