Transcript
Hemorrhage ControlHemorrhage Control
COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)
CMASTCMAST 22
IntroductionIntroduction Review methods of hemorrhage control in Review methods of hemorrhage control in
a tactical environment.a tactical environment.
Hemorrhage is the leading cause of Hemorrhage is the leading cause of preventable death on the battlefield.preventable death on the battlefield.
Hemorrhage control save lives.Hemorrhage control save lives.
New Hemostatic agents available.New Hemostatic agents available.
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Cardiovascular SystemCardiovascular System
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Blood VesselsBlood Vessels
ArteriesArteries ArteriolesArterioles CapillariesCapillaries VenulesVenules VeinsVeins
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PulsesPulses Left ventricle contracts.Left ventricle contracts. Peripheral pulses:Peripheral pulses:
– RadialRadial– Brachial Brachial – Posterior tibialPosterior tibial– Dorsalis pedisDorsalis pedis
Central pulses:Central pulses:– CarotidCarotid– FemoralFemoral
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BloodBlood Adult body:Adult body:
– Contains approximately 5 to 6 liters of bloodContains approximately 5 to 6 liters of blood– Loss of 1 pint of blood without harmful effectsLoss of 1 pint of blood without harmful effects– Loss of 2 pints may cause shockLoss of 2 pints may cause shock
Three phases of hemostasis:Three phases of hemostasis:– Vascular spasmVascular spasm– Platelet plug formationPlatelet plug formation– Blood clotting Blood clotting
(coagulation cascade)(coagulation cascade)
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HemorrhageHemorrhage Pulse vs. Blood Pressure.Pulse vs. Blood Pressure. How long until there are changes?How long until there are changes? Young healthy adults compensate for long Young healthy adults compensate for long
periods, then decompensate rapidly.periods, then decompensate rapidly. At what blood pressure do casualties lose At what blood pressure do casualties lose
consciousness? consciousness?─ @ 50 mm Hg@ 50 mm Hg
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Clinical Signs of Acute HemorrhageClinical Signs of Acute Hemorrhage
ClassClass % Blood % Blood LossLoss
Clinical SignsClinical Signs
II Up to 750 ml Up to 750 ml (15%)(15%)
Slight increase in HR; no change in BP Slight increase in HR; no change in BP or respirationsor respirations
IIII 750-1500 ml 750-1500 ml (15-30%)(15-30%)
Increased HR and respirations; Increased HR and respirations; increased diastolic BP; anxiety, fright or increased diastolic BP; anxiety, fright or hostilityhostility
IIIIII 1500-2000 1500-2000 ml (30-40%)ml (30-40%)
Increased HR and respirations; fall in Increased HR and respirations; fall in systolic BP; significantsystolic BP; significant AMSAMS
IVIV >2000 >2000 (>40%)(>40%)
Severe tachycardia; severe lowering of Severe tachycardia; severe lowering of BP; cold, pale skin; severe AMSBP; cold, pale skin; severe AMS
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Sources of HemorrhageSources of Hemorrhage External:External:
– Visible blood is hard to estimateVisible blood is hard to estimate
Internal:Internal:– May be hidden within the torso or even in May be hidden within the torso or even in
the extremities secondary to fracturesthe extremities secondary to fractures
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Sources of External BleedingSources of External Bleeding Arterial:Arterial:
─ Rapid, profuse and pulsatingRapid, profuse and pulsating─ Bright red in colorBright red in color
Venous:Venous:─ Steady flowSteady flow─ Dark red or maroon in colorDark red or maroon in color
Capillary:Capillary:─ Slow and oozingSlow and oozing─ Often clots spontaneouslyOften clots spontaneously
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Extremity HemorrhageExtremity Hemorrhage
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Internal Signs of HemorrhageInternal Signs of Hemorrhage
Soft tissue bruising.Soft tissue bruising. Abdominal tenderness.Abdominal tenderness. Hemoptysis.Hemoptysis. Hematemesis.Hematemesis. Melena.Melena.
