Bleeding Isn't Cool

"Bleeding Isn't Cool"

How many of you have ever heard that if you place a tourniquet, you'll kill whatever is below it? When I joined the military way back, that was exactly what we told our troops. "Tourniquets are only to be used as a last resort." Well, if you know anyone who is still touting that myth, let them know that it's just that, a myth, because science.
Tourniquet placement times up to 2 hours are common not only on the battlefield, but in the operating room. This prevents blood loss. Blood needs to be in the body and a well-placed tourniquet helps it stay there. It doesn’t matter whether it’s arterial or venous in nature, life-threatening bleeding is still bleeding and needs to be controlled. Bleeding is bad...mmmkay???

There are many instances where the TQ has been in place longer than 2 hours and the victim has still retained their limb. A study conducted in 2008 in Iraq, described how not a single loss of a limb was attributed to TQ placement. The limb may have been lost as a result of the injury which necessitated the application of the TQ but the loss wasn't a direct result of the TQ placement. Also, the quicker the bleeding is controlled, the greater the chances of survivability for the victim. Blood belongs in the body. Period. If hemostasis can be achieved before the victim falls into Stage II Shock (750-1500ml of blood loss), then the chances of survival are around 94%. If the victim falls into Stage II or greater shock, the survival rate drops down to around 14%. (per US Army Institute of Surgical Research) Blood carries oxygen and clotting factors and those need to be in the body when it is wounded, not leaking out onto the ground, so get the bleeding stopped as quickly as possible, however possible. The better our tissues are perfused with oxygen, the less downstream issues we have to deal with. A victim may survive the initial injury and blood loss only to die days later from the downstream effects of inadequate cellular oxygenation. If cells die, tissues die. If tissues die, organs die. If organs die, we die. If they do survive, their organ function may take a very long time to return to a baseline “normal”, if at all.

Even PHTLS and NREMT are teaching TQ's now as they are saying that if hemostasis can't be achieved with direct pressure, then move onto a TQ. Why? Because they work and have been proven to be both safe and effective.
“High and Tight”….Place the TQ high as it's easier to occlude the vessels against one long bone vs two bones in the lower extremities of the arms and legs. Also, arteries can retract a decent distance due to their inherent elasticity, so the "...2 inches above the wound..." may not be feasible and you’ll be putting a TQ below where the artery actually is, which does no good at all. This is called a “hasty” TQ. There has been a change in TCCC guidelines which states if you can ID the bleed, then place it 4” above the wound but that’s more for our medical personnel and is called a “deliberate” TQ. If you can’t readily ID the bleed then go “high and tight” and let the medics sort it out later. Also, and this is very important, get the TQ on as tight as you can on your initial pull. Get all of the slack out of the strap. This will do two things: 1) Get the TQ on to a near-occlusion pressure 2) You won’t have to turn the windlass as much. What does this do? It means a faster TQ application which means less time bleeding, which is a big win.
Securing the TQ is another big thing. If you secure it, stop ALL of the bleeding. Veins are easier to stop the flow so if you still have an ooze, you may have arteries feeding the extremity and you won't have any return through the veins as they are occluded. This can cause a dangerous amount of pressure to build up in the extremity and lead to a life/limb-threatening situation called "Compartment Syndrome". A wound which may have needed a TQ but wouldn't have resulted in an amputation now does due to a poorly secured TQ. So, constantly reassess for any bleeding and ensure you can’t feel a pulse below the tourniquet on a pulse point (ie. Radial artery in the wrist or dorsalis pedis/posterior tibial in lower leg). In addition, don't release a TQ every 20 minutes as was once taught. If it's there, it's there to keep blood from leaking. This isn't the 18th century and we're not trying to rid our patients of "bad humours". ;-)

The big thing to remember is, and this is HUGE, if it's not life-threatening (think blood pouring out of a pitcher), then direct pressure is, more than likely, going to do the trick. Don’t go “full guns” if your kid gets a minor laceration and you try to tourniquet them off. Even small arterial punctures and lacerations can be controlled with direct manual pressure, I did it for many years after taking out arterial lines and sheaths in the ICU. If you have the time and opportunity to utilize a hemostatic or pressure dressing to ensure the wound stops bleeding, then go for it. Remember, the situation dictates the medicine. Don’t overdo it. Primum non Nocere. “First do no harm”. It matters not whether the bleed is arterial or venous in nature, it’s still bleeding and blood belongs in the body. It’s science. Do all you can to keep it there.

Some wounds may need the TQ initially due to an unsafe scene and then can be dressed with a hemostatic gauze and pressure bandage or may just need the hemostatic agent and pressure bandage. The key to using a hemostatic agent is to get the agent down to the source of the bleed and keep applying it until no more can be placed and then holding pressure for the prescribed amount of time, observing for any re-bleed and then reinforcing it with a pressure bandage. You’re trying to put as much of the agent in the wound as possible while the gauze is conforming to the wound and applying compression. If it begins to re-bleed you’ll have to pull that gauze and place a fresh one in. If you have only one, just pack more standard gauze in behind that and continue to hold pressure and then wrap with a pressure bandage. 

The hemostatic gauze we utilize in our kits have two different compounds; Activated Chitosan (Celox Rapid) and Kaolin (QuikClot Combat Gauze). The Combat Gauze helps with the body's own clotting capability to assist in forming a clot while the Celox Rapid acts completely independent of the body’s “clotting cascade” and the gauze helps with the compression. The QuikClot Combat Gauze has absolutely no heat at all associated with it and won’t burn, while the Celox Rapid breaks down into glucosamine and causes no issues with folks who are allergic to shellfish, iodine or CT dye as the proteins (what we’re allergic to) are absent. It also works well with artificially “thinned” blood. Think Coumadin, Heparin, Aspirin, etc. A lot of folks don’t realize it but that Motrin or Aleve you take every day for minor aches and pains is in the same class of drugs that the 81mg Aspirin is that doctors tell their patients who have had, or who are at risk for, heart attacks; Non-Steroidal Anti-inflammatory Drugs (NSAIDS). So, if you take any of the above, or any other “thinner”, like Omega 3’s or NSAID, realize that your blood won’t clot as readily as someone who doesn’t take those medications.

"But it has to be washed out"....every wound, whether it has the old granules or the newer gauze or nothing, will be irrigated copiously and debrided in the OR.
“What about sterility?....Sterility is also another big question and that completely goes out the window when you're shot and or injured. Plus, you'll be getting an equine-sized dose of broad spectrum antibiotics in the ER anyway. The packaging has to be sterile per FDA requirements but unless the outer wrapper is sterilized and you open it utilizing sterile technique with sterile gloves in a sterile environment, the moment you break the seal on the package in the outside environment, while using non-sterile gloves, sterility is now gone. The least of your concerns at the time someone is bleeding to death is whether or not something is sterile. It’s a good idea to keep it as clean as possible but we have to know that it’ll never be sterile after it’s opened. All of the hemostatics we utilize in our kits are solid performers and have been proven to work in austere environments time and again.

The most important thing I can stress about any of the aforementioned items is learning how and when to use them properly, safely and efficiently. We can help you out with that because we offer these products in our kits and the training on how to use them and other items in the event that you don’t have them with you.
A med kit may not be as cool as a new 1 million lumen face-melting SureFire light, but bleeding isn't cool either.

Get a kit. Get trained. Come home.