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

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.

Phases of Tactical Medicine

The Care Under Fire Phase 

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.

2) Return Fire and/or take cover.

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

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

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

6) Stop Catastrophic-Hemorrhage. (self-aid, buddy-aid, medic-aid)
    A) Use tourniquets where applicable.
    B) Hemostatic agents with pressure dressing if tactically feasible.

7) Airway mangement ought to be deferred until the Tactical Field Care phase.
                                                                                         
The above is a loose guide. Do not limit yourself to algorithmic medicine.

Next time we will examine each step more in-depth.

If you have any comments, please send them to alan@tacmedsolutions.com
 

Tourniquets and Scientific Studies

A tourniquet is a piece of  live saving equipment.  With that in mind, it is troubling to know that officers are either carrying tourniquets, or contemplating the purchasing of tourniquets, that are questionable with regard to effectiveness. What is more, they are making these decisions based on a questionable scientific study, most of which they did not completely read ( TQReport). It is not being hyperbolic to state that what it is arguing is a matter of life or death. If you question that, then please revisit the last blog entry.

One not wanting to read the entire study is understandable. It is 90 pages of dry, scientific writing. At first glance, the study is methodologically sound. It is constructed to test the effectiveness of tourniquets in an environment that simulates combat conditions. However, after one reads the study completely, there is one glaring deficiency. The study did not test which tourniquets achieved 100% occlusion. I Repeat: IT DID NOT TEST IF TOURNIQUETS ACHIEVED 100% OCCLUSION.  That should be the FIRST criterion a tourniquet must meet to continue a study.  While the ISR study (see below) tested tourniquets that could achieve 100% occlusion, the Navy study did not, so all other criteria are irrelevant.  Instead, it tested how easy it was to apply an ineffective tourniquet. As the study states:

Applications to arms were performed one-handed, but use of both hands was allowed for applications to thighs. A maximum of 5 minutes was allowed to apply the tourniquet, after which time the trial was terminated as an “application failure.” Application of the tourniquet was successful if the subject vocally declared, “Tourniquet on” — indicating that he had reached a point just before continued tightening would produce unbearable pain and had secured the device — within 5 minutes of being handed the test tourniquet. Upon such a declaration, a double event mark was recorded to mark the end of the application time period. The subject was asked to remain still throughout the remainder of the procedure.

Although the above may not seem like an issue, it is. First, applying a tourniquet until one thinks he/she has achieved hemorrhage control is not how it works. One applies a tourniquet to stop bleeding. One must continue to apply pressure until the bleeding stops. It is as simple at that. Second, using pain as indicator to cease applying pressure is not a good indicator. Doing so requires one to extrapolate the findings of a conscious, non-traumatic subject and apply them to an injured patient that has experienced enough trauma to require catastrophic-hemorrhage control.

Savvy distributors and manufacturers of different tourniquets have begun using this study to tout the effectiveness of their product. Beware. They are doing so based on the age-old assumption that consumers will not take the time to read all 90 pages. For example, they are giving potential consumers a chart that gives you a snapshot of the test that enumerates the tourniquets from best to worst. Please read the studies for yourself and make an educated decision. There are two tourniquets approved for use by the Army’s Institute for Surgical Research (ISR) (ISR Tourniquet Study). Do not let the desire to carry a tourniquet that is small–and possibly ineffective–outweigh the need to achieve hemorrhage control. Furthermore, short transport times DO NOT compensate for an ineffective tourniquet that can INCREASE bleeding. Finally, rid yourself of the disturbingly-common attitude that you will not actually need one . If that is the case, save yourself both money and weight and just don’t carry one. However, read the below post before doing so.

If you have any comments, please email them to alan@tacmedsolutions.com

To Pack or Not to Pack: That is the Question

Hemorrhage control is one of the most important aspects of tactical medicine. As studies suggest, exsanguination from extremity wounds is the leading cause of death on the battlefield. Therefore, effective hemorrhage control is of upmost importance in the field. With this in mind, we must assess the most effective way to control hemorrhage.

As most of our readers know, in the Care Under Fire (CUF) phase of treatment, a tourniquet should be the first tool used for catastrophic-hemorrhage control. Should the care provider fail to achieve hemorrhage control using a tourniquet, or the location of the hemorrhage contradicts its use, then the use of a pressure dressing and/or a hemostatic agent is the next step in the CUF phase, if the situations allows, of course.

With that said, how does one achieve and maintain hemorrhage control with a hemostatic agent or a pressure dressing? First we will explore the use of hemostatic dressings. If the care provider were to just expose the wound and dump the hemostatic agent directly into the wound, the pressure of the bleed could wash it away, thereby negating its positive effects. To prevent this from occurring, the careprovider needs to apply pressure to the wound site, so as to ensure the hemostatic agent remains in place. The most effective way to do so is to pack gauze in the wound, on top of the hemostatic agent. Doing so will provide the requisite amount of time needed by the majority of approved hemostatic agents in the field to work. If a medic decides that the situation dictates a pressure dressing, what are some of the considerations before applying a pressure dressing? If the wound is the result of high-velocity penetrating trauma from a projectile, for instance, one must remember that the projectile has produce two cavities: the permanent and the temporary. The permanent cavity is caused by the projectile coming in direct contact with tissues. The temporary cavity is caused by the lateral energy produce as the projectile passes through the body. Consequently, while a wound may appear to be a simple entry/exit type of wound, thereby requiring that application of a simple dressing, it might be deceiving. In fact, the cavitaion produced by the projectile may have extensively damaged the tissues with which it came in contact (See Figure 1).

With that said, how does a medic achieve hemorrhage control when the wound appears manageable from the outside, yet continues to bleed within? Direct pressure on the wound site might achieve it, but not likely. Should a medic then apply a dressing that is nothing more than a wound pad attached to elastic? Maybe, but that offers little more than circumferential pressure. Inadequate circumferential pressure provided by an elastic bandage is as useless as an ineffective tourniquet, because neither are going to stop bleeding. Additionally, it fails to actually apply pressure to the damaged tissue that is bleeding within the wound tract. Essentially all one has done by applying a elastic bandage to a wound that requires a pressure dressing is applied an expensive dust cover, which might provide a false sense that one has achieved hemorrhage control. A medic must apply pin-point pressure to the wound. To do so, one needs pack the wound with gauze. The illustration below speak volumes. Medics must carefully, yet aggressively go after bleeding! Packing wounds with gauze has been the cornerstone of hemorrhage control for years in the special ops medical community. Until recently, an elastic bandage and a role of gauze has been the treatment of choice for wounds that neither require nor are accessible to other methods such as tourniquets. Unfortunately, some civilian medical directors frown upon medics packing wounds in the filed. Instead, medics are directed to apply direct pressure to wounds. As mentioned above, although direct pressure is useful sometimes, medics must get pin-point pressure on wounds. All is not lost; the tides are slowly shifting. The more medics we come in contact with the more we learn of a paradigm shift toward wound packing within the military and law enforcement medical communities. In the end, whether acting as an adjunct to a hemostatic agent in gaining hemorrhage control or stopping bleeding by exerting pin-point pressure, wound packing is a necessary step that must be considered. pack


(Figure 1)
(Reprinted From Husum H, Gilbert M, Wisborg T, Saving Lives, Saving Limbs, TWN Penang, 2000) )