View Full Version : Can we talk about sequence of operations?
More and more people, both pros and regular joes, are carrying hemostatic agents and tourniquets (as well as trauma dressings) in their personal aid or blowout kits.
For a "bleeder" on a limb, can some of the professionals weigh in with what the sequence of operations would be with regard to the above three items? Do you apply the tourniquet first, then the hemostatic, then the combat dressing? Or is the order of the first two reversed, or what?
Obviously this does not replace the need for actual training in these things, but just like guns a lot of people are wandering around with these items without any training at all (myself included right now), and it might be helpful to at least understand the basics of what order to apply these items.
Joe_Friday
03-04-09, 08:09
Hey Rob,
In my departments and in general in this area, Hemostatic agents (QuikClot, Celox) are not used due to the administration, time, and the cleaning process that must be completed after use of the agent and before any in-hospital treatment can occur. Administration is sometimes difficult as with some of the agents it must be placed directly on the vessel for occlusion to occur and to get the agent to the vessel can be very time consuming depending on the location of the vessel. It is my understanding, from EC Trauma Docs and RNs, that the process to clean the wound is very tedious and time consuming which results in the patient waiting even longer to recieve surgical care (I have not seen this because we do not use these agents but I do have faith in the staff that relayed this info).
As for the order of controlling bleeding. I have always been taught and use this method; Direct Pressure, Elevation and Pressure Point (DPEPP).
Grab the site with a gloved hand (preferably) and the appropriate dressing (it may be a large trauma dressing or an ABD dressing which is fairly small) and place firm pressure on the site. The firm part is really emphasized when dealing with deep veins and arteries such as the femoral artery but should be used at all sites. Remember to NEVER remove the dressing from the site. If it becomes soaked in blood keep stacking more dressings on top of it.
If the bleeding is not stopped elevate the extremity above the level of the heart which in turn will slow the amount of blood flow since it is "travelling up hill". When elevating the extremity be sure to watch for possible spinal cord injuries, fractures, angulations of the joints and any other possible trauma, and if present skip this step. You should consider the patient to have a spinal cord injury if any trauma exists around the spine or head (I know that is a pretty big area but you do not want to turn your buddy into a quad) or depending on the mechanism of injury (fall, MVC, etc.).
If the bleeding still has not stopped, use pressure points. In the lower extremities the pressure point that we use is the femoral artery regardless of the location of the wound. To access the site you must remove any heavy clothing from the patient and place the heal of the hand in the crease formed where the leg and lower abdomen meet. Typically the site is just above the level of the gentalia in the crease. This is a very deep artery and will require a great deal of pressure to occlude. In the upper extremities use the brachial artery which can be located under the arm, along the bone between the bicep and tricep muscles. It is not as deep as the femoral but still requires a great deal of pressure.
Hopefully at this point the bleeding has stopped!!! or your buddy/family member is being transported to the nearest appropriate medical facility by trained personnel with a lot better equipment than you.
If not, this is the point where I would consider the tourniquet for me or my immediate family. I say it like this because there are a few VERY IMPORTANT things to remember when you use a tourniquet. Yes, it will stop bleeding in an emergency situation where the patient may literally bleed to DRT (dead right there). But remember if the patient is not bleeding that much and you place a tourniquet on the extremity you are essentially killing that limb. It is a fact that tourniquets cause irreversible nerve and tissue damage if left on for a prolonged period of time. This is due to the shunting of blood from the area (the bleeding will be stopped) which in turn is also robbing the remainder of the limb from recieving oxygen and nutrients from the bloodstream.
I hope this helps.
Disclaimer: These are the methods that I use and was taught in school and through many classes. If you use it and your patient becomes DRT, DO NOT come looking for me. I am only giving this info to hopefully help someone if they are ever placed in this situation. It is by no means meant to replace thorough training. Just as we all love to train with our EBRs and 1911s for what you hope never happens (home defense, personal defense), you should also at a minimum recieve training in First Aid.
Plus, I am a FF/EMT-I with a wife, two kids and an expensive firearms habit, so I am broke! :D
Gutshot John
03-04-09, 09:03
For a "bleeder" on a limb, can some of the professionals weigh in with what the sequence of operations would be with regard to the above three items? Do you apply the tourniquet first, then the hemostatic, then the combat dressing? Or is the order of the first two reversed, or what?
Generally speaking you don't want to remove bandages that you've applied. Though for hemostats it's not going to do any good unless applied directly. Hence the advantages of having a hemostat impregnated in the bandage.
Take initial step of applying direct pressure, but realize that if you're alone you should call 911 EARLY in the process. I'd say slap a dressing on, then call 911, then start getting into the more intensive hemorrhage control.
Tourniquet is generally the last thing you apply when other methods have been exhausted. The exception to this would be a significant arterial bleed. Elevation is nice, but ultimately the last thing to worry about, after you've done everything else.
SOPs/Protocols may vary, but I'd apply dressing/pressure immediately while prepping the hemostat, then quickly remove dressing to apply hemostat then secure. As noted try pressure points, but you have to know where they are (where the artery runs close to a bone like behind the knee, shoulder or groin/hip).
If bleeding still isn't stopped then apply the tourniquet.
NOTE - Big difference between what civilian paramedics may do and military medics might do. Since the former will be more occupied with restoring/saving a limb which a tourniquet complicates. Civilian paramedics are MUCH more cautious about applying a tourniquet. I've heard that current military protocol is to throw a tourniquet on for any bleeding extremity, this may be a bit too aggressive if a hospital/911 is readily available.
Failure2Stop
03-04-09, 09:41
I agree with Joe.
In a gunfight, my response to a bleeder is primarily to do as much as I can for myself with my training to allow my men to win the fight and then worry about me later, or to quickly help someone else that can't deal with themself for whatever reason. I am not a medic and I do not carry the full spread of supplies or experience needed to actually stabilize a badly injured man. That is why we have dudes trained for that, with all the weight that comes with it.
