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) )