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?