Tourniquet Use in Pre-hospital Civilian Trauma Care

Tourniquets are an effective means of arresting life-threatening
external haemorrhage from limb injury. Their use has not
previously been accepted practice for pre-hospital civilian
trauma care because of significant concerns regarding the
potential complications. However, in a few rare situations
tourniquet application will be necessary and life-saving. This
review explores the potential problems and mistrust of
tourniquet use; explains the reasons why civilian pre-hospital
tourniquet use may be necessary; defines the clear indications
for tourniquet use in external haemorrhage control; and
provides practical information on tourniquet application and
removal. Practitioners need to familiarise themselves with
commercial pre-hospital tourniquets and be prepared to use
one without irrational fear of complications in the appropriate
cases.

See Paper Here: TQs in Civilian Trauma Care

NTOA Member Tested Reviews

We just received the NTOA Member Test reviews for the Olaes Modular Bandage and the Foxtrot Litter, in which both products were rated on a 5 point system. They both were rated very well–4.74 and 4.7, respectively. Please feel free to download a copy of the Olaes Modular Bandage NTOA review and the Foxtrot Litter NTOA review.

Use of Hemostatic Agents

It is important to understand that science has not yet isolated the compounds essential in the production of fairy dust. Modern hemostatic agents require proper technique and training to function properly. Simply placing these products onto or into wounds does not solve all of your problems. If members of your organization are issued hemostatic agents, it is essential that they are trained on the agents and fully understand their limitations.

There are four steps you ought to follow when using hemostatic agents:

    1) Prep your equipment. Set yourself up for success by having all required components ready before addressing a bleed (i.e., agent, gauze, and bandage).

    2) Identify the bleed. Placing or pouring an agent onto or into a wound without identifying the bleed is unwise. If you have a large cavity that requires hemostatic agent, you must make sure the agent is placed DIRECTLY ONTO THE damaged vessels in order for it to work. Otherwise, you are wasting blood cells and agent.

    3) Proper placement. After identifying the bleed, you must ensure the agent is placed DIRECTLY ONTO THE BLEEDER. If you do not, you run the risk of creating a “crust” made of blood and agent above the vessels. In so doing, you have visibly stopped the bleeding by forming a large clot, but it has not stopped the bleed.

    4) Pressure. Hemostatic agents do not relive you of the basics that are required for hemorrhage control. After using a hemostatic agent, you MUST place gauze behind it in order to create pressure, so as to allow a clot to form. Otherwise, you run the risk of the agent being washed away or of a “crust” forming and creating a hematoma. It is also necessary to use the gauze to hold the agent in place and prevent it from shifting during patient movement. A minor shift during movement can cause a re-bleed which could be fatal if overlooked during re-assessments

Considerations/limitations

    1) Can the basics stop the bleed?
    2) Is the casualty hypothermic? If so, clotting is a factor.
    3) External environmental factors. For example, wind (or rotorwash) may blow a powder agent into the casualty’s or your eyes.
    4) Location of injury (e.g., face, neck, abdomen).
    5) Staying basic with the basics
    6) Training is a must. If end-users (i.e., medics, operators, officers) do not know the basics of hemorrhage control, then using hemostatic agents is not wise.

Wound Packing: Techniques and Considerations

The ability to pack a wound is an essential skill for the tactical medic. While a tourniquet is an excellent tool for controlling hemorrhage in extremity trauma, there are many areas that do not allow proper application of a tourniquet. The video on wound packing was produced to show the fundamentals of wound packing.

    A. Identify the bleed
    B. Pack into the bleed
    C. Pack tightly to the bone if possible

A. Identify the bleed-
It is essential that the medic identify the source of the serious hemorrhage. Simply stuffing gauze into a cavity is not always effective. Often times the pressure is not applied where it is needed and the gauze only acts as a sponge. What makes packing a wound effective is that is provides focused pressure directly on the damaged vessel. By occluding the lumen of the vessel with the gauze you get hemorrhage control. If it is not completely controlled it at least slows the hemorrhage to a point where the body’s natural clotting factors can interact with the gauze to form a clot. There are three main methods to identify the location of a bleed.

    1. Visualization
    Visualization is the preferred method, but it is often unrealistic due to ballistic patterns, flooding of cavities and tissue movement. Excess blood filling the cavity can be scooped out to give a quick look, but on high pressure bleeds and blast injuries this can be very difficult.