Since the stuff I carry in immediate access is for me, my response to an injury to me is first direct presure/pressure bandage and elevate if possible. If the pressure bandage isn't working and I can access a pressure point, I will try to use it, but it is pretty unlikely that after losing a bunch of blood I will have the strength to maintain the pressure point for long, especially after I hit myself up with morphine. If the direct pressure isn't working or if I have a traumatic amputation I will have to go to a tourniquet. The moral implications of a tourniquet is greatly reduced as it will be my choice to strap it on or bleed-out. In the case of a lung-shot I might be able to slap an ACS on myself, but it is pretty unlikely that I will be able to do much about the exit wound and it would require removal of my armor without any friends to protect me.
With regard to others I am onside with Joe, but I am pretty limited on what I will do unless the trained medical guy can't get to us or if he is the casualty. First make sure that the guy is breathing and his heart is beating (ABC's)- no use in working on the wound if he isn't breathing or his airway is blocked. Once those those little details are checked off check for head and spinal injuries as best you can, since moving him around might really screw him up if those are damaged. Bleeding from the ear can be a sign of a skull fracture, but can also be due to blast- if the casualty is unconscious it is better to err on the safe side and treat it as a skull injury. Don't move the casualty more than necessary for his safety or to conduct CPR and/or deal with blood-loss.
I have pretty much the same approach for a training injury- do as much as my knowledge and training permits until the evac arrives. I am not going to be rooting around in somebody's thigh to try to clamp off the femoral artery unless I am helping someone that knows exactly what they are doing.
Just my perspective on the matter.
lazythekid
03-04-09, 10:05
Good stuff here. I'll add my two cents to what has been said, however I have little experience with hemostatic agents. Direct pressure is the most important aspect of hemorrhage control. In simple terms, it decreases the size of the openings in the bleeding vessels and creates pressure against which the blood would have to flow. This will stop many bleeders.
The latest from some of the trade magazines, doctors, trauma certifications (PHTLS), is that elevating the limb and utilizing pressure points has shown no benefit. They haven't come out and said to not do it, but rather emphasized going straight from direct pressure to applying a tourniquet. The tourniquet has been a practice of last resort for a long time but that attitude is going away. Extremities can last several hours with a tourniquet applied without permanent damage.
So direct pressure and if still bleeding apply your tourniquet. Apply your tourniquet 1-2 inches proximal (towards the body) of the injury. Meaning, put your tourniquet as reasonably close to the wound as possible without being applied over the wound. Whatever you're using as a tourniquet, remember that the wider the better (within reason). 1-2 inches will work.
This is coming from a civilian paramedic's experience. Hopefully someone can enlighten us to the military side. For me though, I'd expect to do about the same as Gutshot John as far as the application of your clotting agonists.
So, at least in terms of the dressing/tourniquet sequence, it sounds like it would be compression bandage first, then tourniquet if that didn't work?
I think I recall seeing somewhere that tourniquest, hemostatic, bandage was a sequence that was being recommended. Sounds like, at least in terms of injuries sustained in civilization (i.e. with an EMT response time measured in minutes and not hours), the hemostatic can largely be skipped and even the tourniquet is a second line and not a first.
Which brings up the question:
Would the solution/sequence vary depending on distance to a hospital or trauma center? In other words, would you do one thing on a range that's down the street from a trauma center but another if you were 2 hours away in an airboat in the Everglades?
lazythekid
03-04-09, 10:54
So, at least in terms of the dressing/tourniquet sequence, it sounds like it would be compression bandage first, then tourniquet if that didn't work?
That would be my suggestion.
Which brings up the question:
Would the solution/sequence vary depending on distance to a hospital or trauma center? In other words, would you do one thing on a range that's down the street from a trauma center but another if you were 2 hours away in an airboat in the Everglades?
The only differences for ME in these instances would be the application of hemostatic agents. I currently work in an area where I can get to a Trauma I center in five minutes by ground ambulance, and a second Trauma I in fifteen minutes. I don't anticipate using hemostatic agents when the patient is going to get definitive treatment within the first half hour of injury. I would still use pressure, and if necessary, tourniquet to control bleeding. 2 hours away in an airboat? I'd probably be more willing to use the hemostatic agent. And if being 2 hours out on the Everglades is a common occurrence, I'd consider learning how to start an IV. It's not difficult to start an IV on a healthy person.
Assess the wound > apply direct pressure while preparing your agent > apply agent and direct pressure > if still bleeding apply tourniquet.
Again, this is all coming from my viewpoint as a civilian firefighter/paramedic.
Gutshot John
03-04-09, 14:14
Which brings up the question:
Would the solution/sequence vary depending on distance to a hospital or trauma center? In other words, would you do one thing on a range that's down the street from a trauma center but another if you were 2 hours away in an airboat in the Everglades?
Exactly correct. Paramedics operate under the command/license of a physician in the ER. He vets them to make decisions in his place in the field and lays out these protocols.
While protocols have recommendations that change, each command will make determinations based on transport times etc.
If I was five minutes down the street, and the bleed was that serious, I'd waste no time other than slapping on a dressing and driving like hell. If necessary have someone apply the tourniquet in the car, don't waste time with hemostats, blood will be everywhere but just control as best you can. Speed is off the essence.
If I was talking about several hours, and I've done extended transports that lasted as long as 6 hours, you'd definitely want to stabilize things first.
Our medics recommend that you perform basic procedures first and use any type of hemostatic agent as the last resort. It is my understanding that the studies that have come out of the experience in Iraq and A'stan show that a tourniquet can be applied and left for several hours (IIRC) before any permanent damage occurs. Obviously situation will dictate what really happens.
Gutshot John
03-04-09, 16:44
Our medics recommend that you perform basic procedures first and use any type of hemostatic agent as the last resort.
So they recommend that hemostatic agents be applied only after the tourniquet has failed?
Yes, at least as far as I remember. It had to do with the Army and their recent decision to suspend the use of Wound-Stat. Something about thrombosis or something being caused by the agents. I believe that our guys did say that Celox or the bandage that has the hemostatic agent in it are much better.
My feeling is that if a person is bleeding and direct pressure/ bandage has failed and the tourniquet has failed (obviously where appropriate) then the hemostatic would then be applied. Maybe my thinking is wrong on this. But, as I said everything is situation dependent.
So they recommend that hemostatic agents be applied only after the tourniquet has failed?
From what I understand, the newer products like Quick Clot ACS (which is the same as the commercial Quick Clot) in the sponge/bandage alleviates a lot of the problems they were having with the earlier generations.
