By FRANK CALIFANO
Scenario: As you settle in at the firehouse, the lights begin to flash and the bells sound. The speaker blares, “Ladder 173, special call, second alarm, Crossbay and 145th Street, fire in a one-story taxpayer.” You board the rig and ride as the “roof man.” As you approach the scene, your company is directed to the roof to assist Ladder 162 with vent operations. By the time you grab your saw, the chauffeur has the stick to the roof. Heavy fire is showing through the windows at the front of the building.
You and your company climb to the roof. Conditions are not the best; the smoke is heavy, and visibility is poor. You find the crew from Ladder 162 making a trench cut. Your lieutenant directs you and your partner to start a cut from the opposite end of the roof. Conditions are worsening. You start the saw and begin to cut. It bites and takes hold in the melted tar.
|(1) The Combat Application Tourniquet (C-A-T).® (Photo courtesy of Composite Resources.)|
Suddenly, the saw kicks and skips across the roof. As you attempt to regain control, the saw swings behind you and the blade clips your partner in the leg. He wails in pain. The saw stalls from the chunk of turnout jammed in the blade. Your partner’s leg spews blood. You call out, “Mayday, Mayday, Mayday—173 Roof.”
|(2) SOF®-Tactical Tourniquet. (Photo courtesy of Tactical Medical Solutions.)|
Everyone’s attention is now focused on your partner. By the time you make it to the parapet, a tower ladder is there to meet you. You load your partner and descend to the street, where you are met by a medic crew. One of the medics quickly exposes the leg and assesses your partner. He grabs a trauma dressing and applies direct pressure to the wound. The bleeding is still very heavy. He instructs his partner to apply a tourniquet. Once in place, the tourniquet seems to have stopped the bleeding. They load your partner into the bus and head out, code 3, to the hospital.
WHAT WAS ONCE OLD IS NEW AGAIN
I have been a prehospital care provider for more than 30 years. From my first EMT class, I was instilled with the fear of the wrath of the EMS gods if even the thought of using a tourniquet crossed my mind. However, things change, as anyone who has ever been in this business knows. Better research and improved information exchange have brought about significant changes in treatment protocols.
Much of what we have learned about the treatment in prehospital care has come from the battlefield. The wars in Iraq and Afghanistan have provided some great advancements in the treatment of battlefield injuries. Hemorrhage control is one area that has seen significant strides. The use of tourniquets has been slowly increasing in military campaigns since the Vietnam War, but it wasn’t until the Iraq and Afghanistan conflicts that widespread use of the tourniquet has been accepted as a standard of care in the military.1
Hemorrhages contribute to prehospital death in 33 to 56 percent of cases, and exsanguination is the most common cause of death among those found dead on the arrival of EMS personnel.2 Hemorrhages are also the second leading cause of death in civilian trauma. The control of severe hemorrhaging is a skill in which every prehospital care provider should be proficient. The standard for the treatment of patients with severe bleeding from an extremity has long been based on the mnemonic acronym DEPT (Direct pressure, Elevate, Pressure point, and Tourniquet). The current edition of the National Association of Emergency Medical Technicians’ Prehospital Trauma Life Support—PHTLS (6th edition) supports the use of tourniquets if bleeding cannot be effectively controlled by direct pressure alone. In addition, the practice of elevation and a pressure point proximal to the injury have been found to be relatively ineffective in hemorrhage control.
Today, tourniquets are a far cry from the simple belt-and-buckle types from years past; they have seen major improvements in both ease of application and effectiveness. There are several commercially available tourniquets on the market. The design criterion for tourniquets currently being used in the military is its ability to be applied one-handed. Once tightened, it eliminates arterial blood flow distally to its placement.
The military has three styles of tourniquets that meet these capabilities. The Combat Application Tourniquet (C-A-T)® (photo 1) is a small and lightweight one-handed tourniquet with an approximately two-inch-wide nylon webbing that occludes distal arterial blood flow. It incorporates a hook-and-loop closure and a windlass for tightening. The SOF®-Tactical Tourniquet (photo 2) is an approximately two-inch-wide nylon webbing that can be applied single-handedly and incorporates a buckle with locking screw and windlass. The Emergency & Military Tourniquet (photo 3) incorporates an inflatable cuff similar to a blood pressure cuff with the addition of a locking buckle. All three styles have been proven effective in the control of bleeding on the battlefield.
Treating a patient with severe bleeding from an extremity should fundamentally remain unchanged. Approach the patient taking standard precautions; use gloves and glasses or goggles (if needed). If the patient has severe hemorrhaging from an extremity, apply a dressing appropriate to the size of the wound and apply direct pressure with your hand. If bleeding continues, apply a pressure dressing accordingly. If the bleeding still remains uncontrolled, apply a tourniquet proximally (above) two to three inches to the wound. Remove all clothing whenever possible, and apply the tourniquet directly to the skin. Tighten the device until bleeding is controlled. Check for absence of distal pulse, and note time of placement.
|(3) Emergency & Military Tourniquet. (Photo courtesy of Delfi Medical Innovations, Inc.)|
Tourniquets are routinely used in surgery for several hours. Permanent damage to the arm or leg is a rare occurrence if the tourniquet is left in place for less than two hours. The possibility of vascular or nerve damage is outweighed by the risk of death from hemorrhage.
|(4) QuikClot Combat Gauze. (Photo courtesy of Z-Medica Corporation.)|
Some considerations after the tourniquet is in place follow:
- If bleeding persists, employ a second tourniquet proximal to the first.
