Hemorrhagic Control Agents
 

Are we going to use them? Which one? Why? under what conditions?

You hit on something that I have been thinking about lately. I was at Walter Reed the other day and saw a number of amputees. I saw one guy learning to walk again who was a triple amputee. While this soldier's MOI could have been anything, it got me thinking about tourniquets and their rate of employment on the battlefield. I saw a thread somewhere about new, earier to use tourniquets and that recalled someone's quote about when all you have is a hammer, all problems looks like nails.

So, are Hemorrhagic Control Agents a better alternative to a tourney? Does the level of basic first aid training need to be addressed?

From the Special Operations Forces Medical Handbook (2001).

Circulation: Uncontrolled hemorrhage is the leading cause of preventable battlefield deaths. Rapid identification and effective management of bleeding is perhaps the single most important aspect of the primary survey while caring for the combat casualty.
Obvious external sources of bleeding should be controlled with direct pressure initially followed by a field dressing or pressure dressing. If bleeding is not controlled by the previous measures or if gross arterial bleeding is present, an effective tourniquet should immediately be applied. Clamping of injured vessels is not indicated unless the bleeding vessel can be directly visualized. Blind clamping of vessels may result in additional injury to neurovascular structures and should not be done.

NOTE: The current ATLS manual discourages the use of tourniquets in the pre-hospital setting because of distal tissue ischemia, tissue crush injury at the tourniquet site, which may necessitate subsequent amputation. This admonition is based on the civilian model of trauma care where most penetrating injuries are low velocity in nature and rapid evacuation to a trauma center is available. Withholding the use of tourniquets on the battlefield for patients with severe extremity hemorrhage may result in additional death or injury that might have otherwise been prevented.
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NDD note - if you have a Palm and don't have this book in it, you should get it. It is searchable and you can cut and paste to memo and print. It is an absolutely excellent tool. The only complaint that I have is that the images don't show up on mine - the anatomy plates, etc. Small price to pay to have this reference in my hands at all times. No, I'm not telling you where I got mine. The dude did me a favor and I won't abuse him. If you seek, you shall find.

NDD:

Who would be the "we" you are referring to in your initial post 18-D, 91W, civilian medics, etc...?

And... The pictures do not show up for me either. I have been working on it though and will advise if I figure it out.

We, the members of this board. Under what conditions would cover "I might use this in UW, but not in my ambulance rescue unit truck thing." all points of view are valid.

I think the pic thing is a memory issue at point of origin. I have my book on a 128MB chip, so its not an issue there. No big deal, much better to have without the plates than not have. Great resource. It even has a SOAP note section with examples. :munchin

Re: Hemorrhagic Control Agents
 

1.) Yes I think we will/should, but only after every other avenue of treatment has been utilized.

2.) TraumaDEX is 1st choice with Quickclot second.

3.) TraumaDEX can be used on both adult and peds w/o the complication of burns that Quickclot tends to produce. Not that I would not use Quickclot, I would. I firmly believe a 2nd or 3rd degree burn is better than losing a limb or a life.

4.) After bandaging, direct pressure, pressure points, and elevation has proved unsuccessful in hemorrhage control leaving the only other alternative, a tourniquet.


Jimbo:

Hemorrhage control agents are a much better alternative to the tourniquet. It controls the bleeding without denying tissue distal to the injury of much needed oxygenated hemoglobin.

The additional training necessary to use HCA's is not very extensive.

Just had to bring that back up did ya.

Re: Re: Hemorrhagic Control Agents
 

Right. But I don't know if basic battlefield first aid has reflected this advance. I see new, easier to use tourniquet devices being marketed to troops. I think under stressful conditions, a non-medic type might be less able to distinguish hemorrhagic bleeding from severe bleeding and just slap a tourney on it. The result is more amputations than necessary. That is bad.

Jimbo,
Arterial bleeding is a - fairly easy to distinguish and b - very impressive. In my modest experience, there is very little doubt about when to apply a tourniquet. The problem is people usually wait too long, not apply it too soon.

Crip, how long do you have after applying a touniquet before you start having irrepairable damage?

Jimbo:

I cant comment on battlefield training. But use of either adjuncts, HCA or tourniquet, is only considered after the other methods (bandage, direct pressure, pressure point, and/or elevation) have failed to stop the bleeding here in the EMS world. Whether to use it would not be dependant on whether it is venous or arterial in nature, but by the degree of hemorrhage.