Can any of the IP/SMEs shed some light on this?
This was posted over at SOCNET and I thought it pertinent to the discussion.
FROM
CDRUSAMMA FT DETRICK MD//MCMR-MMO-SO//
***PRIORITY***MESSAGE NOT RELEASED
****************UNCLASSIFIED****************
SUBJ: T0B-1218-002
NEW SOLDIER HEMOSTATIC DRESSINS / WOUNDSTAT / MEDICAL INFORMATION
REFERENCE: ALARACT 239/2008, NEW SOLDIER HEMOSTATIC DRESSINGS
1. THIS FRAGO DIRECTS TEMPORARY CESSATION OF USE OF WOUNDSTAT™ (WS) BY 68W
COMBAT MEDICS AND ALL OTHER PROVIDERS DUE TO NEWLY IDENTIFIED SAFETY CONCERNS
ABOUT THIS PRODUCT, PENDING FURTHER EVALUATION.
2. WOUNDSTAT™ WILL BE TURNED IN TO THE MEDICAL SUPPLY SYSTEM IMMEDIATELY.
UNIT SUPPLY PERSONNEL WILL TURN -IN WOUNDSTAT™ TO THEIR SUPPORTING MEDICAL
SUPPLY SUPPORT ACTIVITY (SSA). THE ARMY MEDICAL SSA WILL REVIEW TRANSACTION
REGISTERS AND COMPLETE 100% CONTACT WITH UNITS ISSUED WS TO ENSURE TURN-IN
OF PRODUCT. ARCENT WILL SUBMIT THE TOTAL NUMBER OF WS ISSUED AND COLLECTED
TO OTSG. THE ARMY MEDICAL SSA WILL HOLD WS UNTIL FURTHER NOTICE OR UNTIL DISPOSITION
INSTRUCTIONS ARE RECEIVED FROM OTSG.
3. DATA FROM THE US ARMY INSTITUTE OF SURGICAL RESEARCH (USAISR) SHOW THAT
WS IS ASSOCIATED WITH A HIGH INCIDENCE OF BLOOD VESSEL THROMBOSIS AND DAMAGE
TO THE VESSEL WALL. COMBAT GAUZE AND PLAIN KERLIX WERE NOT ASSOCIATED WITH
SIMILAR FINDINGS. USE OF COMBAT GAUZE IS SAFE, ACCORDING TO CURRENT STUDIES,
AND DISTRIBUTION AND USE SHOULD CONTINUE.
4. MEDICAL PERSONNEL MUST LOCATE AND EXAMINE ALL CASUALTIES PREVIOUSLY TREATED
WITH WS TO VERIFY ADEQUATE LIMB PERFUSION, IF WS WAS USED TO TREAT EXTREMITY
WOUNDS.
5. EXPIRATION DATE CANNOT BE DETERMINED.
Joe pretty much nailed it from an EMS perspective. For care under fire, or in a generally hostile environment, a different sequence of events may be preferrable.
If you are taking fire, the best thing you can do for a wounded man is to maintain fire superiority and get him out of there. It is critical that you unass the area as quickly as possible and get to a place where you can provide care.
Bleeding control is obviously very important. You only have a limited amount of blood to begin with and it is lost rapidly when you are shot. If you are able to devote a lot of time, skill, and material to a casualty, then it is best to go through all of the steps outlined above. If not, you are better off applying a tourniquet and moving on. The potential for a lost limb is well established, but a lost limb is preferable to a dead patient if bleeding cannot be controlled and the simple fact is that a properly applied tourniquet will stop(or at least significantly reduce) bleeding immediately.
In my opinion, if you aren't able to immediately evacuate your casualty to a place that can provide more care, a tourniquet is the way to go for severe wounds.
Here is another from SOCNET about the subject.
Dear Dr. F,
I am writing this letter in response to your request for an unbiased opinion concerning the decision of the Army to temporarily remove WoundStat from clinical use until it could further evaluate the findings from an animal study that raised concerns about its safety. To clarify my position, I am the Chief of Trauma and Surgical Critical Care at Oregon Heath & Science University, which is a Level 1 Trauma Center and I have an active xxxxxxx research laboratory that studies hemostatic dressings. I am also a member of the US Army Reserves assigned to the Institute of Surgical Research (USAISR) and I have been deployed to Iraq where I utilized hemostatic dressings in the care of combat casualties. I have no pre-existing affiliation with WoundStat or TraumaCure and my primary interest as a trauma surgeon is to achieve the best possible outcomes for civilian and military casualties.
My opinion is based on a review of both published and unpublished studies comparing WoundStat to other dressings for safety and efficacy as well as discussions with experts in the field and personal experience with the dressing. The latest published guidelines of the Committee on Tactical Combat Casualty Care (TCCC) indicate that WoundStat should be used as a backup to Combat Gauze for compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal in the tactical field care environment. Studies comparing the efficacy of WoundStat to other dressings have been performed by the Virginia Commonwealth University (VCU), North America Science Associates (NAMSA), the US Air Force, the US Navy and the US Institute of Surgical Research. Ex vivo studies in normal blood, heparinized blood, blood with anti-platelet agents and diluted blood all reveal that WoundStat increases coagulability suggesting that at least part of the dressings’ effect is due to activation of the coagulation system. The dressing has also been noted to function by creating a sealant effect by its conversion to a clay form which has memory and confers compression even after manual pressure has been removed.
Pre-clinical trials have been performed in xxxxx models. These models have primarily involved femoral artery and/or vein punctures with uncontrolled hemorrhage followed by placement of study dressings with a variable compression period and resuscitation. These models are considered to be 100% lethal when treatment is with standard dressings.