    2. Tactile assessment
    Feel works well if you are in a relatively calm mental state and have complete awareness of your senses. It is not a reliable source when you have been carrying heavy loads, firing weapons for long periods of time or participating in any activity that has caused your hands to fatigue. It’s also unreliable if you are wearing multiple layers of gloves.

    3. Anatomy
    A basic understanding of the vascular structure of the human body goes a long way in this situation. It isn’t as good of an indicator as visualizing the bleed, but if you are pressed for time it can be a good solution. It is best when used in conjunction with the other methods. It is also helpful when determining the best angle to pack from.

B. Pack into the Bleed
Notice what the section is titled, “Pack into the bleed”. It does not say pack into the wound. Your first few sections of gauze should go directly to the source of the major hemorrhage. After that hemorrhage has been staunched, the remaining gauze should be packed tightly around it to keep it in place. Your goal is NOT to create a sponge inside the wound, but a solid mass that applies pressure where it is needed. This is a very important point. An often-asked question is, “how much blood does the Olaes bandage absorb?” The answer is this: hopefully none. The purpose of bandages is not to absorb the most blood, it is to STOP bleeding, in order to keep blood where it needs to be: in the body. You don’t put bandages on to keep your vehicle clean.

C. Pack to the bone
The major vessels of the body are not inside muscular tissue! Most vessels run near the major bones in the body. If the wound is in a location that allows you to use the bone as a rigid object to maintain pressure on the damaged vessel, use it. Start by packing into the bleeder, and then use the gauze to squeeze the vessel between it and the bone. This creates the same effect as a vascular tourniquet, or simply holding pressure with your finger.

Educating medical directors and command surgeons in the importance of wound packing is essential. The ability to pack wounds is a necessary skill in an environment with the potential for delayed evacuation times and limited manpower. The idea that you will hold direct pressure for 3-5 minutes during a fire fight is ridiculous. Packing a wound reduces the need for this and frees the medic’s hands up to engage more important things, like the enemy. When used in conjunction with hemostatic agents, it is even more effective. We will cover how these two work together in a future entry.

Phases of Tactical Medicine

The Care Under Fire Phase (Part 2)–Considerations

The Care Under Fire (CUF) phase of treatment requires a basic management plan. The plan is comprised of basic steps. Remember, it is the basics that save lives. They are as follows:

1) Regain your situational awareness.

  1. What type of threat have you encountered? An IED?
  2. What direction is the threat coming from? Will a secondary explosion/engagement occur? Is it occurring now?

  3. Are there any casualties? Am I a casualty?
  4. What do I do now? Treat the casualty? Return Fire?

2) Return Fire and/or take cover.

  1. Because this is the CUF Phase, which means you are still under fire, you are not a medic until fire superiority has been established. As the old saying goes, “fire superiority is the best medicine.”

3) Direct casualty, if applicable, to remain engaged in the fight.

  1. This may prevent the casualty from sustaining further injuries. This must be practiced in training. As Bruce Siddle has noted in Sharpening the Warrior’s Edge, practicing to play the casualty by quitting when shot during training will hinder one’s ability to do otherwise in real-world situations (i.e., do not get in the mindset that an injury precludes you from continuing to fight.

4) If patient is unable to continue to fight, direct him/her to move to cover and/or apply self-aid.

  1. This must be done in training. Get your operators out of the mindset that “doc will do medicine.” You must train them to provided self-aid, then buddy-aid, then, when applicable, expect medic-aid. The casualty is a casualty for a reason: The point of injury is dangerous, underfire, etc. Direct him to treat himself via yelling, radio, etc. Remember, however, that ears will be ringing post-explosion.

5) Prevent patient from sustaining additional wounds (SEE 3 and 4).

  1. In addition to 3 and 4, rescue ought to be considered. Practice tactical rescues in training. Train assaulters to quickly assess casualties during the tactical rescue. For example, if the casualty is talking, then airway is good. If responsive, ask where they are hit. Look for hemorrhage. Are they complaining about difficulty breathing? These are just a few examples.

6) Stop Catastrophic-Hemorrhage. (self-aid, buddy-aid, medic-aid)

  1. Use tourniquets where applicable.
  2. Hemostatic agents with pressure dressing if tactically feasible.

7) Airway management ought to be deferred until the Tactical Field Care phase.

