Tourniquet and Hemostatic Agent use by Red Cross First Aid Trained Layperson

[Hmac]

Over the years I've found that I carry far fewer widgets, and am more aware of things around me that can serve useful purposes.

Yes. Like the very complete trauma pack that the course instructor brought with him and set at the ammo table along with the cell phone and the sign with the latitude/longitude of the range where we were shooting.

[docsherm]

NongShim is correct in what he said. As a SOF medic I will add to what he started.

The SOF-TT is the only TQ worth while. The rest are not as good. The TQ is just like the M4, most of the people that have them do not know how to properly use them. I am also talking about those in uniform. I have seen several people die because some ass-clown did not put a TQ on properly and they bleed out. I have gotten to the point that I carry less stuff but what I do carry I have several of. By that I mean that I carry at least 6 TQs, 3 or 4 packs of Combat Gauze, several tools of Kerlex, and a few ACE wraps of different sizes. I also carry a few chest seals, 14guage cathaters, and 1 or two nasel airways. With that I can keep some alive for some time.

I can tell you that if you know what you are doing you can stop an inguinal arterial bleed with some rolls of Kerlex and an ACE wrap, just as NongShim said, I have done it on several occasions. Just like a M4, medical equipment is good but quality training is better.

TQs are very important, knowing how and when to use them is even more important.

If there are any spacific questions let me know.

[Slab]

From the Civ (fire/EMS) side... In regards to liability, you are "protected" with the "Good Samaritan" laws (and this assumes you have "no duty to act") of your state, however the catch is that the treatment you provide is consistent with your level of training... So in short, if you apply a skill/technique without training for a given skill/technique, you could end up having to answer some difficult questions... In the civilian world the emergency use of TQs is "controversial" and generally for those of us acting under physician's orders, are written in as a "last resort"/action.

[TacMedic556]

As a 12 year Paramedic and 8 year SWAT medic, tourniquets have become dear to my heart. I am passionate about their availability, efficacy and routine carry by both EMS and law enforcement as well as civilians. Here is some valuable information (pardon all of the links but there is great information here). There are some excellent articles out regarding the great comeback of the Tourniquet:

https://www.youtube.com/watch?v=d-UxYNxhJuM
http://www.dailymail.co.uk/news/arti...bloodshed.html
http://www.google.com/url?sa=t&rct=j...qBIBWW2t8lfAcg
http://www.smcaf.org/InPressKragh.pdf
http://www.naemt.org/Libraries/Traum...iterature.sflb
http://stanfordhealthcare.org/
http://www.lawofficer.com/article/tr...ospital-tourni
http://m.jems.com/article/patient-ca...s-city-streets
http://www.jems.com/tags/prehospital-use-of-tourniquets
http://www.jems.com/article/major-in...urniquet-first
http://www.jems.com/article/patient-...er-tourniquets
http://www.jems.com/article/patient-...ts-original-re
http://med.stanford.edu/stanfordhosp...and_DSouza.pdf

Locally tourniquets have saved the lives of severely injured civilians involved in tragic accidents, one of which was a 3 year old girl. Had not a tourniquet been applied, the child would have died. There was a bow hunter jumping behind an Antelope blind who happened to stab his femoral artery ever so slightly enough to cause massive hemorrhage, where a field improvised belt/tourniquet was a factor in his survival.

Here are some notes from a Powerpoint I often use in teaching others regarding the use of tourniquets:

APPLICATION-
Apply without delay if indicated. (HIGH/PROXIMAL on the limb)
Both the casualty and the medic are in grave danger while a tourniquet is being applied in this phase – don’t use tourniquets for wounds with only minor bleeding.
The decision regarding the relative risk of further injury versus that of bleeding to death must be made by the person rendering care.
Non-life-threatening bleeding should be ignored until the Tactical Field Care phase.
Apply the tourniquet without removing the uniform – make sure it is clearly proximal to the bleeding site. (Teachings now state as high or proximal on the limb as possible.)
Tighten until bleeding is controlled.
May need a second tourniquet applied just above the first to control bleeding.
Don’t put a tourniquet directly over the knee or elbow.
Don’t put a tourniquet directly over a holster or a cargo pocket that contains bulky items.

TOURNIQUET MISTAKES TO AVOID-
Not using one when you should
Using a tourniquet for minimal bleeding
Putting it on too proximally (now being taught as not an issue)
Not taking it off when indicated during TFC
Taking it off when the casualty is in shock or has only a short transport time to the hospital
Not making it tight enough – the tourniquet should eliminate the distal pulse
Not using a second tourniquet if needed
Waiting too long to put the tourniquet on
Periodically loosening the tourniquet to allow blood flow to the injured extremity

Points to remember:
-Damage to the arm or leg is rare if the tourniquet is left on for less than two hours.
-Tourniquets are often left in place for several hours during surgical procedures.
-In the face of massive extremity hemorrhage, it is better to accept the small risk of damage to the limb than to have a casualty bleed to death.
-When a tourniquet has been applied, DO NOT periodically loosen it to allow circulation to return to the limb. (Causes unacceptable additional blood loss)
It HAS been happening, and caused at least one near fatality in 2005
-Tightening the tourniquet enough to eliminate the distal pulse will help to ensure that all bleeding is stopped, and that there will be no damage to the extremity from blood entering the extremity but not being able to get out.


