Airway & Respiratory, Operations, Patient Care, Trauma

10 Hemorrhage Control Myths

Issue 12 and Volume 39.

Bleeding is the leading cause of preventable death in both civilian and military trauma.1 There’s a clear consensus that control of bleeding is the top priority during patient care; every second of uncontrolled bleeding worsens outcomes.2 There are many ways to control bleeding, and each technique has advantages and shortcomings.

Advanced trauma life support (ATLS) guidelines simply recommend to “stop the bleeding,” but the various methodologies used to control external hemorrhage are often poorly understood. The use of tourniquets and hemostatic dressings are frequently quoted as the new panacea to control external bleeding, but there isn’t a clear understanding of their limitations and what wounds are appropriate for their use.

There remains a lack of clear direction on the role of direct pressure or even how to apply direct pressure. Wound packing is talked about but rarely ever taught—especially to prehospital providers. New products are also emerging to provide additional and perhaps superior means to control external hemorrhage.

Given that proper use of current technologies should make control of external bleeding from all compressible areas a “problem of the past,” we’ll address and dispel many prevalent myths (“pearls of wisdom”) that prevent us from achieving this goal.3 These myths have been passed down through EMS generations, currently pervade modern textbooks, and constitute generally accepted practices. We’ll only deal with myths regarding external bleeding from compressible areas of the body.

Myth #1: Direct pressure will control bleeding.
Direct pressure is the primary technique EMS uses to control bleeding, but this technique will only work if focused digital pressure is placed on the source of bleeding. Placing an entire palm over the bleeding is often unsuccessful because pressure is diffused over a wide surface area. By reducing the diameter of the surface through which force is applied from 10 cm (palm) to 2 cm (finger), surface area is reduced 25 times and applied pressure goes up by the same ratio.

Some knowledge of anatomy is required for the fingers to press the source bleeding from deep wounds against the underlying structures. Effective digital pressure is difficult to maintain for more than a few minutes (the muscles of the fingers tire). Hemorrhage control via direct pressure is extremely challenging during transport due to constant movement of the patient and provider.

Other hemorrhage control techniques are required to transport a bleeding patient and to free the hands so that other priorities can be dealt with.

Myth #2: Pressure dressings enhance hemorrhage control. Persistent bleeding is managed by the application of additional dressings.
This approach to hemorrhage control is still written and stressed in many modern EMS textbooks.4 However, if persistent bleeding saturates a pressure dressing, then the pressure isn’t focused on the source of bleeding. Pressure dressing should apply pressure directly to the site of vascular injury. The application of additional layers of dry dressing results in a more diffuse, and therefore less effective, pressure atop the existing nonfunctional one.

This continued addition of dry dressing only results in soaking up more blood. The sponge-like effect draws blood from the wound, and ultimately wicks away clotting factors from the site of the vascular injury. Additionally, small motions that naturally occur between the patient and dressing disrupt the clot that may be forming in the gauze matrix and wound. Blood, and the resulting hematoma responsible for sealing the damaged vessel, is better left inside the body and not outside.

Effective hemorrhage control requires the clotting process take place at the site of endothelial damage. While dressing may assist in keeping the forming hematoma in contact with the vessel, the absorptive nature of these products, the diffusion of pressure and the challenges of maintaining the fabric matrix immobile during patient movement make this approach fraught with opportunities for unrecognized failure (the dressing prevents visualization of bleeding from the wound until a significant amount of blood has soaked through).

The use of elastic bandaging and dressings can create effective pressure by wrapping, but this is practical only on the arms and legs. Circumferential wrapping is difficult across other areas of the body such as the scalp, neck, truncal areas, axilla and groin because of the anatomy, and results in greater difficulty generating effective pressure.

The bottom line is that some minor- to moderate-bleeding wounds on the extremities can be adequately controlled with pressure dressings, but it’s mostly an exercise in futility to attempt direct pressure alone elsewhere.

Myth #3: Tourniquets will control all extremity bleeding.
There are many types of tourniquets and each one has its advantages and disadvantages. Strap tourniquets (such as the military-recommended combat application tourniquet [CAT] and SOF tactical tourniquet) are often used in the prehospital setting. These may not adequately control bleeding in the upper third of the limbs, axilla, groin, truncal areas, neck or scalp.

Tourniquets require proper training to apply effectively and quickly. Personnel with limited experience rarely get the initial strap application tight enough, and rely too much on the limited ability of the windlass to tighten the tourniquet.

