BY MICHAEL D. SMITH
While responding as an advanced life support (ALS) first-response engine company to an industrial accident, you remember the last time you went to this factory. On that run a 1,500-pound billet of steel fell on an operator, fracturing and lacerating his leg from just below his knee to his ankle. The plant’s rapid response team was on-scene and attempting to stop the bleeding with towels and trauma dressings.
This current response is not much different; the dispatch message is “a laceration with uncontrolled bleeding.” As the chauffer pulls into the parking lot, several people are frantically signaling you to the back building of a large metal milling auto parts plant. The safety supervisor tells your officer that an operator was using a metal lathe when the spindle broke, sending the part and shrapnel through the guard, causing a large and deep laceration to his right hip/groin area. You find a 50-year-old male with a four-inch-long by three-inch-wide laceration directly over the right femoral artery/vein area with heavy bleeding. The response team had been holding direct pressure with a towel for about four to five minutes and reported that there was spurting blood. The patient’s pants were soaked with blood; you estimate a pool of about 300 to 400 ml of blood surrounding him.
BLEEDING-CONTROL DRESSING
At a recent in-service, your medical director had rolled out the newest in bleeding controla hemostatic dressing designed to stop arterial bleeding in only a few minutes of applied direct pressure. As your patient’s heart rate increases and the level of consciousness declines, you press this new dressing into the wound and apply pressure. As the bleeding slows and IVs are started, you are grateful to have this new technology.
With uncontrolled hemorrhage accounting for up to 80 percent of civilian trauma deaths in the United States (the second leading cause of trauma fatalities)1-2, opportunities for improvement clearly exist. As clot-accelerating dressings make their way from the battlefield onto civilian ambulances, perhaps this statistic will improve. There are two types of clot-accelerating or hemostatic adjuncts: chitosan (KY-ta-san) and an inert mineral substance called zeolite powder.
Zeolite powder [QuikClot® (Z-Medica Corporation, Wallingford, CT)] is poured into an open bleeding wound and absorbs small water molecules, causing a hemoconcentration.3-4 By concentrating the blood, more fibrinogen and platelets are available for rapid clot formation. The U.S. Marine Corps recently added QuikClot® to the individual first-aid kits carried by every Marine. (4)
Two concerns about the granular clot accelerator mandate adequate training prior to deployment. First are anecdotal reports of the powder’s being blown about during the application with the potential of getting into areas for which it is not intended, such as unprotected eyes.5 Second is a well-known reaction of the QuikClot® granules with body fluids, known as an exothermic reaction. The maximum peak temperatures of these exothermic reactions have been reported to range from 68ºC (5) 6 to 140ºC (5, 6). The higher the exothermic reaction, the greater the hemoconcentration.7 Z-Medica has recently released a new formulation with a much lower exothermic reaction and the same potential for hemostasis. (5) It also manufactures zeolite powder-impregnated sponges for use by EMS first responders and consumers.
Chitosan (Hemcon and Celox) is derived from the shells of shrimp and other crustaceans that have been treated to prevent reactions in patients sensitive to shrimp. (7) When exposed to moisture, chitosan becomes very sticky and clings to damaged tissue, attracting clotting mechanisms. The U.S. Army’s Combat Life Saver course recommends the use of chitosan dressings for moderate to severe (arterial) bleeding by applying the dressing with the polyester backing facing up to ensure adherence to the damaged tissue. If the bleeding has not stopped in four minutes, it is recommended that the first dressing be removed and a second one be applied. A chitosan dressing will not stick to the polyester backing of another dressing. Stacking this type of dressing, such as packing with conventional 4 × 4s or gauze rolls in a wound, will not work. The Army is so convinced that hemostatic agents save lives on the battlefield that it has deployed one HemCon dressing with every soldier, three dressings to every combat life saver, and five to every medic. (2)
There have been no reported adverse reactions or complications with the use of chitosan dressings. However, a pig aortotomy model study found the dressing’s efficacy was only 71 percent for complete hemostasis.8 The most effective uses most likely are for groin, axillary, neck, or facial injuries. Medical providers on the battlefield report that hemostatic bandages are most beneficial when used on wounds too proximal to the torso for effective tourniquet application. (2)
Once bleeding is controlled with the application of either hemostatic agent, apply a pressure dressing to ensure continued control of bleeding throughout transport. Carefully monitor the patient’s vital signs and injury site for any changes in homeostasis.
When you arrive at the emergency department, the physician credits the HemCon dressing with the positive outcome for this patient. Your thoughts drift back to the previous auto parts operator at that manufacturing plant; if you had had this technology back then, would the outcome have been better? If you had been able to use a tourniquet back then, you might have had the same positive outcome as today’s run.
TOURNIQUETS
The controversy surrounding the use of tourniquets may be coming to an end. Evidence from the battlefields of Iraq and Afghanistan is proving that tourniquets are very effective in saving lives. The strongest argument for use of tourniquets in the field comes from the experience of the United States military.9 Throughout the history of warfare, there has been a need to stop bleeding while remaining involved in tactical operations.10 While under fire, there is a need to protect the rescuers and stop the bleeding without endangering anyone.
How does this translate to the civilian sector? A quick survey of the members of my fire department revealed that all would use a tourniquet only if they had exhausted all other methods of bleeding control. However, the need to quickly evacuate a patient with excessive hemorrhage warrants a more aggressive approach to bleeding control.