  1. Not always possible. Be prepared to provide a surgical airway. If an airway compromise is sever enough to need attention during the CUF phase, then 99% of the time it will require a Cric. Do you have a Cric-Kit accessible? If it is in your bag, then it is not going to do the casualty much good. You need to have one in a mag-pouch, leg-bag, etc.

The above is a loose guide. Do not limit yourself to algorithmic medicine.

Situational Awareness and Selecting a Treatment Position

It is essential for a medic to constantly update his situational awareness. The tactical environment is constantly changing and threat levels fluctuate every second. While providing treatment to a casualty is important, never let it overshadow the tactical situation around you. Unless you are in a secure area you must constantly reevaluate threat levels and balance the level of care provided with the current threat.

Selecting a proper position in the CCP or positioning yourself during hasty treatment is an essential part of this task. You should position your casualties in a manner that allows you to make quick visual assessments of potential threat areas or at least provide a visual on your security element (if you have one). Placing a casualty in a corner or along a wall forces the medic into the center of the room. Not only does it limit access to the patient, it puts the medic in an exposed position and makes it difficult for them to evaluate their surroundings. It also increases the occurrence of tunnel vision. It’s easy to lose focus when you can only see one thing. If possible, position casualties in the center of a room, just remember you want to minimize their exposure to open doors and windows just as you want to minimize your own. If the room is large, consider placing them near the walls; however, leave enough space between the casualty and the wall to allow yourself workspace and room to maneuver quickly if necessary.

A dead medic doesn’t save lives. Failure to understand what is occurring around you increases your risk of injury or death. In the demo-video, take note of the manner in which the medic positions himself in the room and how he is constantly checking his threat-areas while providing aid.

Take-away Points:
1. Maintaining situational awareness is as important as treating your casualty
2. Position yourself and your casualty so as to lessen your risks
3. Performing your duties as a medic does not relieve of your tactical responsibilities

Hypothermia: Is It a Valid Concern in a Hot Enviroment?

According to information published in the latest “Lessons Learned” from Iraq it is one of the most important variables concerning the survivability of casualties. Hypothermia, as our readers know, is one of the three components of the lethal triad–acidosis and coagulopathy being the other two. Even if it is hot outside, care must be taken to ensure casualties do not loose heat. Below you will find an abstract from an article that speaks to the importance of preventing hypothermia.

The impact of hypothermia on trauma care at the 31st combat support hospital.
The American Journal of Surgery, Volume 191, Issue 5, Pages 610-614
Z. Arthurs, D. Cuadrado, A. Beekley, K. Grathwohl, J. Perkins, R. Rush, J. Sebesta

Abstract

BACKGROUND: The primary objective of this study was to review the incidence of hypothermia, and its effect on surgical management, resource utilization, and survival at the 31st Combat Support Hospital (CSH). METHODS: This study was a retrospective analysis of all combat trauma injuries treated at the 31st CSH over a 12-month period. All trauma admissions were included. Descriptive and inferential analysis were performed using SPSS 11.0 software package (SPSS Inc., Chicago, IL). RESULTS: A cohort of 2848 patients was identified; 18% were hypothermic (temperature <36 degrees C). Hypothermia was significantly (P < .05) correlated with admission Glasgow Coma Scale (GCS), tachycardia, hypotension, lower hematocrit, and acidosis. Hypothermic patients had a significantly higher blood product and factor VIIa requirement. Hypothermia was an independent predictor of operative management of injuries, damage control laparotomy, factor VIIa use, and overall mortality (P < .05). CONCLUSION: Combat trauma patients have a high percentage of penetrating injuries with variable evacuation times. Hypothermia was a pre-hospital physiologic marker, and independent contributor to overall mortality. Prevention of hypothermia could reduce resource utilization and improve survival in the combat setting.

Primary Weapon Placement in Close-Quarters Battle

Selecting a technique for storage of a medic’s primary weapon during treatment is a difficult task.  While there are many excellent slings on the market, none are designed to functionally keep a weapon out of a medic’s way while he or she  is treating a casualty.  Some slings such as the V-tac sling provide an easily accessible point of rapid adjustment that allows a medic to push the weapon aside.  Although such slings are the best currently available, when wearing an aid-bag it can be difficult to prevent your weapon from striking the casualty, possibly causing further injury.

