We often get questions regarding hemostaics:
Which is the best?
How do they work?
What is the mechanism of action?
The TCCC recommendation of Combat Gauze (TM) has clouded the issue of effectiveness with respect to other available agents. That is to say, there are others on the market that were just as effective in studies that were not chosen. Hopefully, the attached study summarizes the pros and cons of most available agents.
Below is an excerpt from a lessons learned compilation titled “First to Cut: Trauma Lessons Learned in the Combat Zone.” Though it is geared toward FST surgeons and forward medical providers, some of the lessons are applicable to tactical medics and mountain rescue. The larger take-away point is that the physiology occurring distally to a tourniquet applied for a long duration needs to be considered when changing or loosening, especially in environments where medical care may be limited (e.g., Third World).
“26 y.o. male with foot traumatic amputation and
multiple frag wounds to the right leg with a high thigh
field tourniquet in place. Arrived to the CSH with SBP of
100 HR of 120. we had no report on duration of the
tourniquet. We took down the tourniquet and he promptly
coded. We put the tourniquet back up, intubated him and
gave him fluid and bicarb and he came back. We found
out later that the tourniquet had been in place for over 4
hours….”
The use of tourniquets – while rare in civilian trauma is
very common in combat injuries. Tourniquets are the
number 1 instrument that a medic can employ to lower the
KIA numbers. The use of tourniquet with application until
the absence of a distal pulse by default causes distal
ischemia. Release of a functioning tourniquet after several
hours can result in the release of acidic fluid and potassium.
The patient intubated and without a head injury can be
briefly hyperventilated. Before taking down a long
duration tourniquet make sure the patient is well hydrated,
resuscitated, adding an ampule of sodium bicarbonate or
THAM can prophylax against the release of “bad humors”,
lactic acid, and potassium. Also release the tourniquet
slowly – if the rare arrhythmia arises re–employ the
tourniquet and retry after further bicarb and fluid. If the leg
is necrotic remember “life before limb” and perform an
amputation.
Lessons Learned:
–Prolonged tourniquet times can result in the release
of acidotic fluid and hyperkalemia
–Perform 4 compartment fasciotomy with all lower
extremities with significant tourniquet times
After reviewing the many submissions for our first contest, 101 Ways to Use a Triangular Bandage, we have selected our winners. Due to the fact that two contestants submitted outstanding submissions, we decided to award two prizes. Our first winner, for the shear volume of ideas, is Lee Whitehead and he will receive $200 worth of Tac Med Gear. Our second winner, who submitted the most unique ideas that range from medical uses to survival, comes to us from Belgium (name withheld for OPSEC), and he will receive the same prize.
Thank you all for your submissions. We will begin posting videos of them over the next few months. If you have any other ideas for contests, let us know.
Tac Med Team
Chest decompression for non-medics is a sticky subject. Recent observations overseas have seen an increase in improper location medially when inserting the needle. The causes of the high rate of improper placement are difficult to determine (i.e., environment, visibility, etc.) and have led to some medical directors prohibiting the procedure for non-medics within the military and LEO teams. However, the below study illustrates that proper initial training leads to high retention rates, thereby making this a skill that ought to remain at the operator level.
Abstract
Introduction: Tension pneumothorax is the second leading cause of preventable combat death. Although relatively simple, the management of tension pneumothorax is considered an advanced life support skill set. The purpose of this study was to assess the ability of non-medical law enforcement personnel to learn this skill set and to determine long-term knowledge and skill retention.
Methods: After completing a pre-intervention questionnaire, a total of 22 tactical team operators completed a 90-minute-long training session in recognition and management of tension pneumothorax. Post-intervention testing was performed immediately post-training, and at one- and six-months post-training.
Results: Initial training resulted in a significant increase in knowledge (pre: 1.3 ±1.35, max score 7; post: 6.8 ±0.62, p < 0.0001). Knowledge retention persisted at one- and six-months post-training, without significant decrement.
Conclusions: Non-medical law enforcement personnel are capable of learning needle decompression, and retain this knowledge without significant deterioration
for at least six months.
In an age when hemostatic agents and pocket-sized BP cuffs monopolize most conversations regarding combat casualty care, a command of the basics is being lost. While the abundance of choices of pre-made kits addressing the majority of field-treatable injuries reduces the chance of needing to improvise, one ought to have a command of the basics using available materials.
