Expanded question: Can bystanders influence the survival rate of bleeding patients?

Answered on February 18, 2025
Yes, bystanders can significantly influence the survival rate of bleeding patients.
The "Stop the Bleed" (STB) program has been shown to be effective in training laypersons to manage life-threatening hemorrhage. Studies have demonstrated that bystanders trained in bleeding control techniques can significantly improve survival rates among trauma victims. For instance, a study conducted in rural Sierra Leone found that 97% of patients who received intervention from STB-trained bystanders survived.[1] Another study highlighted that bystanders' presence and intervention in prehospital trauma scenarios can provide a critical window of opportunity for life-saving measures, particularly in cases of severe bleeding.[2]
The American Heart Association's guidelines also emphasize the importance of community-level training in emergency response, including bleeding control, to improve outcomes in trauma situations.[3] Additionally, the effectiveness of STB training in empowering individuals to act confidently and competently in hemorrhage control has been well-documented.[4-5]
In summary, bystanders trained in bleeding control techniques can play a crucial role in improving the survival rates of bleeding patients by providing immediate and effective first aid before professional medical help arrives.

1.
Stop the Bleed in Rural Sierra Leone: One Year of Interventions and Outcomes by Nursing Trainees.

Parvin-Nejad FP, Padmanaban V, Jalloh S, Barrie U, Sifri ZC.

The Journal of Surgical Research. 2022;273:79-84. doi:10.1016/j.jss.2021.12.017.

Background: Low- and middle-income countries (LMICs) bear the bulk of the global burden of traumatic injury, yet many lack adequate prehospital trauma care systems. The Stop the Bleed (STB) course, designed to equip bystanders with bleeding control skills, is infrequently offered in LMICs, and its impact in these settings is unknown. To examine the frequency and effectiveness of STB interventions in LMICs, we quantified nursing student trainees' encounters with bleeding victims after STB training in rural Sierra Leone.

Methods: Local providers and volunteers from a US-based surgical nongovernmental organization taught an STB course to nursing students in Kabala, Sierra Leone. One month and 1 year after the course, trainees completed follow-up surveys describing encounters with traumatic hemorrhage victims since the course.

Results: Of 121 total STB trainees, 82 completed the 1-month follow-up survey, with 75% reporting at least one encounter with a bleeding victim. This increased to 98% at 12 months (100 responses, average 2 ± 2 encounters). Injuries were most commonly sustained on victims' legs (32%) and most often precipitated by motorcycle crashes (31%). Respondents intervened in 99% of encounters, and 97% of patients receiving intervention survived. Although only 20% of respondents used a tourniquet, this technique produced the highest survival rate (100%).

Conclusions: Nearly all respondents had encounters with victims of traumatic hemorrhage within 1 year of the STB course, and trainees effectively applied bleeding control techniques, leading to 97% survival among victims receiving intervention. These findings indicate the lifesaving impact of STB training in one rural LMIC setting.

2.
Prehospital Deaths From Trauma: Are Injuries Survivable and Do Bystanders Help?.

Oliver GJ, Walter DP, Redmond AD.

Injury. 2017;48(5):985-991. doi:10.1016/j.injury.2017.02.026.

Background And Objectives: Deaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery.

Methods: We examined the Coroners' inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model.

Results: One hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25-50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or "within minutes" in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively.

Conclusions: A high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

3.
Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Cheng A, Magid DJ, Auerbach M, et al.

Circulation. 2020;142(16_suppl_2):S551-S579. doi:10.1161/CIR.0000000000000903.

Leading Journal

1.

A cohort study demonstrated that bystanders with previous CPR training were 3 times more likely to perform CPR. A 40-minute mass, Hands-Only CPR training of more than 5 500 university students was found to promote B-CPR. Community-level promotion of Hands-Only CPR training was associated with increased B-CPR and an increased incidence of survival with favorable neurological outcome. Communities with a higher proportion of residents identifying as having CPR awareness, prior CPR training, and higher self-efficacy were associated with an increased likelihood of B-CPR. Some studies were limited by prior CPR training and ecological community-level measurements.

2.

Several survey-based studies of bystanders described vomit, alcohol on the victim’s breath, and visible blood as physical barriers to initiating CPR., Analyses of dispatch-assisted CPR tapes found that inability to move patients to a hard, flat surface was associated with reduced rates of CPR., Four retrospective cohort studies found that women are less likely to receive B-CPR compared with men.,

3.

Observational studies found that panic, lack of confidence, perceptions of futility, and fear of injury were emotional barriers to initiating CPR., A survey of university students cited burden of responsibility and difficulty in judging a cardiac arrest as additional barriers. These studies suggest that tailored CPR training to address these emotional barriers and providing general awareness of these barriers may improve bystander willingness to perform CPR.

4.
Stop the Bleed Training Empowers Learners to Act to Prevent Unnecessary Hemorrhagic Death.

Lei R, Swartz MD, Harvin JA, et al.

American Journal of Surgery. 2019;217(2):368-372. doi:10.1016/j.amjsurg.2018.09.025.

Background: Uncontrolled bleeding is a leading cause of preventable death from trauma. With the rise in mass casualty events, training of laypersons can be life-saving. "Stop the Bleed" is a campaign to teach the public techniques of bleeding control. We believe that training in these techniques will increase participants' willingness and preparedness to intervene and increase knowledge of trauma/hemorrhage control.

Methods: We created a "Stop the Bleed" training program. School nurses, medical students, researchers, and community members participated in the program. Pre- and post-training questionnaires assessed participants' willingness/preparedness to intervene in a casualty event and knowledge of trauma/hemorrhage control.

Results: There was a significant change in attitudes after receiving training (p < 0.05). There was also an improvement in knowledge regarding bleeding control techniques.

Conclusions: "Stop the Bleed" training empowers participants with the confidence and knowledge to aid others in preventable hemorrhagic death.

5.
Stop the Bleed Training: Rescuer Skills, Knowledge, and Attitudes of Hemorrhage Control Techniques.

Schroll R, Smith A, Martin MS, et al.

The Journal of Surgical Research. 2020;245:636-642. doi:10.1016/j.jss.2019.08.011.

Background: Bystanders play a significant role in the immediate management of life-threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to evaluate the efficacy of STB training for rescuers from different backgrounds. We hypothesized that STB training would be appropriate to increase skills and knowledge of bleeding control techniques for all providers, regardless of level of medical training.

Study Design: Course participants anonymously self-reported confidence in six major areas. A five-point Likert scale was used to quantitate participant's self-reported performance. Results were stratified into medical rescuers (MR) and LRs. Students' ability to perform STB skills were objectively assessed using an internally validated 15-point objective assessment tool. Data were pooled and analyzed using Student's t-test and chi-Squared test with P < 0.05 considered significant. Results are presented as average with standard deviation (SD) unless otherwise stated.

Results: A total of 1974 participants were included in the study. Precourse confidence was lowest for both groups in management of active severe bleeding and ability to pack a bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core areas measured (P < 0.001). The most significant increases were reported in the two previous areas of lowest precourse confidence-management of active severe bleeding-LRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001-and ability to pack a bleeding wound-LR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD 0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated combined 99.3% proficiency on postcourse objective assessments.

Conclusions: This study provides quantitative evidence that Stop the Bleed training is effective, with both LRs and MRs demonstrating improved confidence and skill proficiency after a 1-h course. Future program development should focus on building a pool of instructors, continued training of LRs, and determining how often skills should be recertified.