I hope some of this helps. Get two, keep them in your kits or truck (you never know).

[zacbol]

Just took a three day class from Mike Shertz, who was an 18D, is Fellow of the American College of Emergency Physicians, runs a tactical medic team in Oregon, and is a the founding member of the Guidelines Committee for the Committee on Tactical Emergency Casualty Care (C-TECC) (http://c-tecc.org/)

His position is that the CAT is still the best of the commercial, one-handed tourniquets. Experimental data shows only 50% occlusion when the SOF-T is self-applied to the thigh and, for some odd reason, the SOFTT-W which should be better in theory has shown no more effective that the SOF-T (Savage E, Mil Med 2013). The CAT OTOH has show to be about 70% effective on occlusion to the thigh. He's clear that as soon something better comes along he'll switch but for now it's still the CAT.

He reviewed data for all of the following hemostatic agents in class at length and this is the final summary slide in the presentation. He basically said CombatGauze has the best current evidence, but even there it's not super impressive so he wouldn't worry about not having it.

Hemostatics Summary – 2 or 3 hr survival & 4 or 6mm femoral artery laceration
 Combat Gauze: 46/63 pigs survive
 ChitoGauze: 28/35 pigs survive (Question about validity/methodology)
 Celox (all types): 34/52 pigs survive
 HemCon Bandage: 7/51 pigs survive
 QuikClot ACS: Worse than Hemcon
 WoundState: Clots well, destroys arteries

Combat gauze is the TCCC hemostatic dressing of choice. Chitogauze and Celox Gauze may also be used if CG is not available

Since you also mention IFAK contents here were roughly Mike's recommendations and reasons (it's possible I've missed some nuance)
* 2 x CAT: extremity hemorrhage
* 2 x military cravat: can be used for 'traditional' tourniquet or to further secure a packed junctional hemorrhage (after application of ETD)
* 2 x Kerlix gauze: packing of junctional hemorrhage
* 28F NPA + lube (not clear if he normally has 2): for airway management
* Nitrile gloves
* 2 * 14 gauge needle/angiocath: for tension pneumothorax - Needle decompression is a paramedic level skill though so you probably shouldn't do this unless you want to be sued.
* 2 * Israeli Bandage/ETD: to secure packed junctional hemorrhage
* dedicated windlass (4 tongue depressors taped to eachother). Can be used with cravats for a 'traditional' tourniquet
* 2 * CombatGauze, but he said if he gave something up it'd be this
* Trauma shears
* He also had elements for surgical airway but because this was not covered and is a higher level skill he didn't elaborate

He keeps his hemorrhage control supplies vacuum sealed in their own bag without original packing for easier access. He concluded the review of the contents saying "If that won't keep you alive, your shit is weak and you're going to die"

[TacMedic556]

That is an excellent kit recommended above. Very similar to the ones we have set up.

After using SOF-T and CAT, I have found that the CAT is far easier to apply to one self using only one arm. CATs have an expiration (I think due to the velcro), whereas the SOF-T does not expire.

After attending an excellent LETTC course this year, we really dove into wound packing. I was impressed by the accounts per the instructors on the efficacy of really properly packing a wound with Kerlix. According to guys who know far more than I do, a properly packed wound with Kerlix is as effective as top notch hemostatic agents at times. I still applaud carrying and using combat gauze, however this was good to learn and know the skill of real wound packing and making that "cone of pressure".

The Olaes bandage is also a superb bandage to have in the kit. Having a couple of good Halo or FOX (preferred by instructors in said course) chest seals can be very necessary as well.

As far as Chest needles go for needle decompression I have always carried the larger 10 ga. These offer a little more depth (for thick muscular chest walls) as well as a larger orifice so as to prevent occlusion from hemorrhage, tissue and lung boogers.

As always, acquiring the proper "software" is critical, in order to properly utilize the "hardware".

Stay safe. Carry a good kit. Know how to use it and pray you never have to.

[HappyPuppy]

TacMedic556 is giving excellent advice. I was a navy corpsman and then trained in college etc further. I worked many years as staff in a major trauma center.

A properly used tourniquet can save someone's life. I saved someone in an auto accident years ago , and I have a well appointed kit in my vehicle fit emergency use

"Not all who wonder are lost" .

[buckpatriot]

I keep military grade tourniquets in the glove compartments of my cars as a carry over from my training. The same trauma still applies at home as in combat zone- bleed out is the first risk in the event of a car accident or other, on the road. The key is having the correct type of tourniquet and not a skinny/ homemade one that will be ineffective, allowing for a follow on amputation. Must be the correct with.