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Injured Internal OrgansInjured Internal Organs
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Hemorrhage ControlHemorrhage Control
Assess the tactical situation.Assess the tactical situation. Expose the wound.Expose the wound. Attempt to control the Attempt to control the
bleeding with direct bleeding with direct pressure or a pressure pressure or a pressure dressing.dressing.
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Hemorrhage ControlHemorrhage Control
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Hemorrhage ControlHemorrhage Control
Life-threatening arterial bleeding Life-threatening arterial bleeding (amputation) may require early use of a (amputation) may require early use of a tourniquet.tourniquet.
If under enemy fire or in a dangerous If under enemy fire or in a dangerous position rapidly apply a tourniquet and position rapidly apply a tourniquet and move casualty to cover.move casualty to cover.
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TourniquetsTourniquets
Several new tourniquets have been Several new tourniquets have been selected as primary means to control selected as primary means to control hemorrhage in combat.hemorrhage in combat.
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Combat Application TourniquetCombat Application Tourniquet
WINDLASS
SELF ADHERING BANDWINDLASS STRAP
The C-A-T was selected as the primary The C-A-T was selected as the primary tourniquet tourniquet for every soldier.for every soldier.
C-A-T Step 1C-A-T Step 1
Place the wounded extremity through the loop of the Self-adhering Band
C-A-T Step 2C-A-T Step 2
Place tourniquet above the injury
site
C-A-T Step 3C-A-T Step 3
Pull the free-running end of the Self-adhering Band tight and securely fasten it back on itself.
C-A-T Step 4C-A-T Step 4
Adhere Self-adhering Band completely around the limb until the clip is reached.
C-A-T Step 5C-A-T Step 5
Twist the Windlass Rod until the bleeding has stopped.
C-A-T Step 6C-A-T Step 6
Lock the Rod in place with the Windlass Clip
C-A-T Step 7C-A-T Step 7
For small extremities, continue to adhere the Self-adhering Band around the extremity and over the Windlass Rod.
C-A-T Step 8C-A-T Step 8
Grasp the Windlass Strap, pull it tight, and adhere it to the velcro on the Windlass Clip.
C-A-T TourniquetC-A-T Tourniquet
The C-A-T Tourniquet is now ready for transport.
C-A-T TourniquetC-A-T Tourniquet
NOTE:The friction adaptor buckle is not necessary for proper C-A-T application to an arm. It MUST be used with two hands when applying to a leg.
C-A-T: Lower ExtremityC-A-T: Lower Extremity
To use, wrap the Self-adhering Band through the friction adaptor buckle.
C-A-T: Lower ExtremityC-A-T: Lower Extremity
This prevents the Self-adhering Band from loosening during transport.
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C-A-T TourniquetC-A-T Tourniquet
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C-A-T: Lower ExtremityC-A-T: Lower Extremity
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SOFTT
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SOFTT ApplicationSOFTT Application Similar to the CAT: Similar to the CAT:
─ Slide loop over extremitySlide loop over extremity─ Pull strap tightPull strap tight─ Twist windlass until Twist windlass until
bleeding stopsbleeding stops─ Latch the windlass Latch the windlass
with one of the with one of the tri-ringstri-rings
─ Tighten the safety Tighten the safety screwscrew
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SOFTT ApplicationSOFTT Application
One-handed application Two-handed application
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Improvised TourniquetImprovised Tourniquet Place cravat between heart and wound.Place cravat between heart and wound. Tie a half-knot on upper surface.Tie a half-knot on upper surface. Place a short stick on half-knot.Place a short stick on half-knot. Tie a square knot on top of Tie a square knot on top of
stick.stick. Twist stick (windlass) to Twist stick (windlass) to
tighten.tighten. UNTIL BLEEDING STOPS.UNTIL BLEEDING STOPS. Secure windlass to prevent unwinding.Secure windlass to prevent unwinding.