The only problem I see with the HCA's is them being used as a first level treatment of hemorrhage instead of as a next to last resort.

As I understand the promo for these agents, they are best used in partiatial amputation, hard to control area (groin), and as a last resort to the ABCD's, pressure/elevation/arterial pressure, warmth, and packing. Has there been a change in that algorythem? In an emergent situation has the thinking changed as to new tech products like TraumaDex/QuickClot replacing the above mechanics of hemorrhage control.

I was taught the touniquets were the means of hemmorage control only while in an emergent/tactical condition or if no other means could control blood lose, once removed from direct action/controlled location/time, the ABCD's would be applied, pack/warm/fluid, and transport ASAP. Always looking for better ways of treating the pt, is this a better way?

Looking to the pros for answers. Thanks.

Maya

Maya:

I can only speak from what I have read and from my expereince on the civilian streets.

That being said, the algorhythm for hemorrhage control is the same with the addition of the HCA's before application of a tourniquet.

I thought I would chime in here , seeing as I just learned the answer to that in a class a month ago. I was taught (by WMA) that it takes about 2 hours for a limb to become unsalvagable. I believe that the "unsalvagability" (new word - put it in Webster's) is due to tissue necrosis.

The other danger with removing a tourniquet is reintroducing blood with lots of waste products back into the system. I'm not sure how long the waste build up needs to become a life threat on re-introduction. I'm guessing here, but the toxic blood threat may be the real reason for the civilian EMS rule of "never remove a touniquet".

Cheers.

NDD:

My apologies. I somehow looked over that question. Knocking them out for lack of ATD.


Maple flag:

Your reasoning for not removing the tourney once applied is what I was taught.

How long does it take for somebody to bleed out from say a severed femoral?

1 minute. But you can use pressure until you decide whether or not to tourniquet or HCA, no?

sorry for the intrusion.

My understanding was that tourniquets were very effective in controlling hemorrhage in limb injuries and that HCA’s should primarily be used as a last resort with respect to limb injuries. From what I have read HCA’s best application is in complicated groin injuries and other injuries where a tourniquet can not be applied and where direct pressure is not stopping the bleeding.

Journal of Trauma
Volume 54(5) Supplement May 2003 pp S219-S220
The Tourniquet Controversy
[COMBAT FLUID RESUSCITATION ORIGINAL ARTICLES]

Navein, John MRCGP; Coupland, Robin FRCS; Dunn, Roderick FRCS
From the Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences (J.N.), Bethesda, Maryland, International Committee of the Red Cross (R.C.), Geneva, Switzerland, and Department of Plastic Surgery, Caniesburn Hospital (R.D.), Glasgow, Scotland.

Describing a tourniquet as “an instrument of the devil that sometimes saves a life�1 encapsulates the considerable risk to a limb when a tourniquet is applied to arrest life-threatening extremity hemorrhage. The use of tourniquets is widespread in both military and civilian environments, particularly in the developing world; however, the balance of risk is unclear, and its efficacy is controversial and unduly influenced by folklore and dramatic Hollywood images. The tourniquet controversy remains unresolved and has not, to our knowledge, reached the pages of medical journals since 1940. 2 The clinical questions that remain unanswered are as follows:
* Under what circumstances should a tourniquet be applied?
* Relative to the number of tourniquets applied:
* How many lives are actually saved?
* How many limbs are lost or left with ischemic contractures?
* How long can a tourniquet be left on without risking loss of limb or limb function?
* How does the risk of crush syndrome increase with time?
* When can a tourniquet be released safely?
* How much damage is done to the tissues under a tourniquet?
* Are some tourniquets safer or more effective than others?
* How urgent is the inevitable amputation for a tourniquet that has been left on for more than 6 hours?
* How does the application of a tourniquet influence the priority for movement?