[Hmac]

I keep military grade tourniquets in the glove compartments of my cars as a carry over from my training. The same trauma still applies at home as in combat zone- bleed out is the first risk in the event of a car accident or other, on the road. The key is having the correct type of tourniquet and not a skinny/ homemade one that will be ineffective, allowing for a follow on amputation. Must be the correct with.

The vast majority of civilian trauma is blunt trauma. The need for a tourniquet in blunt trauma would be very rare, especially given typical EMS response times in most parts of this country. Those same civilian response times make amputation a highly unlikely outcome no matter what tools you use to control bleeding in the unlikely event of major bleeding from extremity trauma.

Don't get me wrong...tourniquets are cheap enough, easy enough to learn to use. They're easy enough to toss into a glove compartment. Every ambulance should have one, and probably most police cars . I don't advocate against them, I just don't see them as a particularly valuable tool in the civilian responder role.

[SOW_0331]

Everyone here has given spot on advice. At a later point in my gun carrying previous life, after I hung up my pickle suit for greener pastures, I was a "Team Medic" with EMT-I training and an 18D "Patrol Medic" who I spent all my admin time with. So I'm not nearly as trained up or experienced as some folks here and they're all spot on, DocSherm being a good dude or hit up for advice if needed.

In my experience, TQs are not as common or necessary. QuickClot, Celox, and other hemostatic agent/press packets are also rare. They are however the sort of thing that is covered by the maxim of "when you need it, you need it NOW". It's stupid not to at least seek out training when it's readily available. Either can be applied by a layperson in an emergency setting, either can/will be removed by EMS when they or a higher echelon receive the Pt into their care. I had my team members carry two TQs on them, one in their IFAK/MedK and one positioned for a buddy to grab for them. The second wasn't standardized because that shit is just stupid most of the time. On patrol on foot or mounted as VC, I kept a triangle dressing in my sleeve pocket and my ankle pocket (2x SOF-T, 2x CAT in med kit), because you don't always NEED a pre-fab TQ to get shit done. I've kept identical kits in my daily travel since then, (Lvl 1,2, and 3) though I admit to not keeping as much on the body. Have I used those emergency items? Well...

I've used some ThermoLoc to treat a family friend who lacks the natural ability to clot on their own quickly. It became clear when they sliced their hand pretty goof cutting an apple that they needed something better than a bandaid for the long drive to the ER (40+ minutes) and even pressure points weren't slowing enough to clot. I also used the same clotting powder for the next event.

My mom was riding behind my truck on my dad's bike, my brother and I were showing them how to get to our farm. Making a sharp left turn in a downtown area, I had just made the turn to look up in my mirror. A car, not realizing that only the left Lane turned, quickly jerked the wheel to make the turn. In doing so, they side swiped my folks into a utility pole, causing the back to go end over the handlebars. my brother (frmr NSW Team guy) and I grabbed our kits and jumped out without a word, him running to them, I throwing the truck back around to block traffic. My dad was a wreck (pun!) and trying to help my mom up, she was screaming. The other car had fled the scene by then, leaving their license plate on the pavement. There was blood and confusion, but we did what matters more than any bandage; kept our heads and owned the scene. Checked for any bleeding or breaks including pelvic before lifting the bike off of her. She thought she was paralyzed but was in a pretty severe state of shock. Once we assessed, we discovered her injuries to be a sprained ankle, a deep puncture below the elbow, and her shock being the most dangerous at the time. Brother drove my truck up onto the sidewalk where I had used two TQs and a SAM to apply a splint (TQs weren't necessary, but were fast and we needed to move from the street ASAP,so were gently used as fastens) and had begun bandaging in place her arm. Made several jokes with her and reassured her that she would be just fine...also incredibly important, as it snapped her out of shock. Once to safety, her wound was cleaned out and reassessed. I won't go into much more because the details are somewhat private, but the puncture in her arm was deep enough to fit my thumb to the first knuckle.

Guys train with rifles and handguns every day, they obsess over their gear being just right and the latest and greatest kit. Aside from the Gucci gear I'm not any different, though my end use is a reality. But I encourage, as do so many here, they go out and train and train and train. It's going to be better than the newest keymod Aimpoint in a LaRue KAC mount because they'll at least be basic level proficient. And yet, the average Jim and Joe are how much more likely to need medical knowledge than their carbine and JPC with tactical beard clippings? Don't limit yourself in what you're ready to of to save your own life or a loved one. Get some TACMED courses or look into an EMT line of exposure (go ride in an ambulance and pick up fat people with belly aches 99% of the time) and understand how the body works to treat it. Equip yourself with what you need in the same mind as "first line", "second line", or whatever it's called today. And remember that your ability to stay calm and do what you need to, and to have a plan, are what will save your ass. No different from a rifle carrier mindset.