How might we mitigate such a problem? One method is to place the weapon behind your knees.  This technique, as with everything, has advantages and disadvantages.  The primary disadvantage is that the weapon is no longer attached to your body by a relatively strong piece of nylon.  If there is a large explosion or an incoming mortar round there is a chance you could be separated from your primary weapon.  If your environment doesn’t force you to deal with pesky insurgents lobbing mortar rounds, this may be of absolutely no concern.  Some of the advantages of this technique are well worth the possible disadvantages.  Keeping the weapon behind your knees ensures you always know where it is.  NEVER set your weapon on the ground beside you to work on a casualty.  Many highly skilled and experienced medics have left their weapons to respond to another casualty or initiate the evacuation of wounded.  Keeping it stored behind your knees is an uncomfortable reminder of your primary focus on the battlefield, and it is highly unlikely that you will forget where it is.

Some people will argue that storing your primary weapon in this location is a bad idea because of the amount of time it takes to put the weapon into operation.  The fact is that maneuvering a slung weapon while wearing an aid bag and a Camel-bak™ is not a smooth operation.  If you are presented with a threat serious enough to warrant immediate engagement that requires a reaction time of a few seconds, you are better of answering that threat with your secondary weapon.  Drawing your pistol and accurately engaging targets is something that is practiced over and over again on the range.  Take advantage of training and use it in this situation.  If you are providing aid, you should either be in a “secure” area, cleared room, or behind a position of cover.  If you face a threat that requires immediate engagement in this environment, it will likely be at close range.  If you are proficient with your secondary weapon, it should be more than sufficient to deal with the threat.  Targets at greater distances generally allow enough reaction time to access your primary weapon.

In addition to the benefit of forcing you to maintain control of your weapon,  placing the weapon behind your knees forces you to put the weapon where it belongs when moving about the objective or from one casualty to another: in your hands.  It doesn’t take long for “combat complacency” to kick-in and this is a passive means of fending it off.  A weapon slung across your back is not the best position for engaging targets.  Getting that weapon into a position that you can accurately engage targets after you have spent so much time keeping it out of your way can be difficult.  You are better off removing the weapon when you stop to treat a casualty, then slinging the weapon in a configuration suited for engagement when it is time to move.

You will have to decide what works best for you in your environment.  The key is to religiously practice the techniques you implement.  Don’t let your first time be the time that counts!

We will post an instructional video next week in order to demonstrate the above-mentioned techniques.

Tourniquet Storage in a Tactical Environment

With the increased use of tourniquets in tactical medicine, there is an active debate concerning the best location and proper method of storing a tourniquet on an individual’s equipment.  While in the end it comes down to individual preference or unit SOP, there are some locations and methods that don’t make sense.

A tourniquet is an immediate lifesaving intervention and it should be treated similarly to a secondary firearm.  Chances are your pistol is not carried in its original box packed away so you can claim a capability.  It is positioned so the operator has access to it in seconds, under the most extreme circumstances.  The same standards for accessibility and immediate operational use should be applied to your tourniquet.  The time taken to implement this intervention should be kept to an absolute minimum.  Storing a tourniquet in its plastic wrapper can be a fatal mistake.  While it increases the service life of the product, it can create a situation in which the tourniquet cannot be accessed by the individual in need.  The same situation can be created by storing the tourniquet inside a difficult-to-open, tightly-packed zippered pouch.  While storing the tourniquet in a pouch attached to your equipment is advantageous if you are the victim of a large blast since it is far less likely to be torn from your gear, the disadvantages of this location (e.g., not being able to access it quickly) outweigh the advantages. 

The best location for a tourniquet in a tactical environment is on the armor, along the midline of the operator’s body, unwrapped and pre-rigged for application.  One technique is to secure the tourniquet with multiple rubber bands.  The tourniquet can be accessed with either hand, is secured tightly to your individual equipment and is easily removed when needed. Furthermore, storing the tourniquet exposed rather than in a case or pouch provides the oft-needed visual stimulus for a rescuer or casualty to begin the act of tourniquet application.  There is a lot to be said for having the answer staring you in the face when you look down or look at a casualty.  The stress response to seeing a friend severely injured can often cause a brief period of inaction.  Having the tourniquet readily available is one small step to combat this condition.

If your unit SOP is to carry tourniquets wrapped in plastic and stored tucked away inside of a pouch, you should seriously consider reevaluating the standard.