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Training & Speed Are Crucial


Exsanguination accounted for more than half of the preventable deaths in Vietnam; almost 50% of combat fatalities before evacuation from Iraq were attributed to uncontrolled hemorrhage.1,2 Uncontrolled hemorrhage also results in the death of a large number of civilian trauma fatalities each year.

Recent military conflicts have led to many new and novel approaches to control hemorrhage. Many of these new devices and substances will soon be added to your kits and ambulances. This article, therefore, will discuss the variety of new products available to control hemorrhage, as well as how to effectively train on their use in the civilian prehospital setting.

As discussed in this supplement, direct pressure is an easy and effective initial way to control hemorrhage and should be the first method for hemorrhage control. We know that if direct pressure fails to control hemorrhage, it signifies deep, massive or arterial injury, which usually needs surgery or a more effective bleeding control measure.

When training on direct pressure, use methods that simulate difficult-to-control hemorrhage and stress to your students and crews that:
1. Direct pressure should be held for at least 5 minutes before checking to see if it’s effective.
2. Application of direct pressure requires two hands pushing against the injured patient while they’re lying on a flat, hard surface.
3. A bandage does not equal direct pressure. In fact, they may “wick” or absorb blood from the wound without actually aiding in clotting. And they often hide ongoing bleeding.
4. Dressings must cover the entire wound, and a bandage is used to hold the dressing in place. The bandage can provide additional pressure if it is applied tightly enough.
5. Leaning into the delivery of direct pressure may be required to stem aggressive arterial flow. Impaled foreign bodies should not be removed because profuse bleeding can occur.
6. Elevation of an affected extremity will decrease most bleeding and should be used as an adjunct with direct pressure.3 However, even after splinting, elevation of an extremity can make transportation problematic.4
7. Compression of the artery proximal to the wound can also decrease bleeding, but pressure points are may be difficult to access and maintain, especially during patient movement and treatment. Note: The use of pressure points and elevation were deemed by the AHA to be Class III interventions—meaning that procedures should not be performed.
8. Splinting the extremity can decrease bleeding, especially if the limb is restored to an anatomical position, and may improve hematoma formation, especially with fractures.
9. Blind clamping is more likely to cause additional injury than to control bleeding and should therefore be avoided.
10. Neurovascular compromise distal to the wound site must be continuously assessed.
11. The iTClamp and other tools that maintain direct pressure and hasten clotting can be extremely useful during triage, mass-casualty incidents or when wounds are deep or beyond the normal “reach” of the rescuer.
12. Significant blood losses are associated with coagulopathy (impaired blood coagulation). Coagulopathy combined with hypothermia and acidosis forms the lethal triad of death. The control of hypothermia and acidosis are vital to prevent morbidity and mortality for severe hemorrhage.
13. All patients should be resuscitated to prevent shock.
14. Patients who are hemorrhaging should be carefully protected from heat loss and hypothermia. Although these practices are not directly related to the control of life-threatening hemorrhage, they’re vitally important to the ultimate recovery of the patient and should be part of any efforts to control severe bleeding.

The education (and re-education) of your personnel about hemorrhage control must include proper description of each device, realistic simulation of severe hemorrhage and repetitive practice to ensure their proper and rapid use in the face of severe hemorrhage. It is equally important that your crew understand how each of these devices, substances or processes work, when they should be used and any obstacle to their use or complications that may be encountered.

Hemostatic Agents
Several hemostatic agents are currently on the market, and although they have seen some success in the combat arena, much of the scientific data regarding the efficacy of these agents is animal-based, or in the form of case reports from the battlefield. Educators must teach their personnel the applicability and limitation of these agents.