Study endpoints have included short term survival, blood loss, resuscitation volumes and laboratory values. The numbers of xxxxx per group ranges from 5 to 10 and there are generally multiple dressings studied. These analyses are underpowered to show differences in survival or blood loss unless the differences are very large. Studies performed by VCU, NAMSA, Travis Air Force Base and the USAISR have revealed a 100% survival rate in xxxx treated with WoundStat. No other dressing achieved 100% survival rates in any of these studies. xxxx treated with WoundStat also had less than 10 ml/kg of post-treatment blood loss which was numerically less than any other dressing. The USAISR performed the only study that compared WoundStat to Combat Gauze. In this study, xxxxx treated with WoundStat had 100% survival compared to 80% for Combat Gauze. Blood loss was approximately 10 ml/kg in the WoundStat group versus approximately 40 ml/kg in the Combat Gauze group. These differences in survival and post-treatment blood loss did not achieve statistical significance. Histologic changes in tissues treated with various dressings were analyzed in the USAISR study and they were graded as mild to moderate tissue injury in both the combat gauze and WoundStat groups. Also of note, the USAISR has performed computed tomography angiograms to evaluate injured femoral vessels after they have been treated with various dressings and these studies have revealed that all agents have resulted in obstructed blood flow. These preliminary studies have uniformly shown excellent efficacy of WoundStat resulting in tremendous enthusiasm for its use and its addition to the TCCC guidelines as a secondary agent when Combat Gauze fails or the wound is more amenable to a granular agent.
Studies showing evidence of tissue injury and obstructed blood flow with hemostatic dressings induced the USAISR to produce a new model that was primarily designed to test safety in larger blood vessels. This model involves dissection of the carotid artery and external jugular vein followed by clamping and a 50% transection of both vessels made with scissors. Free bleeding is allowed for 30 seconds after which dressings are placed and compression is held sequentially until hemostasis is secured. xxxx are resuscitated with 500 ml of Hextend followed by LR to maintain a mean arterial pressure of 65 mmHg. Dressings are left in place for 2 hours and subsequently removed. The vessels are then primarily repaired and blood flow is restored. During the repair, xxxxx are given 1 liter of lactated Ringer’s. The wounds are subsequently closed. Heparin is not utilized either locally or systemically. Two hours after blood flow is restored, the wounds are reopened and blood flow is assessed with computed tomography angiography. The wounds are then reopened and blood flow is confirmed. Histology is obtained from the injured vessels as well as from lung and brain to look for evidence of material or clot embolization.
Combat Gauze, WoundStat and kerlix were compared utilizing this model. Post-treatment blood loss was significantly greater in the kerlix group but not significantly different between Combat Gauze and WoundStat. Combat Gauze and WoundStat xxxxxxx also required significantly less total compression time. In terms of safety, 7 out of 8 carotid arteries and 6 out of 8 jugular veins treated with WoundStat developed occlusive thrombi. All vessels that were treated with Combat Gauze and kerlix were patent but there was restricted flow in some of the vessels treated with these agents. There was also a large clot and WoundStat residues found in the lung of two xxxxxx that were treated with WoundStat. Histology revealed transmural injury in all vessels that were treated with WoundStat. Histologic changes associated with Combat Gauze and kerlix use were reported to be mild and equivalent.
It is important to note that QuikClot shares some common characteristics with WoundStat. QuikClot is a granular agent that has been shown to have pro-coagulant effects in vitro which are similar to WoundStat. QuikClot has the disadvantage of being an exothermic agent that induces thermal injury. QuikClot has been used extensively by military and civilian agencies. There is a published report of its use in 103 patients and neither pathologic vessel thrombosis nor embolization has been reported. QuikClot has not been studied in the USAISR safety model.
There have been scattered verbal reports of WoundStat use in human patients. However, to my knowledge, none of these reports have been published to date. Additional studies evaluating WoundStat for safety and efficacy are either planned or ongoing.
Based on the available data, I would make the following observations:
1. WoundStat is extremely effective in xxxx models of lethal hemorrhage. The trials that have been performed have been small and they do not have the power to distinguish the efficacy of WoundStat compared to Combat Gauze.
2. The findings by the USAISR of full thickness vessel injury and thrombosis associated with the use of WoundStat are of some concern. It is not clear if these finding are related to a mechanical effect of WoundStat related to the product’s intrinsic memory and its ability to maintain pressure when compression has been removed, an abrasive quality of the granules or a chemical reaction of the product. These findings should be interpreted within the scope of the xxxxx model. Similar to the femoral vessel injury model, the cervical model involves dissection of the vessels and partial transection with scissors exposing the vascular endothelium. The injuries were primarily repaired. This differs from injuries seen in combat in that those injuries generally involve high energy impact with significant damage to the vessels and surrounding tissues. The vast majority of these injuries require resection of injured vessels to healthy areas and interposition grafting. In addition, either systemic or local heparinization is used in clinical settings to help achieve prolonged patency. Finally, xxxxxx are a hypercoagulable xxxxx compared to humans. Further research studying the etiology of the thrombosis and endothelial injury seen with WoundStat as well as comparing WoundStat and Combat Gauze in injury models associated with high energy and the use of interposition grafting would help clarify the relative safety of these two products in realistic settings. It would also be interesting to test QuikClot in the USAISR cervical model to help determine if the findings seen with WoundStat are reproduced with another FDA approved agent that has similar characteristics.
3. It is not uncommon for potent hemostatic agents to cause thrombosis or systemic complications when they are exposed to the vascular endothelium. Topical thrombin which is used on a widespread basis by surgeons to control bleeding is contraindicated for intravascular use or for the treatment of brisk arterial bleeding. This has not prevented thrombin from being used widely for severe bleeding.
In conclusion, WoundStat is a granular hemostatic agent that differs mechanistically from tourniquets and Combat Gauze, expanding the medics’ ability to stop bleeding in extreme scenarios. In light of WoundStat’s intrinsic hemostatic capacity compared to preliminary data suggesting its potential for causing injury to blood vessels as well as thrombosis and embolization, it seems reasonable to continue using WoundStat when other measures have failed especially when the alternative is death. The safety of WoundStat has not been studied in realistic models that include modern vascular replacement techniques and heparinization. Furthermore, the use of WoundStat should be safe and potentially lifesaving in coagulopathic patients in whom large vessel bleeding has been controlled and exposure to vascular endothelium is limited. Both recombinant factor VIIa and tourniquets are commonly used to treat combat casualties. These agents have known complications that are limited by using them appropriately and the same concepts should be applied to WoundStat.
I wonder how that carries over to Quick Clot, specifically the ACS and others that are part of a sponge. IIRC, Wound Stat is typically applied in the granulated form.