Loose placement of the tourniquet is not uncommon, and can result in an increase in complications.5 A properly tightened tourniquet must occlude arterial flow, and will produce extreme pain in the extremities. Tourniquets don’t work well when attempting to occlude the artery located between two bones in the leg or arm, such as in the lower leg or forearm. There are inconsistent guidelines as to where to place tourniquets. The U.S. Military Tactical Combat Casualty Care guidelines call for placement 2–3 inches above the injury.6 For maximum efficacy, the tourniquets should also be applied to the mid muscle areas on the upper leg or arm.

Additional nuances must be considered:

  • The CAT strap needs to be passed through both loops to function properly on the leg. The pressures that must be exerted on the strap are often in excess of the holding power of the single loop on the tourniquet, and may result in failure of the device and loss of arterial occlusion.
  • Difficult-to-control bleeding often requires the use of two commercial tourniquets to compress large thigh muscles.
  • Bleeding wounds need to be carefully monitored for rebleeding. Additional bleeding often occurs after the bleeding is stopped and the patient’s blood pressure returns to normal. This results in increased leakage through the vascular injury, ultimately requiring the tourniquet to be further tightened.

Myth #4: Application of hemostatic agents to bleeding wounds will control all external bleeding.
It’s not uncommon to see hemostatic dressings being placed on top of a bleeding wound with the belief it will stop the bleeding. Hemostatic agents (most are bound to gauze but some are still in powder formulations) need to be packed into a wound against the injured vessel and effective compression maintained for at least three minutes.

The technique for packing the wound is critically important and should ideally be taught in a live tissue training environment. Proper technique pushes the hemostatic agent to the bottom of the wound and is successively packed in with a single finger to maintain effective pressure on the bleeding source.

Hemostatic impregnated gauze does enhance bleeding control, but some studies have suggested that the addition of the hemostatic agent enhances the effect of the gauze by about 15%.7–9

Chemical hemostatics won’t substitute for effective control of the injured vessel.

Myth #5: Direct pressure devices can be used to control bleeding in every region of the body and on every wound.
An absolute contraindication to use of direct pressure devices, such as the iTClamp, is that it can’t be used on the eyes and will not stop internal bleeding into the chest or abdominal cavities. The clamp creates a pressure and watertight seal of the skin edges. The resulting wound pocket fills with blood until pressures equalize and bleeding is tamponaded. The wound must be amenable to forming a pocket for the clot to form. In order to do that, it requires skin edges be brought together, which means the device will often be ineffective on large amputations, areas of large skin loss, and extensive open wounds on mangled extremities. Tourniquets are better options for these types of wounds.

Myth #6: Trauma patients should be treated using the Airway, Breathing, Circulation, Disability, Exposure/Examination approach.
The basis of this approach, which has been adopted by ATLS, PHTLS, ITLS, etc., is based on the idea that airway problems:

  • Will cause death in the first few minutes;
  • That breathing problems are next; and
  • That death from bleeding takes somewhat longer.

Therefore, the treatment priority has been ABC.

The concern with this approach is that it doesn’t take into consideration the cause of, nor the length of time it takes to treat, airway and breathing problems. For example, if the patient has airway and breathing problems because of loss of consciousness from hemorrhagic shock, it doesn’t make sense to spend five or 10 minutes to intubate and ventilate before addressing the root cause.

Now that there are reliable devices for rapid hemorrhage control (45–60 seconds to apply a tourniquet to an amputation, or five seconds to apply a direct pressure device), it makes more sense to address the root cause first in situations where patients are experiencing active hemorrhage.

Myth #7: During a mass casualty incident, all patients are triaged to determine the order of treatment.
During a mass casualty incident (MCI), all patients are quickly triaged to determine the order of treatment, tagged, and then treatment is based on priority.

Most triage systems will only allow for quick treatments of airway (reposition the body, etc.) and uncontrolled bleeding during the initial assessment phase. Typically only direct pressure from another person or the victim themself is available for rapid control.

Tourniquets can be placed in 45 seconds by experienced users. Typical approaches to triage take about 20–40 seconds per patient.

Mass casualt-y or active shooter situations require a modified triage and treatment approach to maximize lives saved. Rapid hemorrhage control is often the most important intervention, but the ability to establish and maintain direct pressure on multiple wounds and multiple patients is often beyond the capability of a limited number of responders.

