Wound Packing 101

The majority of this presentation is taken from both:Dr. Peter Taillac’s presentation to the 2016 “Gathering of Eagles”

West Hartford Police Officer Brian Wallace’s hemorrhage control presentationThanks to both Peter and Brian – content used with permission

Hemorrhage ControlAggressive Hemorrhage Control should be your first priority

• Remember, 85% of the Potential Preventable Deaths in Operation Iraqi Freedom (OIF)/ Operation Enduring Freedom (OEF) were due to Hemorrhage

• Two terms student should understand:– “Compressible” – think tourniquet / extremities– 31% Compressible injuries in OIF/OEF

• “Non-compressible” – think armpits, groin– 69% Non-compressible

From evaluation of 982 casualties, and casualties could have more than 1 cause of death. (Kelly J., J Trauma 64:S21, 2008)

Hemorrhage Control

Remember - Aggressive Hemorrhage Control should be your first priority

Your thought process for treating bleeding should be:1. Should I be acting to stop the bleeding now?2. Apply direct pressure while working on better solution3. Can I put a tourniquet on? 4. If I can’t, pack the wound & put a dressing on.5. Is it working?

Hemorrhage Severity• Life Threatening– Arterial– Fast venous– Long term venous

• Non- Life Threatening– Slow venous– Capillary

Even slow bleeding may become life-threatening if not controlled with direct pressure

Why Wound Packing?

• OLD - Placing dressings on top of a wound:– Absorbs blood– Keeps ambulance clean– Does little to stop bleeding

• NEW - Direct pressure must be applied to source of bleeding– Finger on an isolated severed vessel might work– May require a knee to provide sufficient pressure– Wound packing helps apply pressure directly to source of

bleeding and may promote clotting

But, I Was Told EMR/EMTs Are Not Allowed to Pack Wounds…

• Nope. Just another EMS myth/dogma.• This may have arisen from concerns of clot

dislodgement or foreign bodies ending up in body cavities

• The effectiveness of this bleeding control technique outweighs potential concerns

• Just another form of direct pressure

When Should I Pack a Wound?

• Wound packing is not always necessary– Direct pressure alone is usually sufficient– Uncontrolled extremity bleeds may be managed with a

tourniquet• Severe, uncontrolled junctional hemorrhage may

benefit most from wound packing– Lower abdomen– Groin– Axillae– Proximal extremities

Do I Need to Buy Expensive Gauze to Pack Wounds?

Nope - Standard gauze may work just as well as hemostatic gauze

Comparison of ChitoFlex®, CELOX™, and QuikClot® in control of hemorrhage. Devlin J, et al. J Emerg Med 2011;41(3):237 CONCLUSION: In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents.

However, no agents were superior to standard gauze in our model of limited access.

Wound Packing 101 OK, So How To Do This?

• Step 1 – Apply direct pressure– Gloved finger– Gloved hand– Knee– Gauze– Shirt– Whatever is needed

Wound Packing 101

• Step 2 – Consider putting finger/hand in the wound (yes, IN the wound) to get to the source of bleeding and push hard – May be unsafe if sharp bone or shrapnel

fragments present (injury/location dependent)• Can wrap finger in gauze/shirt to minimize risk

– Use gloves/PPE– Mask/eye protection recommended

Wound Packing 101

• Step 3 – Pack the gauze in and keep packing, and packing, and packing– Pack gauze tightly down and deeply into the wound

toward the source of bleeding– Keep packing– You can start backing your finger/hand out while still

applying pressure/packing around it– Keep packing till you can not pack any more gauze in

Wound Packing 101• Step 3 continued – Keep packing!!– Pack until you REALLY can’t push any more gauze

in there– Leave any remaining gauze over the wound to aid

in applying direct pressure

Wound Packing 101

• Step 4: Apply very firm pressure for at least 3 minutes– Think ‘knee’ or two handed palms (just like

pressing for CPR)

Wound Packing 101

• Step 5: Assess – Is the wound still bleeding?– No• Limit movement (splint, etc.) • Apply pressure dressing• Continue supportive care

– Yes (soaking through or around packing)• Pack some more if possible• Apply more pressure (e.g. knee)• Rapid transport

Pressure Dressing• Important to maintain pressure and keep pack from

coming loose• Any stretchy bandage can work• Twisting bandage when passing over wound may focus

pressure on wound site

Wound Packing 101• Communicate with hospital providers– Let the receiving hospital know what/how much

material you crammed into the wound– Describe the force, duration and color of bleeding

prior to wound packing

External Hemorrhage ControlApply direct pressure

Hemorrhage controlled with direct pressure?Yes

No

Extremity wound?Yes

No

Apply tourniquet(s)

Pack wound with gauze bandage (plain or hemostatic impregnated) with continued direct pressure

Hemorrhage controlled? Yes

Maintain Direct PressureConsider Pressure Dressing

Supportive Care

Some Videos of Wound Packing

Packing an extremity wound:https://youtu.be/2KHaXzwdyes

EMS practice with packing a simulated wound:https://youtu.be/L1JjQZ_aYME

Questions?