That letter states it very well. There will be situations and certain wounds where the basic steps will have little effect and it's nice to have another option.
I would learn to know the difference between a wound that will be treated well with the basic steps and a wound that will need aggressive treatment.
As always, the best tactical medicine is overwhelming force. Medicine is much easier when you remove the tactical.
Gutshot John
03-04-09, 18:29
The ACS is an improved application that works well for simple TnT gunshot wounds. It's packaged in pairs (entrance/exit wounds) which makes things convenient.
They won't work well for something like a traumatic amputation, though they are probably all the hemostat that most people here will need relevant to GSW.
Things like CELOX applicator use the granulation to place it very specifically into the wound.
For simplicity's sake, I'd confine things to impregnated dressings. It just eliminates a step.
A few things to bear in mind when talking about bleeding control in the face of penetrating trauma, especially if there is an ongoing threat.
The sequence is exactly as IraqGunz said, massive bleeding is actually prioritized above airway, and tourniquets are emphasized much earlier in the bleeding control sequence due to the speed that they can control bleeding and the over-arching needs of the existing tactical situation. Stopping the shooter/s results in less of us getting shot. Shot officers/soldiers are assets that need to be kept in the fight. Tourniquets are fast and can be converted to pressure dressings later after the fight is over. Stair stepping up thru the bleeding control continuum just allows the casualty to bleed more. But this is situation dependant as people have already talked about.
There are a few take home points for using hemostatics. They fill a couple niches wherein we prioritize their use sooner. These niches are severe bleeding that isn't easily compressible or isn't being controlled by direct pressure, or can't be tourniqueted.
A: The neck, large vessels, difficult to compress, there are some bandaging possibilities, but you have to be creative so as not to compress vessels on both sides, or the airway.
B: Axilla(armpit), likewise, large vessels, somewhat easier to compress, but difficult to tourniquet.
C: High femoral/groin: large vessels again, sometimes you can get a tourniquet high enough to actually act as a adjunct to the pressure dressing. But still, a difficult, spot to control bleeding depending on how high the wound is.
Those are our 3 sites that we may go directly or very quickly to hemostatics. Extremities we tourniquet. The bleeding from torso injuries "in general" is internal and not compressible and we don't address it other than dressings and Ashermans if its thoracic. There are other instances that we use hemostatics, but that is beyond the scope of what we are talking about here and is more of a remote/austere prolonged evac setting.
A couple more notes about Hemostatic agents, I've used all of them except woundstat. They all work about equally well, the low temp QuickClot doesnt scorch wounds anymore, and they are all easy to remove afterward. The biggest single factor in getting control of bleeding is using whatever agent correctly.
Get heavy pressure on the wound quickly, we teach kneeling on it if thats possible, or putting a gloved fist onto it with much of your body weight, get out your supplies, or take the downed officers IFAK off and use his, open up at least one, preferably two battle dressings, and the hemostatic agent (we use QuickClot ACS). Release pressure and immediately sweep the wound to clear excess blood, place the hemostatic agent as deep into the wound as possible to get to the bleedng vessels, put a battle dressing back onto / into the wound and put the same heavy pressure back onto the wound for 2 minutes. If the wound is deep you may need the additional dressing to build up enough so that the pressure you are applying at the top of the wound is transmitted all the way down to the base of the wound.
While the tourniquet info is geared more toward a care under fire setting, the hemostatic take home points are valid for .civ ems or TEMS/Military.
Additionally we are looking at CombatGuaze for scalp lacs/avulsions.
Joe_Friday
03-04-09, 18:53
Hey Rob,
I have just a couple of questions that may help to answer your question and I should have asked before posting, being I made the original reply pretty generic.
1. What is the intended purpose? You alone, you and another, or more than two individuals.
2. Will you be depending on applying the kit to yourself or directing another to do so?
3. How far in minutes will you be from defined care if an incident were to occur? (estimate, I know you are never sure)
4. Is this going to be on your "GoTo" Rig or are you going to keep these items for the range mainly?
I know some of these questions may seem to be a moot point but it really helps to know as everyones situation may be different. As Iraqgunz said "everything is situation dependant." Do you know what the local EMS/trauma facility protocol is on using an hemostatic agent. I know that you live in a heavily populated area from your other posts but if you went to Podunk General because it is the nearest facility they may not have a clue what QuikClot or Woundstat is which could exacerbate the problem with Roscoe poking at it with a stick (trust me I have been to a few Podunk Generals before). Just something to think about. Of course as others have said, if your fixin' to be DRT who cares what anyone else thinks, pour it in and pray.
Oh and the tourniquet, I did not say anything about the amputations because Ray Charles can even see that you need to put a tourniquet on an amputation. Basically there will not be any tissue to save anyway.
To be honest with you, I have a little problem with the IFAK kits that I see a lot of people running around with anyway :rolleyes:. The HSLD crowd has a definite need for some of these items but they have also been given the appropriate level of training as to when and, more importantly, when not to use certain items. While I agree that you should do everything you can to save someone, especially if it is numero uno, many do not understand that what they are doing is causing even more harm.
YMMV
My academy gave us the following procedure for treating trauma-
1. Call EMS
2. Direct Traffic
Like others have said the proximity of well equipped and educated care has something to do with preliminary treatment. That is how I understand it anyway. Learning here.
Joe_Friday
03-04-09, 19:19
My academy gave us the following procedure for treating trauma-
1. Call EMS
2. Direct Traffic
Awesome !!! :D You beat my post hands down!!!
They all work about equally well, the low temp QuickClot doesnt scorch wounds anymore, and they are all easy to remove afterward
Scorch? I knew it got warm but I didn't know it burnt you.
The original QuickClot powder compound got really warm. to the point that you didnt want to hold onto it if it had blood mixed with it. After flushing it out of a wound, the wound edges were very irritated, and discolored. "Scorched" may not be a technical term, but it's what the wound looked like to me.
The new formula doesn't have that problem. I've used it on live tissue, pulled it out after bleeding was controlled and all the wound edges were 'normal' looking.
The old hi temp formula is still being produced, but, to my knowledge isnt being sold on the .civ market and even in our limited market, I'm not seeing it.
Additionally, the bean bags solved some of the other issues with it blowing around, and the CombatGuaze seems to offer a lot of promise.
i've had good success with Celox also.