Tourniquets and direct pressure devices can provide reliable, safe, effective hemorrhage control in less than five seconds. Not only will this help to stabilize the patient in question but it quickly frees the first responder to complete other lifesaving interventions and triage all victims for more definitive care and transport.

The same rationale also applies to tactical situations where every second is critical for carrying out other tasks.

Myth #8: The wound isn’t bleeding very much. It doesn’t require treatment.
Loss of blood volume and shock will result in a significant decrease in active bleeding. This can be very deceptive—especially in children and athletes who can compensate for even extensive blood loss. Recognition of the severity of the patients’ condition is vital if they’re to be saved. Persistent slow bleeding will result in significant blood loss over time, and is more frequent in situations in which the injured can’t attempt self-care, such as entrapment or tactical scenarios, or those at extremes of the age spectrum. Also, it may be hard to appreciate the small arterial bleeding coming from scalp wounds. These may continue to bleed indefinitely and will often only stop upon wound closure.

Myth #9: “Stay and play” is acceptable with trauma patients.
When Princess Diana was removed from her severely damaged car in France, she was still conscious and in a state of severe shock from internal hemorrhage. The physician-staffed ambulance sat on the scene to treat her instead of treating and moving her to a trauma center/operating room. The ambulance spent nearly an hour doing onsite treatment of a symptom—falling blood pressure— rather than treating its cause: an internal vascular injury.10

Severe trauma patients require rapid treatment and transport. Delays in either can allow a patient to lapse into irreversible shock. EMS providers must be conscious of this and get the patient moving to a trauma center ASAP.

Excessive or unnecessary extrication procedures should be eliminated or reduced when confronted with a dying trauma patient with suspected internal hemorrhage. Work with rescue crews and command officers to expedite patient removal and transport when faced with a patient bleeding out internally and in need of trauma center/operating room care.

Myth #10: Helicopters are the answer for all severe trauma cases.
Helicopters are vital, functional resources in an EMS system, but are just one of the assets and resources we have to combat severe shock. Waiting for a helicopter to arrive and not treating severe hemorrhage fast or properly, or delaying patient packaging and movement to a helicopter can allow a patient to lapse into difficult-to-reverse shock or die.

For more about using helicopters to transport your patient, see “Fly or Drive? Will requesting a helicopter help your patient?, by Ryan Gerecht, MD, CMTE; Keith Widmeier, NREMT-P, CCEMT-P, BA and William Hinckley, MD, FACEP, CMTE, in the October issue.

Conclusion
The control of bleeding is often a subjective assessment based on visualization of ongoing bleeding. For patients who have already lost a significant amount of blood or are bleeding from their scalp, the amount and rapidity of blood loss can be hard to appreciate in a prehospital environment. When the myths exposing the drawbacks and limitations of current recommendations to stop external and some internal bleeding situations are appreciated, new approaches can be imagined.

References
1. Jenkins, DH. (June 22, 2011.) National Trauma Institute. [Testimony before the U.S. Senate Committee].
2. Ball CG, William BH, Tallah C, et al. The impact of shorter prehospital transport times on outcomes in patients with abdominal vascular injuries.
J Trauma Manag Outcomes. 2013;7(1):11.
3. 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.
4. American College of Surgeons:
Advanced Trauma Life Support For Doctors (Student Course Manual), eighth edition. American College of Surgeons: United States; 2008.
5. Butler FK Jr, Holcomb JB, Giebner SD, et al. Tactical combat casualty care 2007: Evolving concepts and battlefield experience.
Mil Med. 2007;172(11):1–19.
6. T
actical Combat Casualty Care Guidelines. (Oct. 23, 2013.) National Association of EMTs. Retrieved Oct. 17, 2014, from www.naemt.org/Files/TCCC/041114/TCCC Guidelines_131028.pdf.
7. Bennett BL, Littlejohn L. Review of new topical hemostatic dressings for combat casualty care.
Mil Med. 2014;179(5):497–514.
8. Gegel BT, Austin PN, Johnson AD. An evidence-based review of the use of a combat gauze (QuikClot) for hemorrhage control.
AANA J. 2013;81(6):453–458.
9. Gegel B, Burgert J, Gasko J, et al. The effects of QuikClot Combat Gauze and movement on hemorrhage control in a porcine model.
Mil Med. 2012;177(12):1543–1547.
10. Sancton T:
Death of a princess, did princess Diana have to die?: A case study in French emergency medicine. The Internet Journal of Rescue and Disaster Medicine. 1999;1(2).

