What should be the initial action if direct pressure fails to control hemorrhage after a missile injury through the thigh with intact pulses?

In the context of managing a significant hemorrhage following a missile injury, particularly in an extremity like the thigh, it is vital to consider effectiveness and immediacy in stopping the bleeding. When direct pressure has failed to control the hemorrhage, the most appropriate step is to apply a proximal tourniquet.

Using a proximal tourniquet serves several purposes: it exerts direct and significant pressure on the vessel, effectively occluding blood flow distal to the application site. This method is particularly crucial in traumatic injuries where there is a high risk of arterial bleeding, as is the case with missile injuries. The tourniquet should be placed a few inches above the site of injury, avoiding any joints, and should be tightened enough to stop the blood flow, as indicated by the cessation of bleeding.

In contrast, other options, while potentially beneficial in other scenarios, are not the immediate next steps once direct pressure has failed. Applying a pressure bandage may not provide enough pressure to overcome the arterial bleeding and therefore isn't the best initial action. Raising the leg above heart level does not directly address the source of bleeding and may not be effective in this circumstance. Administering fluids is important in cases of shock but does not address the immediate threat of hemorr