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Improvised TourniquetImprovised Tourniquet
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Tourniquet PrinciplesTourniquet Principles Never cover a tourniquet.Never cover a tourniquet. Mark a “T” on the casualty's forehead or Mark a “T” on the casualty's forehead or
somewhere obvious (sharpie pen).somewhere obvious (sharpie pen). In combat when the tactical situation In combat when the tactical situation
allows, loosening a tourniquet is allows, loosening a tourniquet is appropriate. appropriate.
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Tourniquet RemovalTourniquet Removal Once the tactical situation allows, Once the tactical situation allows,
tourniquets should be loosened and other tourniquets should be loosened and other methods to stop bleeding applied.methods to stop bleeding applied.─ Direct pressure - pressure dressingDirect pressure - pressure dressing─ HemCon Chitosan BandageHemCon Chitosan Bandage─ QuikClot powder QuikClot powder
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Tourniquet RemovalTourniquet Removal When loosening a tourniquet, do not When loosening a tourniquet, do not
remove it from the limb.remove it from the limb. If the tourniquet has been in place for If the tourniquet has been in place for > 6 hours, do not remove.> 6 hours, do not remove. If fluid resuscitation is required, it should If fluid resuscitation is required, it should
be accomplished before the tourniquet is be accomplished before the tourniquet is removed.removed.
Tourniquets are very painful, provide pain Tourniquets are very painful, provide pain medications as needed.medications as needed.
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Tourniquet RemovalTourniquet Removal If tourniquet has been in place for only 1-If tourniquet has been in place for only 1-
2 hours, loosening and using other 2 hours, loosening and using other methods to control hemorrhage can methods to control hemorrhage can salvage limbs.salvage limbs.
Remember: if unable to control Remember: if unable to control hemorrhage by other means, re-tighten hemorrhage by other means, re-tighten the tourniquet.the tourniquet.
It is better to sacrifice the limb than to It is better to sacrifice the limb than to lose a life to hemorrhage.lose a life to hemorrhage.
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AmputationAmputation Apply a pressure dressing to cover the Apply a pressure dressing to cover the
end of the stump.end of the stump. Kerlix and 6” Ace wrap for effective Kerlix and 6” Ace wrap for effective
pressure dressing.pressure dressing. Rinse amputated part free of debris. Rinse amputated part free of debris. Wrap loosely in saline-moistened sterile Wrap loosely in saline-moistened sterile
gauze.gauze.
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Preservation of Amputation PartsPreservation of Amputation Parts Seal amputated part in a plastic bag or Seal amputated part in a plastic bag or
cravat.cravat. Place in a cool container; do not allow to Place in a cool container; do not allow to
freeze. freeze. Never place an amputated part in water.Never place an amputated part in water. Never place amputated part directly on ice.Never place amputated part directly on ice. Never use dry ice to cool an amputated part.Never use dry ice to cool an amputated part.
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Hemostatic AgentsHemostatic Agents
HemConHemCon®® Chitosan Bandage. Chitosan Bandage.
QuikClotQuikClot®® Hemostatic Powder. Hemostatic Powder.
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Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Hold the foil over-pouch so that instructions can Hold the foil over-pouch so that instructions can be read. Identify unsealed edges at the top of the be read. Identify unsealed edges at the top of the over-pouch.over-pouch.
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Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Peel open over-pouch by pulling the unsealed Peel open over-pouch by pulling the unsealed edges apart.edges apart.
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Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Trap dressing between bottom foil and non-Trap dressing between bottom foil and non-absorbable green/black polyester backing with absorbable green/black polyester backing with your hand and thumb.your hand and thumb.
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Chitosan Hemostatic DressingChitosan Hemostatic Dressing
Hold dressing by the non-absorbable polyester backing Hold dressing by the non-absorbable polyester backing and discard the foil over-pouch. Hands must be dry to and discard the foil over-pouch. Hands must be dry to prevent dressing from sticking to them.prevent dressing from sticking to them.