Patient Care, Trauma

10 Hemorrhage Control Myths

Issue 12 and Volume 39.

Bleeding is the leading cause of preventable death in both civilian and military trauma.1 There’s a clear consensus that control of bleeding is the top priority during patient care; every second of uncontrolled bleeding worsens outcomes.2 There are many ways to control bleeding, and each technique has advantages and shortcomings.

Advanced trauma life support (ATLS) guidelines simply recommend to “stop the bleeding,” but the various methodologies used to control external hemorrhage are often poorly understood. The use of tourniquets and hemostatic dressings are frequently quoted as the new panacea to control external bleeding, but there isn’t a clear understanding of their limitations and what wounds are appropriate for their use.

There remains a lack of clear direction on the role of direct pressure or even how to apply direct pressure. Wound packing is talked about but rarely ever taught—especially to prehospital providers. New products are also emerging to provide additional and perhaps superior means to control external hemorrhage.

Given that proper use of current technologies should make control of external bleeding from all compressible areas a “problem of the past,” we’ll address and dispel many prevalent myths (“pearls of wisdom”) that prevent us from achieving this goal.3 These myths have been passed down through EMS generations, currently pervade modern textbooks, and constitute generally accepted practices. We’ll only deal with myths regarding external bleeding from compressible areas of the body.

Myth #1: Direct pressure will control bleeding.
Direct pressure is the primary technique EMS uses to control bleeding, but this technique will only work if focused digital pressure is placed on the source of bleeding. Placing an entire palm over the bleeding is often unsuccessful because pressure is diffused over a wide surface area. By reducing the diameter of the surface through which force is applied from 10 cm (palm) to 2 cm (finger), surface area is reduced 25 times and applied pressure goes up by the same ratio.

Some knowledge of anatomy is required for the fingers to press the source bleeding from deep wounds against the underlying structures. Effective digital pressure is difficult to maintain for more than a few minutes (the muscles of the fingers tire). Hemorrhage control via direct pressure is extremely challenging during transport due to constant movement of the patient and provider.

Other hemorrhage control techniques are required to transport a bleeding patient and to free the hands so that other priorities can be dealt with.

Myth #2: Pressure dressings enhance hemorrhage control. Persistent bleeding is managed by the application of additional dressings.
This approach to hemorrhage control is still written and stressed in many modern EMS textbooks.4 However, if persistent bleeding saturates a pressure dressing, then the pressure isn’t focused on the source of bleeding. Pressure dressing should apply pressure directly to the site of vascular injury. The application of additional layers of dry dressing results in a more diffuse, and therefore less effective, pressure atop the existing nonfunctional one.

This continued addition of dry dressing only results in soaking up more blood. The sponge-like effect draws blood from the wound, and ultimately wicks away clotting factors from the site of the vascular injury. Additionally, small motions that naturally occur between the patient and dressing disrupt the clot that may be forming in the gauze matrix and wound. Blood, and the resulting hematoma responsible for sealing the damaged vessel, is better left inside the body and not outside.

Effective hemorrhage control requires the clotting process take place at the site of endothelial damage. While dressing may assist in keeping the forming hematoma in contact with the vessel, the absorptive nature of these products, the diffusion of pressure and the challenges of maintaining the fabric matrix immobile during patient movement make this approach fraught with opportunities for unrecognized failure (the dressing prevents visualization of bleeding from the wound until a significant amount of blood has soaked through).

The use of elastic bandaging and dressings can create effective pressure by wrapping, but this is practical only on the arms and legs. Circumferential wrapping is difficult across other areas of the body such as the scalp, neck, truncal areas, axilla and groin because of the anatomy, and results in greater difficulty generating effective pressure.

The bottom line is that some minor- to moderate-bleeding wounds on the extremities can be adequately controlled with pressure dressings, but it’s mostly an exercise in futility to attempt direct pressure alone elsewhere.

Myth #3: Tourniquets will control all extremity bleeding.
There are many types of tourniquets and each one has its advantages and disadvantages. Strap tourniquets (such as the military-recommended combat application tourniquet [CAT] and SOF tactical tourniquet) are often used in the prehospital setting. These may not adequately control bleeding in the upper third of the limbs, axilla, groin, truncal areas, neck or scalp.

Tourniquets require proper training to apply effectively and quickly. Personnel with limited experience rarely get the initial strap application tight enough, and rely too much on the limited ability of the windlass to tighten the tourniquet.

