What is the standard approach to controlling external bleeding from an extremity when direct pressure fails?

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When direct pressure fails to control external bleeding from a limb, the standard approach is to apply a tourniquet proximal to the wound to stop arterial inflow and control the hemorrhage. Place the tourniquet high on the limb (typically about 2 inches above the injury, away from a joint) and tighten until the bleeding stops and distal circulation is no longer present. After applying it, reassess distal circulation to confirm perfusion has been adequately interrupted and monitor the patient while preparing for transport. If bleeding remains uncontrolled, you may apply another tourniquet proximal to the first, but the priority is to stop the bleed with a tourniquet rather than waiting or relying on other measures. Ice and elevation alone don’t stop arterial bleeding, waiting for spontaneous clotting isn’t sufficient, and on-scene surgical ligation isn’t a standard prehospital approach.