• Trauma Dex: Trauma Dex is a sterile, plant-based starch agent that’s poured directly into a bleeding wound. The hemostatic effect of the product is achieved by absorbing water from the blood and plasma and facilitating clot formation. The powder is bio-inert and doesn’t generate exogenous heat. It performs as advertised in small wounds in animal models, but it wasn’t shown to have significant benefit over standard gauze dressings when used in a lethal animal groin wound model.5
• QuickClot: QuickClot (QC), a granular hemostatic agent, is also placed directly into the wound. The composition of the product is proprietary but is free of botanical or biological products, which may reduce the chance of allergy or disease transmission. Animal studies have shown some success, and there are multiple case reports in the military arena.6 QC has the potential to cause burns due to an exothermic reaction, but it has been modified to reduce this effect. The U.S. Marine Corps deploys QC for life-threatening hemorrhage not responding to standard therapy.
• Dry fibrin sealant dressing: This FDA approved dressing is composed of two layers of clotting proteins sandwiching a layer of calcium chloride and human thrombin, freeze-dried to a dexon mesh backing. The fibrinogen and thrombin react to form an adherent fibrin layer, staunching blood flow. Combat theater use has shown these dressings to be fragile, and they are expensive.7,8 Civilian use is not currently widespread due to cost and complexity of use.
• Modified Rapid Deployment Hemostat Dressing: This dressing is currently FDA approved but not widely used in the civilian sector.  It’s composed of an algae-derived protein. Its mechanism of action is red cell aggregation, activation of platelets and the clotting cascade, as well as local vasoconstriction. It has shown some promise in animal models, and some success in military and civilian use.9
• HemCon: HemCon Chitosan Bandage is a biodegradable complex carbohydrate product of Chitin, a naturally occurring glucosamine. It works via its mucoadhesive properties, but may also enhance platelet function. Animal studies have shown promising results, and there are multiple case reports from the U.S. Army’s combat operations.10,11
• Celox: Celox is made with chitosan, a natural polysaccharide, and is broken down into glucosamine. It is derived from shellfish, but does not appear to cause skin reactions in those hypersensitive to fish or shrimp. It works via a direct interaction with the blood, not through the clotting cascade, and has shown effectiveness in patients on anti-platelet and anti-coagulation therapy. It comes in a granular form as well as impregnated gauze.12,13
All hemostatic agents require proper wound packing and pressure.14

Several tourniquets are currently commercially available, with the C.A.T. most frequently used by the military.15 Lessons learned include:
• The need to apply the tourniquet before the onset of shock and use by all personnel, including self-use—a basic-level skill.
• If a single tourniquet doesn’t eliminate distal pulses, then a second should be applied just proximal to the first. This effectively increases the tourniquet width, controls bleeding more effectively and reduces complications.
• The Velcro band should be as tight as possible before the application of the windlass. Three 180-degree turns of the windlass should be sufficient to occlude arterial flow if the Velcro strap has been effectively tightened.
• Military researchers have carefully studied the routing of the friction band through the buckle of the C.A.T. The band can be routed through one or both slits of the buckle. Recommended routing depends on the application by one or two hands and the placement on upper or lower extremity. The friction band should always be placed through both slits in the buckle when applied with two hands or when used on the lower extremity. This prevents the tourniquet from slipping when more torque is applied, as is usually the case on the lower extremity. Use of a single slit is only acceptable in upper extremity use.

Transexamic Acid
Transexamic acid (TXA) is an anti-fibrinolytic that blocks the action of plasminogen, an enzyme that dissolves blood clots. TXA is now used by both the U.S. and Britain to treat severe wartime injury and hemorrhage. Current guidelines recommend that patients receive a 1 g loading dose of TXA in the first three hours after injury, followed by IV infusion of another gram over eight hours. The earlier the initial dose is administered, the more likely it is to prevent fibrinolysis. For more information on TXA, see this article.

Combat Ready Clamp
The Combat Ready Clamp (CRoC) is an FDA-approved device for control of hemorrhage in junctional areas, where tourniquet application is impossible, and in the axillary. Sites such as the inguinal, axillary, and pelvic areas are difficult areas to provide hemorrhage control. This device applies direct pressure over packed inguinal injury sites and applies pressure midway between anterior superior iliac spine and pubic tubercle (occluding the external iliac artery).

The CRoC is placed in the inguinal area to stop circulation to the pelvic and femoral region when a casualty is in danger of bleeding to death from wounds that are poorly accessible to treatment by traditional bandages or tourniquets.16

SAM Junctional Tourniquet
The SAM Junctional Tourniquet for hemorrhage control is designed to control bleeding where tourniquets would not be effective, such as with IED/blast injuries or high-level amputations. It is compact, easy to use (only four steps), and quick to apply (typically under 25 seconds).

The target compression device (TCD) is placed at or near the injury site and pumped up until the bleeding stops. Two TCDs can be used to occlude blood flow bilaterally if needed. The patented buckle provides the clinically correct force every time, taking the guesswork out of tightening.

The FDA-approved iTClamp Hemorrhage Control System, developed by Canadian trauma surgeon Dennis Filips, MD, who served in Afghanistan, is a small, lightweight, single-use, disposable plastic device that features eight 21-gauge surgical needles and two pressure bars that quickly creates a fluid-tight seal across the wound. It is designed to be used by care providers to control bleeding in seconds or even to be self-applied by wounded personnel (e.g., police officers or combat soldiers). The device is approved in the U.S., Canada and Europe. For more information, see this article.

Training Focus, Adjuncts & Approaches
With all these new options, training can prove to be overwhelming. First, EMS providers should be well versed and competent with the basic techniques of direct pressure, elevation and splinting. Providers must properly demonstrate the basics on manikins or simulators, and also on each other where safe and applicable. Artificial skin/body organ props can be obtained to augment your training. Ideally, training should include live tissue active bleeding. Students should use training devices in a realistic setting to ensure proper understanding of the limitations of these products and to practice their use under stress.

