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The next thing we need to consider is if the tourniquet has not stopped the bleed and if there is still a distal pulse what do you need to do? The first thing to check is that the tourniquet may not be tight enough and you may need to apply more pressure. When you apply a tourniquet, you need to use a lot of force for it to be effective.

If the first tourniquet is on at the right pressure, then you need to decide what you are going to do next. The choices are: applying direct pressure to the wound, use a haemostatic dressing or apply another tourniquet.

The first thing to consider will be the use of direct pressure and a pressure dressing. This may not have worked before but now the tourniquet is in place, the blood pressure would have reduced.  Direct pressure and a pressure dressing may now work. This is the most simple option.

The next options are to use a haemostatic dressing or applying another tourniquet. There is not much guidance on which to use and you will have to make a decision on what is best. If you do not have another tourniquet or a haemostatic dressing, the choice may be made for you but you could apply an improvised tourniquet if you do not have a commercial one.

If you do apply another tourniquet, apply it above or below the first one on a single bone if possible keeping it 5cm above the joint. You could apply it to the lower arm or leg as it may be effective there now the blood pressure has dropped. Note the time of the second tourniquet application and do not remove either tourniquet.

It is not common, but you could apply the third tourniquet if necessary.