Loose placement of the tourniquet is not uncommon, and can result in an increase in complications.5 A properly tightened tourniquet must occlude arterial flow, and will produce extreme pain in the extremities. Tourniquets don’t work well when attempting to occlude the artery located between two bones in the leg or arm, such as in the lower leg or forearm. There are inconsistent guidelines as to where to place tourniquets. The U.S. Military Tactical Combat Casualty Care guidelines call for placement 2–3 inches above the injury.6 For maximum efficacy, the tourniquets should also be applied to the mid muscle areas on the upper leg or arm.

Additional nuances must be considered:

  • The CAT strap needs to be passed through both loops to function properly on the leg. The pressures that must be exerted on the strap are often in excess of the holding power of the single loop on the tourniquet, and may result in failure of the device and loss of arterial occlusion.
  • Difficult-to-control bleeding often requires the use of two commercial tourniquets to compress large thigh muscles.
  • Bleeding wounds need to be carefully monitored for rebleeding. Additional bleeding often occurs after the bleeding is stopped and the patient’s blood pressure returns to normal. This results in increased leakage through the vascular injury, ultimately requiring the tourniquet to be further tightened.

Myth #4: Application of hemostatic agents to bleeding wounds will control all external bleeding.
It’s not uncommon to see hemostatic dressings being placed on top of a bleeding wound with the belief it will stop the bleeding. Hemostatic agents (most are bound to gauze but some are still in powder formulations) need to be packed into a wound against the injured vessel and effective compression maintained for at least three minutes.

The technique for packing the wound is critically important and should ideally be taught in a live tissue training environment. Proper technique pushes the hemostatic agent to the bottom of the wound and is successively packed in with a single finger to maintain effective pressure on the bleeding source.

Hemostatic impregnated gauze does enhance bleeding control, but some studies have suggested that the addition of the hemostatic agent enhances the effect of the gauze by about 15%.7–9

Chemical hemostatics won’t substitute for effective control of the injured vessel.

Myth #5: Direct pressure devices can be used to control bleeding in every region of the body and on every wound.
An absolute contraindication to use of direct pressure devices, such as the iTClamp, is that it can’t be used on the eyes and will not stop internal bleeding into the chest or abdominal cavities. The clamp creates a pressure and watertight seal of the skin edges. The resulting wound pocket fills with blood until pressures equalize and bleeding is tamponaded. The wound must be amenable to forming a pocket for the clot to form. In order to do that, it requires skin edges be brought together, which means the device will often be ineffective on large amputations, areas of large skin loss, and extensive open wounds on mangled extremities. Tourniquets are better options for these types of wounds.

Myth #6: Trauma patients should be treated using the Airway, Breathing, Circulation, Disability, Exposure/Examination approach.
The basis of this approach, which has been adopted by ATLS, PHTLS, ITLS, etc., is based on the idea that airway problems:

  • Will cause death in the first few minutes;
  • That breathing problems are next; and
  • That death from bleeding takes somewhat longer.

Therefore, the treatment priority has been ABC.

The concern with this approach is that it doesn’t take into consideration the cause of, nor the length of time it takes to treat, airway and breathing problems. For example, if the patient has airway and breathing problems because of loss of consciousness from hemorrhagic shock, it doesn’t make sense to spend five or 10 minutes to intubate and ventilate before addressing the root cause.

Now that there are reliable devices for rapid hemorrhage control (45–60 seconds to apply a tourniquet to an amputation, or five seconds to apply a direct pressure device), it makes more sense to address the root cause first in situations where patients are experiencing active hemorrhage.

Myth #7: During a mass casualty incident, all patients are triaged to determine the order of treatment.
During a mass casualty incident (MCI), all patients are quickly triaged to determine the order of treatment, tagged, and then treatment is based on priority.

Most triage systems will only allow for quick treatments of airway (reposition the body, etc.) and uncontrolled bleeding during the initial assessment phase. Typically only direct pressure from another person or the victim themself is available for rapid control.

Tourniquets can be placed in 45 seconds by experienced users. Typical approaches to triage take about 20–40 seconds per patient.

Mass casualty or active shooter situations require a modified triage and treatment approach to maximize lives saved. Rapid hemorrhage control is often the most important intervention, but the ability to establish and maintain direct pressure on multiple wounds and multiple patients is often beyond the capability of a limited number of responders.

