Stop the Bleeding!

From the battlefield to the ED, improvements in hemorrhage contral have changed the way we practice. Here’s a practical guide to recent advancements, from tourniquets to hemostatic agents.   

 

An American soldier sustained this explosive injury when a grenade was tossed into his HUMVEE during a tour in Iraq. He saved his life and leg by forcing the explosive under the dash with his foot. The injury could have been accompanied by significant blood loss were it not for the quick attention of the Navy corpsman and his application of QuikClot, a hemostatic agent in granular form. (picture by Mark Plaster, MD)

 

 

Despite the horrors of  war, conflicts can also result in some positive contributions for delivery of medical care on and off the battlefield.  In fact many of today’s medical advances such as the concept of the “golden hour,” hemorrhage control products and the development of advanced aeromedical services can be attributed to combat trauma research.
 
Because mortality secondary to uncontrolled hemorrhage continues to be the leading preventable cause of mortality death in both the civilian and current military environments, accounting for up to 40% of civilian and 50% of combat related deaths, the military has focused much of its medical research on development of hemorrhage control. During this current conflict improved tourniquets, hemostatic agents and dressings have been developed, researched and fielded by the military with unprecedented speed. Furthermore, the “dogma” of applying the “ABC” principles to every patient in every circumstance has recently been called into question. In situations of massive external hemorrhage, many military educators are now teaching C (control bleeding) then A(airway) followed by B (breathing). These principles may have application to civilian practice, especially for an explosive injury or mass-casualty incident.

Tourniquets; not necessarily a “last resort”

Despite the civilian doctrine that tourniquet use is a “last resort,” tourniquets have been used safely and effectively on the battlefield since the 17th century. In spite of many strong opinions against tourniquet use by our civilian colleagues, this simple device is carried by every solider on today’s battlefield and is used frequently. While it is easy to see that the benefit of tourniquet use clearly outweighs the risk in a combat situation, there may also be civilian situations where tourniquet use is appropriate. Physicians and medics with combat experience have reported that many lives have been saved by a liberal use of proper, appropriately applied tourniquets.  

 

CAT – Combat Application Tourniquet (CAT-Phil Durango, LCC)
MAT–Mechanical Advantage Tourniquet (MAT-Bio Cybernetics International)
SOFTT–Special Operations Forces Tactical Tourniquet
(SOFTT-Tactical Medical Solutions, LLC)
EMT–Emergency Military Tourniquet (EMT-Delfi Mecial Innovations Inc.)

Despite this, there remains resistance to the use of tourniquets in civilian settings.  However, several tourniquets (in graph above) have been studied in both animal and human settings and have demonstrated effectiveness with little to no harm. 
 
The tourniquets in the graph above have a mechanical advantage over improvised tourniquets by employing a windlass (CAT, SOFTT), a block-and-tackle (MAT), or pneumatic compression (EMT) system that allows for more effective vascular occlusion.

Also a wider strap allows for occlusion of blood flow at lower pressure, thus helping to minimize the potential for damage to underlying tissues.  In our tests, it seemed that the EMT device produced significantly less circumferential pain in both the leg and the arm than the other effective devices, but all of the above devices have shown effectiveness in both animal and observational human studies.

Hemostatic Agents

Hemostatic Agents were initially being developed in 1997 for combat trauma with the initial work on the dry Fibrin Dressing by Col John Holcomb and the American Red Cross. This work expanded exponentially after the start of the global war on terror and the immediate need for agents to aid in the control of external hemorrhage from penetrating trauma. This initial work has resulted in a myriad of hemostatic agents in 2007. This has been a good thing as the bottom line is that all hemostatic agents work better than plain gauze which was the “gold standard” since the time of the Spanish American war. It is also true that no agent is 100% effective, all these agents will or can fail in some circumstances. It is simply untrue that any agent will be 100% effective in every given wound.  The prices listed are based on several internet sources as of Jan 08.

 

click to view a high-res version of the chart below