- Do not place the tourniquet directly over the knee, elbow, or objects that may be in pants pockets.
- Leave the tourniquet visible, and mark time of application with an indelible marker.
Points to remember when using tourniquets include the following:
- DO NOT periodically loosen to allow circulation to the limb, as was taught in the past.
- Avoid use for venous/capillary bleeds.
- Properly tighten the tourniquet to eliminate distal pulse. If it is not tight enough, blood may become trapped, creating the potential for a compartment syndrome.
- Always apply a tourniquet to all traumatic amputations.
- DO NOT REMOVE the tourniquet, especially in the following circumstances:
- –Transport is within two hours of application.
- –Tourniquet was used in the treatment of a traumatic amputation.
- –Patient is in shock.
- –Tourniquet has been in place for more than six hours.
TREATING THE WHOLE BODY
Injured extremities are not the only areas of the body that may suffer a loss of high volumes of blood; lacerations or punctures to the torso or neck can also produce severe hemorrhaging. Controlling hemorrhaging in these areas can be challenging. Injuries to major arteries such as the carotid artery can result in rapid exsanguination. Note that penetrating injuries to the neck may include a number of major vessels, not just the carotid arteries. A small laceration of the jugular vein can prove just as lethal and can result in a rapid introduction of air into the vascular system, resulting in a pulmonary embolus.
Use an occlusive trauma dressing to treat wounds to the neck. Closely examine neck lacerations to ensure that proper treatment is administered. Penetrating injury to the abdomen involving the liver or spleen can also result in major blood loss. The traditional method—direct pressure by applying a large trauma dressing—has been the general course of treatment.
Hemostatic agents also aid in hemorrhage control and can be used in conjunction with tourniquets, independently when the criteria for tourniquet application are not warranted, or when the bleeding site is not involving an extremity. Originally, these agents were granular products consisting of materials such as kaolin, a natural clay-like material, combined with inert minerals such as silicon, aluminum, magnesium, and sodium (all found in volcanic rock). When introduced topically to a bleeding wound, it absorbs water, resulting in a concentration of clotting factors, platelets, and red blood cells to promote clot formation.
The one limiting factor to these products was their resulting exothermic reaction, which, at times, caused burns to the wound area. The second generation of these products has significantly reduced that effect. The granular type product had limited usefulness in treatment of “high pressure” bleeds such as carotid or femoral arteries, where the volume of blood would wash away the agent before clotting could occur.
The most recent development has come from the incorporation of hemostatic agents into traditional gauze bandages. Hemostatic bandage and gauze pads have undergone extensive testing in the treatment of battlefield injuries. Kaolinite-impregnated gauze has proven to be effective in hemorrhage control regardless of the location or extent of the injury. Kaolin is a white alumina silicate that has been known for years for its ability to activate blood’s clotting agents. Kaolin works by activating blood plasma’s XI and XII factors, stimulating the body’s coagulation cascade. By fostering platelet adhesion, kaolin forms an active, natural, and stable clot.
Several commercially available products have been introduced to the prehospital care market. QuikClot Combat Gauze™ (photo 4) is a three- by four-yard-long roll of nonwoven gauze impregnated with kaolin. Combat Gauze has all the advantages of normal gauze (easy application, flexible, large coverage area, and easily removable) with the additional advantage of hemostatic function from the kaolin. It is designed for packing into deep wounds that are actively bleeding (i.e., arterial injury in the groin). Prehospital personnel can also use Combat Gauze as they would any standard Kerlix gauze. PHTLS recommends using topical hemostatic agents to control hemorrhaging occurring at sites not amenable to tourniquet placement and that cannot be controlled by direct pressure alone.
Hemostatic agents and gauze can be used in the treatment of nonextremity hemorrhaging. Commercially available gauze comes packaged several ways. Traditional rolled hemostatic gauze comes packaged in a “Z” fold format, is used like any standard “kling” style bandage, and is effective in treating moderate topical hemorrhaging. It is designed to aid in the treatment of deep penetrating injuries such as gunshot or knife wounds. The “Z” folding allows for easy packing of these wounds as outlined in the PHTLS Combat Casualty Care course.
The basics of hemorrhage control, for all intents and purposes, remain unchanged. Some old tools have been dusted off, and some new tools have been added to aid in your procedure. Recognizing and effectively treating hemorrhagic injuries is a skill at which you should be proficient. Review the use of tourniquets and hemostatic agents, and develop in-service training to aid in the implementation of updated treatment protocols. As with any new or updated treatment method, check with your agency having jurisdiction as to what treatment protocols are approved for your organization.
1. Stuke L. Prehospital Tourniquet Use—A review of the current literature. PHTLS. Page 1, 2010.
2. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. Journal of Trauma. 1995;38:185-193.
FRANK CALIFANO, BS, EMT-P, CHSP, is an emergency management coordinator assigned to the emergency management division for North Shore—LIJ Health System, Network Emergency Management in Syosset, New York. He is also a 30-year member and a company safety officer for Roslyn (NY) Rescue Hook & Ladder Co. #1, having also served as captain of EMS. He has a bachelor of science degree in community services/emergency management from State University of New York—Empire State College. Califano has been a speaker at FDIC as well as other national conferences. He is a certified hazardous materials specialist and a certified healthcare safety professional.
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