Tourniquet the Limbs, Pack the Junctions, Seal the Box

So, lets talk a little bit about tourniquets, hemostatic agents, and chest seals. 

So much has changed in the last few years concerning tourniquet use, thankfully. Tourniquets were the last resort for many years and still are in many civilian settings, but as we learn more about the human body, our skills and tools have improved. Now tourniquets are credited for saving many, many lives after being the first item placed in the event of a life-threatening hemorrhage. To that end, we need to know the "How?", the "when?" and the "Why?", which brings us to our first piece of info: How to tourniquet the limbs...

An old myth is, "Once you place the tourniquet, everything else below it is dead."

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, bleeding is still bleeding and needs to be controlled. All bleeding is bad. Full stop. End of story.

A study conducted in 2008 in Iraq, described how not a single loss of a limb was attributed to TQ placement. 

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 over 90%. If the victim falls into Stage II or greater shock, the survival rate drops down to around 20% or less. 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 of other complications related to multi-system failure later. If they do survive, their organ function may take a very long time to return to a baseline “normal”, if at all. So, stopping the bleeding and getting the victim to a definitive care facility to get blood back onboard is going to increase survivability exponentially.

Tourniquet use is now a widely accepted method of controlling hemorrhage and the majority of the up-to-date bleeding control curriculum reflects that.They agree with the general consensus that pretty much all bleeding is bad and that if hemostasis can't be achieved with direct pressure, then move onto a TQ.

High and Tight

For the layperson, we teach the “hasty” tourniquet placement method in that we place the TQ as high on the extremity as it can be difficult to ascertain exactly where the bleedingis coming from, so we go “high and tight” on the extremities. Also, arteries can retract a decent distance due to their inherent elasticity, so the old adage of "...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. So, we “Tourniquet the Limbs” “high and tight”.

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).

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. However, if you do, their therapist will thank you for it in later years since you’ll be helping them pay for their new Mercedes. ;-)

Blood Belongs in the Body. It's Science.

If you have to utilize a hemostatic or pressure dressing to ensure the wound stops bleeding, then go for it. It matters not whether it’s 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 pressure bandage. Also, some wounds may not be amenable to tourniquet placement and the only way to control the bleed is through the placement of a roll of hemostatic gauze. Those areas of the body we can’t apply a tourniquet to are where we are looking at; the “junctions” like where the neck meets the shoulders, the arms meet the armpits and the legs meet the groin. So, we “Pack the Junctions”. The key to success when using a hemostatic agent is to get the agent down to the source of the bleed through constant, consistent pressure 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.

Hemostatic Agents

The hemostatic gauze we utilize in our kits have two different compounds;Chitosan (ChitoGauze) and Kaolin (QuikClot Combat Gauze and Bleeding Control Dressing). The Combat Gauze helps with the body's own clotting capability to assist in forming a clot while the ChitoGauze 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 ChitoGauze 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” 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 someone is 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.

Seal the Box

What about packing a penetrating wound to the chest? Nope. We call anything from the collarbone to the pelvis and allll the way around the trunk, “The Box”. One, we don’t pack anything into a penetrating injury to the chest, two, we can’t tourniquet it off, three, there’s a lot of ways there that air can get into the pleural spaces and collapse a lung. So, if we can’t tourniquet it off or pack it, what do we do? We “Seal the Box”with a non-porous occlusive dressing. The first choice is one which is “vented”. This means it allows any pressure building up inside the chest to be released passively so that it doesn’t continue to build and cause an excess of pressure.That said, we must know the signs and symptoms of a tension pneumothorax because just because you have a vented seal in place over a penetrating chest injury does not mean that it will be working. There are many things which can occur with this type of injury which can cause the wound to occlude and not “vent”. So, know your signs and symptoms and constantly reassess the victim for any increased difficulty breathing and other indicators of this dangerous build up of pressure.There are many types of chest seals out there and we utilize the HALO or Hyfin as they are excellent performers and pack easily into our kits and other stand-alone kits.

The key with any of the aforementioned items is learning how and when to use them. Get the training and be prepared. 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. 

The time chooses you. Will you be ready?