Iraq Ninja
03-04-09, 22:34
Scorch? Like it heats up an Cauterizes the wound?
Heat is a bad thing. It was never intended to cauterize. This is the Gen 1 QC junk. Also, if the stuff got in your eyes, it hurt like hell.
One of our guys got hit by an IED a few years back. A piece of metal came thru the vehicle and hit him in the head, removing part of the skull. His ignorant team mates poured Gen 1 QC into the wound. His brain got fried. He lived, but he lost more of his brain due to the QC than the wound.
We use the Hemcons and the new QC pads now.
The Celox stuff is very good, especially the one in a syringe that you shoot into the wound (celox-A).
Rumor has it that instant mash potato powder can be used in emergencies, but I never verified that story.
I hope some combat medics will chime in and give us the latest poop. I am just an end user...
Cool, thanks for the explanantion.
The bag/sponge QC is the way to go, huh?
The Quick Clot ACS sponges are gtg. The latest reccomendation from TCCC is for CombatGuaze. Essentially the same compound, just impregnated in a roll of guaze, made by the same company. ZMedica. It gives you a few more options, but I wouldn't feel under equipped with any of the major hemostatics, the biggest factor, all things considered is using the product appropriately.
Iraq Ninja
03-04-09, 23:03
Lets not forget that WoundStat has problems now, and is being pulled from the troops...
SUBJ: T0B-1218-002
NEW SOLDIER HEMOSTATIC DRESSINS / WOUNDSTAT / MEDICAL INFORMATION
REFERENCE: ALARACT 239/2008, NEW SOLDIER HEMOSTATIC DRESSINGS
1. THIS FRAGO DIRECTS TEMPORARY CESSATION OF USE OF WOUNDSTAT™ (WS) BY 68W
COMBAT MEDICS AND ALL OTHER PROVIDERS DUE TO NEWLY IDENTIFIED SAFETY CONCERNS
ABOUT THIS PRODUCT, PENDING FURTHER EVALUATION.
2. WOUNDSTAT™ WILL BE TURNED IN TO THE MEDICAL SUPPLY SYSTEM IMMEDIATELY.
UNIT SUPPLY PERSONNEL WILL TURN -IN WOUNDSTAT™ TO THEIR SUPPORTING MEDICAL
SUPPLY SUPPORT ACTIVITY (SSA). THE ARMY MEDICAL SSA WILL REVIEW TRANSACTION
REGISTERS AND COMPLETE 100% CONTACT WITH UNITS ISSUED WS TO ENSURE TURN-IN
OF PRODUCT. ARCENT WILL SUBMIT THE TOTAL NUMBER OF WS ISSUED AND COLLECTED
TO OTSG. THE ARMY MEDICAL SSA WILL HOLD WS UNTIL FURTHER NOTICE OR UNTIL DISPOSITION
INSTRUCTIONS ARE RECEIVED FROM OTSG.
3. DATA FROM THE US ARMY INSTITUTE OF SURGICAL RESEARCH (USAISR) SHOW THAT
WS IS ASSOCIATED WITH A HIGH INCIDENCE OF BLOOD VESSEL THROMBOSIS AND DAMAGE
TO THE VESSEL WALL. COMBAT GAUZE AND PLAIN KERLIX WERE NOT ASSOCIATED WITH
SIMILAR FINDINGS. USE OF COMBAT GAUZE IS SAFE, ACCORDING TO CURRENT STUDIES,
AND DISTRIBUTION AND USE SHOULD CONTINUE.
NinjaMedic
03-05-09, 01:06
In my experience you can basically tell by just looking at an extremity wound, whether or not a specific hemorrhage site will be able to be controlled with gauze and direct pressure. If I have any question at all that I might have difficulty controlling a bleed or I need to expedite pt movement, I will use a tourniquet. When things have calmed down, I have more hands, or the pt has been removed to a safe area for further treatment, I can begin worrying about bandaging a site and removing the tourniquet. Tourniquets do not destroy tissue, and I can fix almost anything thats going to kill you right now. The one thing I cant do (with todays technology) is give you whole blood or some other compound that carries oxygen to your vital organs. My 1ST priority is stopping a life threatening bleed as absolutely quickly as possible so that all of that other ABCD stuff can stay relevant. You will begin to see tourniquets become more and more accepted as a front line treatment for hemorrhage control in civilian medical care in the coming years as all the old myths about them disappear.
calebgriffin31
03-05-09, 12:58
Keep the great information coming!
Iraq Ninja
03-05-09, 14:07
If you are part of a team, then everyone on the team has to know the location of everyone's med kit. Some groups require specific locations, for instance, on the left side of your vest. If IEDs are a threat, then the left side is best since most blasts come from the right side. So, you don't want your med kit to get messed up in the blast.
Everyone in your family needs to know how to use your kit as well.
A medic once taught me to carry some of those strong altoids mints. Use them around situations where the smell may make you nauseated, such as open bowel wounds, smelly dead folks, Iraqis who haven't bathed since Saddam was President, etc. I guess the mints overload your sense of smell.
If you expect to do some shooting, then expect to get shot. That means each hit you take may have and entrance and an exit wound. Carry more than one field dressing. I once took an AK round in my right leg, but the bullet partially broke apart when it went thru the vehicle. Some of the shrapnel went into my left leg. I only had two dressings, and used them up quickly. I carry at least four now. :) We had a total of four guys hit, and we went thru our medical supplies very fast.
Medical training in a classroom is like rifle shooting off of a bench. It is not the best way to learn. Can you use your med kit in the dark, or in a moving vehicle, or upside down in a ditch?
browningboy84
03-11-09, 22:22
After talking to a few flight medics that I know, who service parts of the Panhandle in Florida, some services down there use the Quick CLot ACS, but only after consulting with an ER physician, also known to those of us who are in the EMS business as medica control. It is used, but only on a very limited basis. I have used a tourniquet before, but it was a last resort, and he was tore up from a boat propeller. You can get away with using a tourniquet, but I was told to leave it on for a max of 15 minutes!!!! Remember, most of the time, you can get things done with pressure, a dressing, and elevation!!!!!! Best bet, haul ass to the hospital. You could always do what I have seen a guy do, then he could not stand the pain and called EMS. He took a piece of rebar, heated up with a torch, and cauterized his wound where he fell on a piece of metal......... he wound up worse off doing that..... HINT: Dont do what he did.