Tourniquets and direct pressure devices can provide reliable, safe, effective hemorrhage control in less than five seconds. Not only will this help to stabilize the patient in question but it quickly frees the first responder to complete other lifesaving interventions and triage all victims for more definitive care and transport.

The same rationale also applies to tactical situations where every second is critical for carrying out other tasks.

Myth #8: The wound isn’t bleeding very much. It doesn’t require treatment.
Loss of blood volume and shock will result in a significant decrease in active bleeding. This can be very deceptive—especially in children and athletes who can compensate for even extensive blood loss. Recognition of the severity of the patients’ condition is vital if they’re to be saved. Persistent slow bleeding will result in significant blood loss over time, and is more frequent in situations in which the injured can’t attempt self-care, such as entrapment or tactical scenarios, or those at extremes of the age spectrum. Also, it may be hard to appreciate the small arterial bleeding coming from scalp wounds. These may continue to bleed indefinitely and will often only stop upon wound closure.

Myth #9: “Stay and play” is acceptable with trauma patients.
When Princess Diana was removed from her severely damaged car in France, she was still conscious and in a state of severe shock from internal hemorrhage. The physician-staffed ambulance sat on the scene to treat her instead of treating and moving her to a trauma center/operating room. The ambulance spent nearly an hour doing onsite treatment of a symptom—falling blood pressure— rather than treating its cause: an internal vascular injury.10

Severe trauma patients require rapid treatment and transport. Delays in either can allow a patient to lapse into irreversible shock. EMS providers must be conscious of this and get the patient moving to a trauma center ASAP.

Excessive or unnecessary extrication procedures should be eliminated or reduced when confronted with a dying trauma patient with suspected internal hemorrhage. Work with rescue crews and command officers to expedite patient removal and transport when faced with a patient bleeding out internally and in need of trauma center/operating room care.

Myth #10: Helicopters are the answer for all severe trauma cases.
Helicopters are vital, functional resources in an EMS system, but are just one of the assets and resources we have to combat severe shock. Waiting for a helicopter to arrive and not treating severe hemorrhage fast or properly, or delaying patient packaging and movement to a helicopter can allow a patient to lapse into difficult-to-reverse shock or die.

For more about using helicopters to transport your patient, see “Fly or Drive? Will requesting a helicopter help your patient?, by Ryan Gerecht, MD, CMTE; Keith Widmeier, NREMT-P, CCEMT-P, BA and William Hinckley, MD, FACEP, CMTE, in the October issue.

Conclusion
The control of bleeding is often a subjective assessment based on visualization of ongoing bleeding. For patients who have already lost a significant amount of blood or are bleeding from their scalp, the amount and rapidity of blood loss can be hard to appreciate in a prehospital environment. When the myths exposing the drawbacks and limitations of current recommendations to stop external and some internal bleeding situations are appreciated, new approaches can be imagined.

References
1. Jenkins, DH. (June 22, 2011.) National Trauma Institute. [Testimony before the U.S. Senate Committee].
2. Ball CG, William BH, Tallah C, et al. The impact of shorter prehospital transport times on outcomes in patients with abdominal vascular injuries.
J Trauma Manag Outcomes. 2013;7(1):11.
3. 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.
4. American College of Surgeons:
Advanced Trauma Life Support For Doctors (Student Course Manual), eighth edition. American College of Surgeons: United States; 2008.
5. Butler FK Jr, Holcomb JB, Giebner SD, et al. Tactical combat casualty care 2007: Evolving concepts and battlefield experience.
Mil Med. 2007;172(11):1–19.
6. Tactical Combat Casualty Care Guidelines. (Oct. 23, 2013.)
National Association of EMTs. Retrieved Oct. 17, 2014, from www.naemt.org/Files/TCCC/041114/TCCC Guidelines_131028.pdf.
7. Bennett BL, Littlejohn L. Review of new topical hemostatic dressings for combat casualty care.
Mil Med. 2014;179(5):497–514.
8. Gegel BT, Austin PN, Johnson AD. An evidence-based review of the use of a combat gauze (QuikClot) for hemorrhage control.
AANA J. 2013;81(6):453–458.
9. Gegel B, Burgert J, Gasko J, et al. The effects of QuikClot Combat Gauze and movement on hemorrhage control in a porcine model.
Mil Med. 2012;177(12):1543–1547.
10. Sancton T:
Death of a princess, did princess Diana have to die?: A case study in French emergency medicine. The Internet Journal of Rescue and Disaster Medicine. 1999;1(2).