Simulated bleeding, whether via high-fidelity simulation or flow-generating cadaveric specimens, often isn’t practical because the hemostatic products require the elements in fresh blood to work—something that can be obtained only from animal subjects or human victims.

However, a recent product that offers realism to training is LUNA’s TrueClot Blood Simulant. This non-toxic, non-stain, realistic “blood” actually clots when used in conjunction with simulated wound clot dressings and the iTClamp.

Unlike hemostatic agents, devices that work through a compressive mechanism such as tourniquets, the CRoC, and the iTClamp can be taught through the use of high-fidelity simulation (HFS). Models that are capable of generating arterial level pressures and flow can serve as good trainers. Emphasis on proper placement, technique and complications is important, and HFS is capable of meeting these requirements.

My experience is that, despite the high quality of these simulators, they don’t impart the same sense of confidence as cadavers and live tissue. Although cadaveric training is more expensive, I believe it provides the best training available, resulting in the best retention and highest skill level, and ensuring the most appropriate use of devices and techniques.

As with any techniques or tool, it must be used as part of the overall care of the patient, and any training should include the additional principles of body heat retention and avoidance of acidosis.

1. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3–S11.
2. PHTLS: Prehospital Trauma Life Support, Military Version. Elsevier Science Health Science Division: Miamisburg, OH, 2006).
3. Shapiro MB, Jenkins DH, Schwab CW, et al. Damage control: collective review. J Trauma. 2000;49(5):969–978.
4. Perkins J, Beekley A. Damage control resuscitation. In Savitsky E, Eastridge B (Eds). Combat Casualty Care: Lessons Learned from OEF and OIF. Office of the Surgeon General, Department of the Army: Fort Detrick, Md., 121-164, 2012.
5. Alam HB, Uy GB, Miller D, et al. Comparative analysis of hemostatic agents in a swine model of lethal groin injury. J Trauma. 2003;54:1,077–1,082.
6. Wedmore I, McManus JG, Pusateri A E, et al. The chitosan-based hemostatic dressing: Experience in current combat operations. J Trauma. 2006;60(3):655–658.
7. Holcomb J, MacPhee M, Hetz S, et al. Efficacy of a dry fibrin sealant dressing for hemorrhage control after ballistic injury. Arch. Surg. 1998;133: pp.32–35.
8. Pusateri AE, Holcomb JB, Harris R A, et al. Effect of fibrin bandage fibrinogen concentration on blood loss after grade V liver injury in swine. Mil. Med. 2001;166:217–222.
9. King D, Cohn S, Schreiber M et al. A Modified Rapid Deployment Hemostat Bandage: Surgeon Experience at Level 1 Trauma Centers. General Surgery News. 2010;37(2). Retrieved 9/6/13 from www.generalsurgerynews.com/ViewArticle.aspx?d_id=77&a_id=14637.
10. McManus J, Wedmore I. Modern Hemostatic Agents for Hemorrhage Control – A Review and Discussion of Use in Current Combat Operations. Emergency Medicine & Critical Care. 2005:76–79. Retrieved 9/6/13 from www.touchemergencymedicine.com/articles/modern-hemostatic-agents-hemorrhage-control-review-and-discussion-use-current-combat-operat.
11. Alam HB, Burris D, DaCorta JA et al. Hemorrhage control in the battlefield: role of new hemostatic agents. Mil Med. 2005;170(1):63–69.
12. Millner R, Lockhart AS, Marr R. Chitosan arrests bleeding in major hepatic injuries with clotting dysfunction: an in vivo experimental study in a model of hepatic injury in the presence of moderate systemic heparinisation. Ann R Coll Surg Engl. 2010;92(7):559–561
13. Köksal O, Ozdemir F, Cam Etöz B, et al. Hemostatic effect of a chitosan linear polymer (Celox®) in a severe femoral artery bleeding rat model under hypothermia or warfarin therapy. Ulus Travma Acil Cerrahi Derg. 2011;17(3):199–204.
14.  Littlejohn LF, Devlin JJ, Kircher SS, et al. Comparison of Celox-A, ChitoFlex, WoundStat, and combat gauze hemostatic agents versus standard gauze dressing in control of hemorrhage in a swine model of penetrating trauma. Acad Emerg Med. 2011;18(4):340–350.
15. Combat Application Tourniquet. U.S. Army Medical Department Medical Research and Materiel Command. Retrieved 9/6/13 from www.usamma.amedd.army.mil/assets/docs/CAT.pdf.
16. Kragh JF, Murphy C, Dubick MA et al. New tourniquet device concepts for battlefield hemorrhage control. US Army Med
Dep J. 2011;38–48.




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