A medic cannot have a more basic piece of kit than a triangular bandage. Therefore, we are having a contest to encourage submissions of different ways to use a triangular bandage to treat combat trauma. The details are as follows:
Prize: $200 in free Tac Med gear
Submission Format: Either submit a description to the comments section or email them to alan@tacmedsolutions.com. How-to videos are welcomed, but not required. We will be filming the most unique and helpful techniques for the blog.
Deadline: All submission must be in by 1 MAR 2010. We will announce the winner by 15 MAR 10. Due to concerns with operational anonymity, we will request your approval before sharing your name.
Below is an article from the latest Journal of Special Operations Medicine. It is an even-handed review of considerations when one is building a personal medical kit. It not only applies to SOF Operators, but to patrol officers and SWAT teams as well.
We have thus far discussed considerations for packing Level 1 and Level 2 equipment. Remember that Level 1 gear is what you carry on your person (e.g., IFAKs and Med Vests) and Level 2 gear is carried in your first-aid bag. Level 3 gear is generally considered kit stored on your vehicle or supplement packs pre-positioned on resupply platforms. For instance, you might want to store the following on your vehicle:
1) pre-made IV kits
2) hypothermia prevention kits
3) backboards, rigid litters, evacuation prep kits
4) splinting material
With regard to pre-made bundles on resupply vehicles, it is a good idea to meet with helicopter crews that are supporting you, or the QRF, and ask to have numbered pre-made bundles for which you can call. For example,specific hemorrhage control items in a bag they can kick out the door, or a whole pre-packed aid bag. The latter can be be a bad idea, because you could find yourself with extra gear you don’t need and can’t store.
In the end, you must pack for your needs and trust your skills to make due with what you have, lest you find yourself imitating a pack mule.
As mentioned in an earlier post regarding Level 1 kit, you must pack your medical gear to reflect the mission requirements and constraints. Here are some considerations when packing your Level 2 gear:
1) Pack supplements to Level 1. For instance, medics may need more bandages and tourniquets.
2) Pack for Tactical Filed Care phase of treatment. In this phase, you may need:
3) An aid-bag for the above items. Err on the side of too small, as carrying a “tick” on your back might be more of a burden than an asset, depending on the mission. That is your call.
The above serves as a framework. We will cover Level 3 in the next post.
Historically, tension pneumothax has been the 2nd leading cause of preventable death on the battlefield. Therefore, this is an important skill and is being taught to medics at the lowest level of care. However, as with all procedures, risks are involved. Feedback from the field has indicated that medics are performing this procedure too often and TOO medial, causing multiple complications.
The above video covers the hazards of a needle decompression. Below you will find a brief review of indications, contra-indications, etc. As always, please follow local protocols.
INDICATIONS:
Needle decompression is indicated for the treatment of:
A. Tension pneumothorax and / or
B. Tension hemopneumothorax
CONTRA-INDICATIONS:
A. Chest decompression is indicated in the field only in the face of a life-threatening
tension pneumothorax. In that situation, there are essentially no contraindications since
the only alternative is almost certain death.
CAUSES OF TENSION PNEUMOTHORAX:
A. Blunt force trauma to the chest that ruptures a portion of lung tissue
B. Fractured rib that punctures the lung tissue
C. Spontaneous pneumothorax for no apparent reason
D. Conversion of a simple pneumothorax to a tension pneumothorax by positive pressure
ventilation as with a bag-valve mask device etc.
E. Open pneumothorax that is covered and left unattended developing into a tension
pneumothorax
SIGNS/SYMPTOMS
A. Chest pain
B. Severe respiratory distress
C. Tachycardia
D. Hypotension
E. Decreased or absent breath sounds on affected side
LATE SIGNS / SYMPTOMS:
A. Cyanosis
B. Distended neck veins
C. Tracheal deviation away from affected side
(Source: Canadian Tactical and Operational Medical Solutions)
COMPLICATIONS:
A. Creation of pneumothorax where none existed previously
B. Laceration of lung tissue
C. Bleeding from laceration of intercostal blood vessels
D. Severe pain to conscious patient (since this is life-threatening, the procedure must be
continued )
E. Local hematoma
F. Laceration and/or puncture of the heart