Iraq Ninja
03-11-09, 22:31
15 minutes max for a tourniquet? LOL. That is so 80's. We have much more experience now that shows otherwise.
Joe_Friday
03-12-09, 06:45
No offense bb84, but I would not advise taking a tourniquet off until I was at a medical facility that could control the bleeding. It is already a last resort and you have basically given up hope for that limb anyway.
Besides that what are you doing listening to FL medics anyway? :p
No flames please, I have friends that are medics in FL and its just a friendly joke between most of us concerning what GA medics can do vs. FL medics.
lazythekid
03-12-09, 10:46
JEMS put out a pertinent series of articles a couple of months ago.
http://www.jems.com/resources/supplements/war_on_trauma.html
browningboy84
03-12-09, 12:09
They were flight medics that used to work in Grady County part time when I was working down there. As for the tourniquet, the ER doc himself told me to put it on for 15 minutes, and no more. Besides in 10 minutes, the chopper crew was landing, and 15 minutes later, the medevac was takin off headed to Grady Memorial. No longer my call. I was taught in medic school 15 minutes if you have to use a tourniquet.... Either way, I dont like using a tourniquet!!!!!!!
I was taught in medic school 15 minutes if you have to use a tourniquet....
Please understand I mean no disrespect, and am trying to learn from those that know more than me...
Do you mind if I ask when you went to medic school? From everything I'm researching and learning with regards to lessons learned coming out of the GWOT, the current thinking has shifted such that tourniquets are considered good for upwards of 4 hours without tissue damage based on real-world case studies from actual use. To the point (if I'm not mistaken) that it's being taught as the first course of action by some agencies.
I'm curious to know if your instructors had this latest (meaning the last few years) information at their disposal when you went through school.
again, not questioning your opinion or experience, just looking for clarification to measure it against conflicting information I'm getting from elsewhere.
browningboy84
03-12-09, 12:20
I graduated in 2007, and my instructor has been around teaching almost 30 years now. She did say that the millitary was conducting studies from what they learned in Iraq and Afghanistan. The ER doctor told me no more than 15 minutes when I had the boating accident back last July. I am not trying to piss anybody off. Personally, I will do what I gotta do to save a life, and if I get in trouble for taking a chance, then so be it. Life over Limb is the guiding principle here.
No offense bb84, but I would not advise taking a tourniquet off until I was at a medical facility that could control the bleeding. It is already a last resort and you have basically given up hope for that limb anyway.
We convert tourniquets to pressure dressings, there is a protocol for it . One of the biggest reasons is precisely how free we are in having people go to a tourniquet. They don't fool around with one failed step in the bleeding control continuum, to go to the next level, etc etc, all the while bleeding out. Getting hit in a low light setting, with the threat still in play means our guys wil go to a TK first. We teach them not to white light illum themselves to try and differentiate from a venous vs an arterial bleed. For obvious reasons.
Tourniquet it. When the threat is addressed, and the dust settles a medic will take a look at you, and based on experience either leave the TK in place or convert it.
As was stated earlier, we have come a long way in de-bunking most of those old tourniquet myths. A lot of it was due to too narrow tourniquets, torqued to a point that they crushed the underlying tissues and structures resulting in needless limb loss. This is no longer an issue with any of the purpose built tourniquets that are commonly being carried.
The current window on tourniquets staying in place is 4 hours, there are people I respect that are saying 6. We don't teach any form of a 15 minute rule, nor have I seen that referenced in any literature or courses I have attended. If we place a tourniquet due to bleeding we couldnt control otherwise, the tourniquet stays on.
Joe_Friday
03-13-09, 14:44
We convert tourniquets to pressure dressings, there is a protocol for it .
To give a little insight to those that may not know, protocols are developed by the Medical Director (Physician) of an individual EMS service. Therefore, you can have two adjacent counties, or two services in the same county, with totally different protocols. What I am getting at is YOU have a protocol for this. In Ohio. I am in GEORGIA and I do not have a protocol for this. As I stated in my orginal post, this information is what I was taught in my AO and in the departments that I have worked for. It may not pertain to you or you may wish to go a different route. If so that is your prerogative.
While I agree that there have been new ideas and new studies that support the use of Tourniquets, there are still many areas that do not agree with these studies and still do not advocate the use of tourniquets except as a last resort or for amputations. The NR, in their infinite wisdom has even added tourniquets to their skills this year, from what I understand.
I have invited a friend and former co-worker that is an EMT-P and the medic that wrote the standards for Tactical Medic I, II and Operator Tactical Medic III for the NAOTM, to join M4C and give us a little insight. He is a gun guy and all around good person. When I talked with him at the range the other day he stated an interest in joining but also said that he was pretty busy with the new NAOTM site (naotm.com), hopefully he will join us.
The whole tourniquet issue gets polarized based on what your background is.
I came up in .civ EMS and it was pounded into my head that tourniquets were the stuff of bad action movies - It is good that this is rapidly being reassessed as evidenced by inclusion in mainstream EMS pubs such as JEMS and recent editions of texts. I can say that in a decade and a half or so of civilian employment, I only used them a few times - usually on amputations or severely mangled extremities (such as the boat propeller injury mentioned above).
Then I got exposed to the TCCC side of the house. It was eye opening and I experienced a paradigm shift. It's not always about what you can do to control the bleeding (99.999% of injuries can technically be controlled using more conventional measures - eventually...), but what you should do based on the totality of the circumstances... What works on an MVA scene with a couple of extra sets of hands and a fully stocked Mobile Intensive Care Unit with a 6 minute transport to a LVL 1 Trauma Center may not be the best course of action in the aftermath of a complex VBIED on Route Irish with SAF followup - or an ND into a shooting partner at a remote rifle range. This isn't about proving what a stellar medic you are and showing off your bandaging skills - it's about taking the right course of action in a evolving situation and damn the peanut gallery. Taking such training in a team room during IDF attacks does a great deal to open one's mind to more progressive techniques...