The potential risks of tourniquet use may have led to their current position as a last-resort bleeding-control measure in civilian EMS. Some of these complications include pain, paresthesia, vascular spasm, muscle injury,11 edema, ischemia, and gangrene.12 These risks are generally localized to underlying tissue when compressed for long periods of time. (11) There have been reports of systemic complications from tourniquet use in elective surgeries, but these are usually transient in nature. The worst systemic reactions reported have been cardiac arrest secondary to a functional increase in circulating blood volume in patients with poor cardiac function.(11)
Many of the issues with tourniquets have been related to incorrect application, insufficient tightness, too narrow a width, or improvised materials that continue to allow arterial flow while occluding venous return, causing a localized increase of pressure distal to the tourniquet.13 Many of these complications could be eliminated with rapid transport to an appropriate medical facility prepared to handle complicated vascular and orthopedic emergencies. One well-known complication seems to appear rarely when the literature is reviewedloss of limb secondary to extended application or unnecessary use.14 It seems that the rapid evacuation to a surgical facility has reduced this complication to only the extremities that would have been lost without the use of a tourniquet. (14)
It is a rare situation when nontactical civilian EMS responders find themselves in a tactical scenario. However, there are times when the use of a tourniquet seems to be more practical than a last-ditch effort: when a patient is trapped and has suffered a large extremity wound, when there is moderate to severe hemorrhage with signs of shock, and when there are long transport times with continued hemorrhage despite measures to control the bleeding or providers on-site may not be allowed to administer fluids.
Do not take the decision to use a tourniquet lightly; weigh all risks and complications against the benefit to the patient. Adhere to some commonsense rules: Always apply between the wound and the patient’s heart; never cover a tourniquet once applied; in a multiple-casualty incident (MCI), mark a “T” on the patient’s face/forehead; and never release a tourniquet once applied. Other ideas when applying a tourniquet include the following: Ensure that it is applied tightly enough to stop all bleeding distal to the tourniquet, never apply it over a joint or around an impaled object, and splint the affected extremity to prevent other injuries secondary to the fractures that could accompany a devastating injury. Although virtually all external hemorrhage can be controlled with direct pressure alone, the combined use of clot-accelerating dressings, tourniquets, and pressure dressings provides sufficient adjuncts to stop all bleeding even in the worst of extremity injuries.
You will never know if a hemostatic dressing or a tourniquet would have been of any benefit to the patient with the femoral laceration at the auto parts plant. However, you now know the benefits of these new adjuncts for the hemorrhaging patient. You also know firsthand how they might benefit your patient. There should be no patient who presents in shock with moderate to severe bleeding from an extremity for whom a tourniquet or a hemostatic dressing is not considered as a first-line intervention. (9)
Hemostatic dressings and tourniquets have changed the way bleeding is controlled on the battlefield and have now moved into civilian EMS systems, hopefully with the benefit of saving more lives. The second leading cause of traumatic death is uncontrolled hemorrhage. As more prehospital providers implement these bleeding-control techniques, it should be only a matter of time before this statistic starts dropping.
References
1. Sauaia A, EE Morre, et al, “Epidemiology of trauma deaths: a reassessment,” JTrauma, 1995; 38:185-193.
2. Wedmore I, J McManus, A Pusateri, J Holcomb, “A special report on the Chitosan-based Hemostatic Dressing: Experience in Current Combat Operations,” JTrauma, 2006; 60:655-658.
3. Alam HB, D Burris, JA DaCorta, P Rhee, “Hemorrhage control in the battlefield: Role of new hemostatic agents,” Military Med, 2005; 170:63-69.
4. Pusateri AE, et al, “Making Sense of the Preclinical Literature on Advanced Hemostatic Products,” JTraum, 2006; 60:674-682.
5. Pusateri AE, AV Delgado, EJ Dick Jr., et al., “Application of a granular mineral-based hemostatic agent (QuikClot) to reduce blood loss after grade V liver injury in swine.” J Trauma, 2004;57:555-562.
6. Alam HB, GB Uy, D Miller, et al., “Comparative analysis of hemostatic agents in a swine model of lethal groin injury,” J Trauma 2003; 54: 1077-1082.
7. Siekman, P, “A shrimp bandage? An exotic military wound dressing invades the civilian market,” Fortune Small Business Magazine, On Line. September 22, 2006.
8. Kheirabadi, BS, EM Acheson, R. Deguzman, et al. “Hemostatic efficacy of two advanced dressings in an aortic hemorrhage model in swine,” J Trauma, 2005; 59: 25-34.
9. Wencke JC, TJ Walters: “Physiologic evaluation of the US Army one-handed tourniquet,” Mil Med, 2005; 170:776-781.
10. Butler FKJ, “Tactical medicine training for SEAL mission commanders,” Mil Med, 2001; 166:625-631.
11. Landi A, A Saracino, M Pinelli, G Caserta, MC Facchini, “Tourniquet paralysis in microsurgery,” Ann Acad Med Singapore, 1995; 24:89-93.
12. Richey SL, “Tourniquets for the control of traumatic hemorrhage: a review of the literature,” World of Emergency Surgery, 2007; 2:28 1186/1749.
13. Bunker TD, AH Ratliff, “Uncontrollable bleeding under tourniquet,” Br Med J (Clinical Research Education), 1984; 36:48-50.
14. Ficke, JR, “Extremity War Injuries: Development of clinical treatment principles,” J Am Acad Orthop Surg, 2007; 15:590-595.
MICHAEL D. SMITH, CCEMT-P, is a firefighter/paramedic with the Grandview Heights (OH) Division of Fire, a flight paramedic for Medflight of Ohio, an Outreach critical care educator for Grant Medical Center’s LifeLink, and a paramedic instructor at Ohio University-Lancaster. He has been involved in EMS since 1986.
