Tourniquet the Limbs, Pack the Junctions, Seal the Box

So, let’s 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. However, thankfully times have
changed and as we learn more about the human body, our skills and tools have improved. Tourniquets,
once maligned, are now 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?” when it comes to our first piece of info; “Tourniquet the Limbs”.
An old myth is, "Once you place the tourniquet, everything else below it is dead". False. 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.
There are many instances where the TQ has been in place longer than 2 hours and the victim has still
retained their limb. A nine-month study in Iraq described how there wasn’t 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 less than 20%. Blood carries oxygen, removes waste and has vital clotting
factors. All of 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 related complications 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.
For TQ placement, we teach “deliberate” and “hasty” placement. Basically, a “Deliberate” placement is
if you can see where the blood is coming from, you’ll want to place the TQ 2-3” above that wound,
unless there’s a joint involved, in which case, you’ll want to place it a couple of inches above that joint.
Now, let’s say the scene is chaotic, multiple victims, blood-soaked clothing, poor lighting, etc….and you
just can’t tell where the bleeding is coming from, that’s where you can apply a “Hasty” TQ. You’re going
to place the TQ as high up on the limb as you can and then secure it. This is also called the “High and
Tight” placement method used in CUF (Care Under Fire) scenarios. This type of TQ placement may stay
as it is until the victim is at a higher level of care or it could be “converted” to a “Deliberate” TQ
placement by the First Responders if the wound is easily identified. What they would do then is place a
second TQ 2-3” above the wound, secure it and then release the first “High and Tight” TQ to prevent
more tissue from being affected by no blood flow. This has to be done within the two-hour window we
talk about in class and why it is absolutely vital that we mark any TQ with the time of application. This
two-hour window is very important in that it lets First Responders know how long the TQ has been in
place.
Securing the TQ is another big thing. If you secure it, stop ALL of the bleeding. Veins are lower pressure
and it’s typically easier to stop venous flow, so if you still have an ooze, you may have arteries (higher
pressure and harder to occlude) 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). Once the TQ is secured
and all the bleeding is stopped, you’ll want to note the time and write that on the place provided on the
TQ. If all the bleeding isn’t stopped with one TQ, you can add a second one directly adjacent to the first
one, whether above or below (wherever you have the most room) and then secure and mark the time of
application. Individuals with larger limbs may need more than one TQ to successfully stop the bleeding
because not only does a TQ work on circumferential compressive force, it also acts on the surface area
which is being compressed. Therefore, if one TQ doesn’t work, you are doubling the surface area being
compressed by adding a second TQ and increasing your chances of successful hemostasis.
When do I not use a TQ?? Simple…. if it's not life-threatening. What’s life-threatening? Any of the
following could be viewed as life-threatening:
-Blood pouring out of a pitcher
-Blood-soaked clothing
-Bright red arterial spray
-The victim is lying in a large pool of blood
-The bleeding won’t stop with direct pressure
If the bleeding doesn’t look like the aforementioned, then, more than likely, good old fashioned direct
pressure is going to do the trick. Don’t go “full guns” if your kid gets a minor laceration and you try to
put a tourniquet on their limb. Even small arterial punctures and lacerations can be controlled with
direct manual pressure.
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; this is called a
“tourniquet conversion”. 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 (or whatever type of packing material you have on hand) in behind that and continue to hold
pressure and then wrap it and secure it with a pressure bandage.
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”. 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. They
are both solid, proven hemostatics. They are impregnated into the gauze to get to the source of the
bleed for better delivery and to start building the clot. The gauze is there as a framework for the clot and
to add compression into the wound.
"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.
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?
For more information on our products and training go to:
SIMPLICITY UNDER STRESS