Little evidence exists to resolve these questions; however, the following points appear uncontroversial and represent first principles to support a coherent strategy:
* Most extremity hemorrhage, including that from traumatic amputation, can be controlled with direct pressure and elevation.
* Tourniquets have saved lives.
* It is accepted military practice to apply a tourniquet to move an injured person from the point of injury to a place of relative safety (or to continue fighting).
* The tourniquet should be broad, tight enough, and as low as possible, but not over a joint.
* Narrow, improvised tourniquets can crush the underlying tissues but may be unavoidable at the point of injury.
* An improvised tourniquet should be removed or replaced as soon as possible.
* Tourniquets lead to more (possibly many more) ischemic complications and unnecessary amputations than lives saved.
* Severe hemorrhage may not reoccur when an effective tourniquet is released after 2 hours.
* The “tourniquet time� for extremity surgery is 2 hours. 3
* Surgical doctrine holds that if an occlusive tourniquet has been applied for more than 6 hours, the limb should be amputated above the level of the tourniquet without it being removed.
* When a tourniquet has been applied for a large wound or traumatic amputation and left in place for 12 hours or more, there is a high risk of gas gangrene that increases with time.
* A tourniquet is very painful.

It seems there are few, if any, exclusively clinical reasons to apply a tourniquet to arrest extremity hemorrhage. For instance, in the admission room of a hospital, control is achieved by other means such as direct manual pressure. However, as injured people move from the point of injury to a surgical hospital, other factors come into play that may impact on and in some circumstances override purely clinical considerations. In the military context, the point of injury is a very dangerous environment, with considerable risk of injury to the care provider and of further injury to the injured person. There may be neither the time nor the materials to control hemorrhage, and it is rarely feasible to extract injured people from danger while maintaining manual pressure and keeping the injured limb elevated. The initial imperative must be to move people to relative safety; applying a tourniquet to expedite this clearly outweighs the clinical risk.

The nonclinical factors that must be considered when deciding whether to apply a tourniquet may pertain to situations other than at the point of injury. Moving injured people toward definitive care means that manual pressure and elevation may be impossible. There may be insufficient materials to apply adequate dressings or insufficient hands to apply manual pressure. Multiple casualties may accentuate this. This relative lack of resource can make conventional care impossible and so tourniquets become an appropriate and pragmatic solution.

Accepting that tourniquets may have to be applied, there are some universal rules that state that tourniquets should only be applied if hemorrhage is genuinely life-threatening, all feasible conventional measures have failed, and the consequences of applying a tourniquet can be managed adequately. Beyond these rules lies the question of how to manage tourniquets once they are applied. First principles suggest two key points in time that represent either end of a spectrum of risk. At one end, removing a tourniquet at 2 hours has minimal risk of ischemic complications and hemorrhage may have been controlled. Beyond 6 hours, the risk of arrhythmias and crush syndrome is so high that amputation above the level of the tourniquet is mandatory. Between these time points, the likelihood of serious complications including death increases with time and the chance of salvaging the limb decreases toward zero. These risks have not been quantified.

We feel that the controversy can be resolved as follows. It is unlikely that there are any exclusively clinical situations in which a tourniquet must be applied to arrest hemorrhage. Outside the surgical hospital, nonclinical constraints may override clinical considerations. A strict, safe, and generic strategy for the use of tourniquets has been published pointing to the need for further research. 1 It accepts the occasional need for tourniquets to arrest hemorrhage and proposes three concepts governing their application, as follows: the tactical tourniquet, a trial of tourniquet, and a tourniquet of last resort.

The “tactical tourniquet� is a short-term, usually improvised tourniquet applied at the point of injury either by a care provider or by the injured person. Its specific aim is to arrest life-threatening hemorrhage while the injured person is moved to a place where initial care can be given in relative safety. At this point, the need for the tourniquet ceases and best possible care begins.

The “best possible� initial management of hemorrhage must always be application of a pressure dressing and elevation of the limb. In some circumstances, nonclinical factors mean that hemorrhage cannot be controlled in this way. A “trial of tourniquet� involves both correct application of a tourniquet to the limb and the most effective pressure dressing possible on the wound. The tourniquet is released after 2 hours (or 2 hours after application of a tactical tourniquet if one was applied). In many cases, hemorrhage will have ceased and there remains a chance of retrieving a functional limb in the long term. If serious hemorrhage recurs and it still cannot be controlled by a pressure dressing and manual pressure, then the trial has failed and the tourniquet must be reapplied.

