Can we talk about sequence of operations?

**rob_s** · 03-04-09, 04:30

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!

**Gutshot John** · 03-04-09, 09:03

Originally Posted by rob_s

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.

**rob_s** · 03-04-09, 10:28

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

Originally Posted by rob_s

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

Originally Posted by rob_s

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.

**Iraqgunz** · 03-04-09, 16:34

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.