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Chitosan Hemostatic DressingChitosan Hemostatic Dressing
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Chitosan Hemostatic DressingChitosan Hemostatic Dressing Place the light colored sponge portion of the Place the light colored sponge portion of the
dressing directly to the wound area with the dressing directly to the wound area with the most severe bleeding. Apply pressure for 2 most severe bleeding. Apply pressure for 2 minutes or until the dressing adheres and minutes or until the dressing adheres and bleeding stops. Once applied and in contact bleeding stops. Once applied and in contact with the blood and other fluids, the dressing with the blood and other fluids, the dressing cannot be repositioned.cannot be repositioned.
A new dressing should be applied to other A new dressing should be applied to other exposed bleeding sites; each new dressing exposed bleeding sites; each new dressing must be in contact with tissue where bleeding must be in contact with tissue where bleeding is heaviest. Care must be taken to avoid is heaviest. Care must be taken to avoid contact with the casualty’s eyes.contact with the casualty’s eyes.
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Chitosan Hemostatic DressingChitosan Hemostatic Dressing
If dressing is not effective in stopping If dressing is not effective in stopping bleeding after 4 minutes, remove the original bleeding after 4 minutes, remove the original and apply a new dressing. Additional and apply a new dressing. Additional dressings cannot be applied over ineffective dressings cannot be applied over ineffective dressings.dressings.
Apply a battle dressing/bandage to secure a Apply a battle dressing/bandage to secure a hemostatic dressing in place.hemostatic dressing in place.
Hemostatic dressings should only be Hemostatic dressings should only be removed by responsible persons after removed by responsible persons after evacuation to the next level of care.evacuation to the next level of care.
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CMASTCMAST 5454
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QuikClotQuikClot
Warning: Avoid contact with wet skin; Warning: Avoid contact with wet skin; product reacts with small amounts of water product reacts with small amounts of water and can cause burning. and can cause burning.
Stop burning by brushing away granules Stop burning by brushing away granules and flooding area with large volume of and flooding area with large volume of water. water.
If ingested, immediately drink two or more If ingested, immediately drink two or more glasses of water.glasses of water.
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QuikClotQuikClot Directions:Directions:1-Apply direct firm pressure to wound using sterile 1-Apply direct firm pressure to wound using sterile
dressing or best available substitutedressing or best available substitute
2-If bleeding is stopped or nearly stopped after 2-If bleeding is stopped or nearly stopped after approximately 1 minute of pressure, wrap and tie approximately 1 minute of pressure, wrap and tie bandage to maintain pressure on woundbandage to maintain pressure on wound
3-If moderate to severe bleeding continues, hold 3-If moderate to severe bleeding continues, hold pack away from face and tear open at tabspack away from face and tear open at tabs
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QuikClotQuikClot4-Use wiping motion to remove gauze and 4-Use wiping motion to remove gauze and
excess blood – immediately start a slow excess blood – immediately start a slow pouring of one QuikClot packet directly onto pouring of one QuikClot packet directly onto the wound. Stop pouring as soon as dry the wound. Stop pouring as soon as dry granules cover the wound areagranules cover the wound area
5-Use only enough QuikClot to stop bleeding. If 5-Use only enough QuikClot to stop bleeding. If bleeding continues open a second packet of bleeding continues open a second packet of QuikClot and continue to use as directed QuikClot and continue to use as directed
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QuikClotQuikClot
6-Reapply firm pressure to QuikClot covered 6-Reapply firm pressure to QuikClot covered wound using sterile gauze. Wrap and tie wound using sterile gauze. Wrap and tie bandage to maintain pressurebandage to maintain pressure
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QuikClotQuikClot
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Treatment GoalsTreatment Goals Hemorrhage control continues to be the Hemorrhage control continues to be the
priority in battlefield care.priority in battlefield care.
Hemorrhage is the leading cause of Hemorrhage is the leading cause of preventable death on the battlefield.preventable death on the battlefield.
Our focus must be on stopping soldiers Our focus must be on stopping soldiers from bleeding to death on the battlefield.from bleeding to death on the battlefield.
CMASTCMAST 6262
Questions?Questions?
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