A “tourniquet of last resort� is applied if the trial of tourniquet fails; unless the injured person reaches a surgical hospital within minutes, he or she is likely to require surgical amputation of the limb above the level of the tourniquet without the tourniquet being removed. Decisions about the priority for movement to hospital are complicated by many factors including time, resources, and the condition and number of others injured. In some cases, there may be no realistic possibility of a wounded person reaching a surgical hospital; not applying a tourniquet of last resort in this situation may be the kindest option.

We believe that strict adherence to these guidelines will result in fewer tourniquets being applied but in a safer manner. Application of tourniquets should not be taught in occasional first aid courses.

Of the questions above, three remain. Answering each will help to refine the guidelines further. They are as follows: Is it true that all extremity hemorrhage can be controlled without tourniquet given adequate skills and resources? Is it true that a trial of tourniquet is usually successful? What is the spectrum of risk of removing a tourniquet beyond 2 hours? We hope these questions will guide research in the future.

Great article! Where I work, I don't usually see the kind of extremity trauma that causes one to reach for a tourniquet, so I respect the decisions of those that deal with that kind of trauma on a more regular basis. That said, I've always been concerned about how many limbs are lost where a tourniquet may not have been needed.

The above seems to be a good start towards going beyond the life over limb equation and moving towards a protocol that saves both lives and limbs.

Enters HCA's.

HCA's definately have a role to play in hemorrhage control, and I look forward to new developments in HCAs.

That said, it's good to see more study being put into tourniquet protocols that allow for a quick stop to blood loss without committing to leaving the tourniquet on and sacrificing the limb.

Between HCAs and newer TQ protocols, there will hopefully be a lot less amputees out there.

Cheers.


P.S. I'm curious, never having worked the ER side of things, what assessment and treatment protocols are used when receiving a Pt. with a tourniquet? There must be assessment criteria that call for removal of the tourniquet vs. amputation. Any insight into the specifics there?

Re: Re: Hemorrhagic Control Agents
 

I was curious about this so I looked the products up. Quickclot is a synthetic derivative of volcanic rock, and TraumaDEX is an engineered microporous polymer derived from plants.

The part relating to differential burns is probably the physics.. QuickClot works electrostatically. TraumaDEX works osmotically. I am not smart enough to figure out what this means today.

The cool thing about TraumaDEX is that it not only adsorbs water.. it also seems like it lets the platelets etc adhere, acting as a central clotting point.

i was asked to respond about protocols for tourniquet removal in the ER...

we don't have one...

most tourniquets placed in the field are on for such a short time in the EMS system that none is needed except the ability to control bleeding when they come off.

the closest thing I can think of to compare to a tourniquet on for a very long time would be when we take an aortic cross clamp off that has been on for a while... lots of badness gets released and we usually prepare anesthesia. They will pretreat, if able, with things like mannitol and bicarb to help with the free oxyen radicals and metabolites that have built up and the acidosis that will often ensue.

Thank you Doc T.

Thanks Doc T

I voted for Qucikclot. If I can't stop it with pressure, I want the strongest stuff I can get.

Thats interesting NDD.

I thought about QC, but I started thinking about Peds and chose TraumaDex.

Have you had any experience with Hemicon dressings?

Negative.

Haven't run into too many bleeding babies on the battlefield either - although legs tend to cry like babies. :D

I was not questioning your rational, but rather stating the reason for my decision.

Legs huh...

Thanks for the insight.

x

You're right, my question was worded poorly. I agree, all tourniquets must come off eventually.

I was interested in learning about how the complications of a long duration tourniquet were assessed and managed pre and post Tq removal, which Doc T kindly provided.

Thanks.

x

Doc T,
Are your EMS guys using HCAs in the field?

no...I am not aware of any groups using them except experimentally... following protocols and such.

doc t.

Thank you. I was wondering what the clean up was like.

4-month-old poll with only 5 votes? Sounds like we need to recruit some more 18Ds . . .

at a conference I heard a talk about the different agents...the gentleman giving the talk said he wouldn't want quick clot used on him with any other alternative available... he stated on the animals it destroyed too much in its path...muscle, nerve, etc...

so again....probably the LAST alternative but better than nothing.

Must have worked for traumadex...

lol...nope...they have to come clean on that kind of stuff at the start of any talk....

but good try. I take it you voted for quick clot?

Its all I've got, but I would use it.