There are times when you can manage things without a TQ - if you think that's the case and the situation allows, then give it a shot. You can always throw a tourniquet on if you start down that road and see it ain't working out.
There are other times when "let's try this, first" is a non-starter... If you're the one who got perforated and you're alone, then it's not a great idea to watch blood go in-and-out instead of round-and-round and end up unconscious while your textbook pressure dressing flips you the bird. In short, if you're working without a net, err on the side of caution and place the TQ. If it's arterial blood flow, then the scale starts tipping towards a tourniquet a little more quickly. Like the poster above stated, the incidence of necrosis over a period of a few hours is low (I have also been taught that less than 4 is basically a non issue, and 6 is probably going to be OK, I'll try to dig up the actual stats in a bit). Worst case scenario? Some neo-god in a response role is going to think you jumped the gun - big deal. Pride related injuries are rarely fatal. The same cannot be said for uncontrolled exsanguination...
As far as hemostatics, I like them as an adjunct. They work well enough in conjunction with your other efforts, but if I had to choose between TQs, pressure dressings or hemostatics to fit in a kit, the hemostatics fall into the "nice to have, but not a deal breaker" category for me. On an extremity wound, it may be superfluous (you stand a really good shot at being successful with a correctly applied TQ), but the hemostatics are a little more useful on wounds not amenable to TQ use due to location - torso, etc.
All that being said, for the OP's original question
For a "bleeder" on a limb, can some of the professionals weigh in with what the sequence of operations would be with regard to the above three items? Do you apply the tourniquet first, then the hemostatic, then the combat dressing? Or is the order of the first two reversed, or what?
Assuming I'm not dodging incoming or having to suppress a threat, my first reaction is always the same - put something on it. Firm direct pressure may not fix it, but it gives your hands something to do for a few seconds while the "oh shit factor" gets back under redline. After a few seconds holding a trauma dressing, t-shirt or whatever on it you're getting an impression of what you're dealing with. If it's a isolated wound (clean GSW or laceration/injury of a size that you can effectively apply pressure), then you may be ready to tie some direct pressure to your dressing and get gone. If you see that bleeding isn't being controlled, then step it up and place your TQ.
As far as where the hemostatics fall into that sequence? I'd normally go with Direct Pressure (if I didn't rule it out as a possible fix on first sight), then TQ if necessary, then augment either or both with the hemostatic if indicated. The impregnated dressings help alleviate that concern by letting you kill 2 birds with 1 stone on the first step.
If the blood loss is adequately addressed/definitive care is within reach/the tactical environment allows, then it should go without saying that the least invasive procedure which is successful and can be maintained becomes the correct answer.
The only hard and fast rule is to make the red stuff stay inside. If a bandaid does the trick, easy day. If you have to escalate to TQ's, multiple hemostatic applications and a bulk order of gauze, vengeful ParaNinjas ain't gonna drop from the sky hurling star-of-life shaped shurikens at you. If they do, have them hold pressure while you reassess the casualty...
Not sure if any of that made any sense whatsoever to anyone but me - I tend to ramble on slow shifts...
Excellent post Hell Bent. Joe, I wasn't digging at you, the protocol comment could have been explained better thus: " After reviewing outcomes of our own incidents, and as a consequence of how freely we tourniquet wounds based on the tactical situation as opposed to the medical necessity, we developed a tourniquet release / conversion protocol." You are absolutley right though, it can be highly regional in how it gets implemented.
As Hell Bent alluded to, once you start down the path of doing trauma care during the wounding process, as opposed to responding to the incident afterward and generally it being safe, a lot of what you used to take for granted about medicine changes. We plan the greatest majority of our ops during low light, so we had to make sure we were constructing policy that would reflect having to function in that and not cause more casualties. I could have done a better job of explaining that.. The training I had in medic school didnt prepare me for it, and I had to do a lot of 'un-learning' so as not to advocate for things that while medically sound were tactically inappropriate.
To appeal to a wider audience though, and not make this too 'tactical- 'centric, I think that hemostatics do have a place for the outdoorsmen or hunter. We had a bowhunter just a few miles from my house die from a high femoral bleed last year, from somehow shooting himself with his own crossbow. I don't know all the details, but from what I heard it was one of those pesky wounds that would have been difficult to tourniquet. Helluva a way to end a good day hunting.
One of the things, especially from reading through some TCCC resources that I see a lot is two kinds of care: under fire and not.
Obviously the vast majority of civilian (even civilian LE) incidents are more likely to be dealing with the injury when NOT under fire as the incident (barring a Red Dawn or West Hollywood scenario) will be over by the time the injured realizes he's hit.
Clearly, if you're actively under fire you have to finish the fight, and if you're part of a team that responsibility extends to not only preserving your own life but holding up your end of the team.
I think I'm starting, for my own purposes, to put the type of environment for treating the injury into three potential categories.
1) Injury is realized, no threat remaining (something like an ND on the square range)
2) Injury is realized, no immediate threat appears (something like a home invasion where you've neutralized the only visible threat, but there may be more)
3) Injury is realized, immediate threat remains (multiple assailants, battlefield, etc.)
Would this seem reasonable, and could one start to break down responses based on which of the three is the case?
Gutshot John
03-14-09, 14:08
Try not to think of it as "under fire" or not, think of it as scene security. Scene security is something that exceeds that particular consideration or rather incorporates a totality of circumstances that you're going to have to be aware of. This really gets a lot of coverage in PHTLS. Your focus is going to be on the casualty (tunnel-vision), try and see the bigger picture. Not being under fire simplifies things significantly, but that doesn't mean there are no other threats.
Your first priority irrespective of casualty type is to assure scene security meaning you can't render adequate care if there is a strong possibility of yourself getting injured. You aren't going to do anyone any good as a just another casualty. This might mean ending the fight, but that's not always possible (see North Hollywood Shootout).
Scene security involves threats from other shooters, but also might be the patient himself, potential environmental hazards (downed powerlines, leaking gasoline, ignition sources, turning off a running engine etc.) or other.
You're not always going to be able to eliminate the threat first so you think about what you're going to do before charging out into the FOF to either render care or pull someone back.
Lots of circumstantial variables I'm afraid, but in general your first rule is to CYOA.
Deal with the bullets in the air first.
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