![Page 1: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/1.jpg)
Wound Care Management during a Mass Casualty
Emergency: An Evidence-Based Approach for Triage,
Tourniquets, Wound Packing, and Chest Seals
The Athletic Trainers Ability to think beyond the basics
On Field or Off, you may face the event
![Page 2: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/2.jpg)
Introductions
• Mr. Edward Strapp, TP-C/FP-C, NRP, ATC– Trooper/Flight Paramedic, Maryland State Police
– Rotational Athletic Trainer, US Ski and Snowboard
![Page 3: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/3.jpg)
Provider Disclaimer• In compliance with continuing education requirements, all presenters must disclose
any financial associations with the manufacturers of commercial products, supplies of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use.
• Event committee, and the presenters for this seminar do not have financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters.
• This presentation does not involve the unlabeled use of a product or product under investigational use.
• There was no commercial support for this activity.
***Warning*** Some pictures may be graphic in nature.
![Page 4: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/4.jpg)
Presenter Conflict• No Conflict
• The views expressed in these slides and the today’s discussion are ours
• Our views may not be the same as the views of our company’s clients or our colleagues
• Participants must use discretion when using the information contained in this presentation
![Page 5: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/5.jpg)
Learning Objectives
• Understand the need for the rapid identification and management of gross bleeding in the trauma patient.
• Identify the phases of shock and the physiological changes.
• Identify the rationale for the application of different advanced wound care interventions.
![Page 6: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/6.jpg)
Learning Objectives
• Acquire the skills needed for tourniquet and wound packing interventions.
• Learn how to adapt common sports medicine equipment for tourniquet applications.
• Develop a go bag option for management of acute trauma patients.
![Page 7: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/7.jpg)
This is why I am here
![Page 8: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/8.jpg)
March 20, 2016
• Northwestern Indiana
• A school bus carrying a high school basketball team ended up on its roof
• The bus driver swerved after getting sideswiped by another vehicle whose driver had spilled coffee.
![Page 9: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/9.jpg)
Background
Athletic Competition
Local Event Coverage
Bus Trips
Active Shooters
![Page 10: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/10.jpg)
• When tragedy strikes anywhere in this nation, the willingness and capability of everyday citizens to take action instead of being passive bystanders can mean the difference between life or death.
• With very little training and equipment, the individuals closest to the scene of an accident or mass casualty situation can control bleeding until first responders arrive to take over treatment.
JOE BIDEN Vice-President of the United States (Hartford Consensus)
Background
![Page 11: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/11.jpg)
Why this topic?
“As the profession of athletic training continuously evolves and ATs practice in various settings, these healthcare providers must have the ability to maintain a high level of preparation and proficiency in all aspects of immediate and emergency care. This ability is critical to minimizing risk to the injured participant.” – BOC, 2015
![Page 12: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/12.jpg)
According to the National Trauma
Institute, hemorrhaging is
responsible for almost 35% of pre-
hospital deaths and 40% of deaths
in the first twenty-four hours after a
traumatic event and the U.S.Army considers hemorrhage as the
number one preventable cause of
death on the battlefield.
![Page 13: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/13.jpg)
When Direct Pressure Isn’t Enough
• Everything has advantages and disadvantages
• Each option can be implemented in a variety of situations
There is no “Gold Standard”
Stopping blood loss in a severe hemorrhage is really the Gold Standard
![Page 14: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/14.jpg)
Critical Interventions
• Take care of yourself
• Take care of others
– Triage
– Critical Interventions
• Use others to help
– Give everyone that is injured a buddy
![Page 15: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/15.jpg)
Initial Care
Where do I focus my Attention:
– ABCD
– Depending on Triage Criteria
– Depending on Resources
• Is Airway management more important? ABC
• Is Gross Bleeding most important?
![Page 16: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/16.jpg)
Circulation
• Evaluation and Recognition is Key
• Basic bandaging of soft tissue injuries is often overlooked by first responders.
• These basic concepts are critical to the casualty’s survival.
![Page 17: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/17.jpg)
Click through
![Page 18: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/18.jpg)
Hemorrhage and Shock
![Page 19: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/19.jpg)
Hemorrhage and Shock
• What happens when you start to bleed?
![Page 20: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/20.jpg)
Understanding Shock• In 1862
– Samuel Gross described shock as the "rude unhinging" of the machinery of life.
• Inadequate Tissue perfusion with oxygenated blood
• Failure of adequate tissue oxygen delivery and utilization during shock can lead to organ dysfunction and death.
![Page 21: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/21.jpg)
Hemorrhage and Shock
• What happens when you start to bleed? – it depends on how much blood you lose
![Page 22: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/22.jpg)
Hemorrhage and ShockBleeding from extremity wounds
• How quickly this occurs obviously depends on where and how the damage occurs, but…
• Bleeding out and death can occur in 3 to 5 minutes in the worse case.
![Page 23: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/23.jpg)
Recognizing Shock• May be difficult to judge blood loss in an
accident scene
• Look for Signs and Symptoms
– mental status
– radial pulse
![Page 24: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/24.jpg)
Recognizing Shock• mental status
• radial pulse
• heart rate (HR)
• blood pressure (BP)
• respiratory rate (RR)
• likelihood of death
![Page 25: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/25.jpg)
Normal Adult Blood Volume
5 Liters Blood Volume
![Page 26: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/26.jpg)
500 cc Blood Loss
4.5 Liters Blood Volume
![Page 27: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/27.jpg)
• Mental state – alert
• Radial pulse – full
• Heart rate – normal or somewhat increased
• Systolic blood pressure – normal
• Respiratory Rate – normal
• Is he going to die from this? NO
500 cc Blood Loss
![Page 28: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/28.jpg)
1000cc Blood Loss
4.0 Liters Blood Volume
![Page 29: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/29.jpg)
• Mental state – alert
• Radial pulse – full
• Heart rate – Slightly Elevated 100 +
• Systolic blood pressure – Normal if Lying,
• Respiratory Rate – normal
• Is he going to die from this? NO
1000 cc Blood Loss
![Page 30: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/30.jpg)
1500cc Blood Loss
3.5 Liters Blood Volume
![Page 31: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/31.jpg)
• Mental state – alert but anxious
• Radial pulse – may be weak
• Heart rate – 100+
• Systolic blood pressure – may be decreased
• Respiratory rate – 30
• Is he going to die from this? PROBABLY NOT
1500cc Blood Loss
![Page 32: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/32.jpg)
2000cc Blood Loss
3.0 Liters Blood Volume
![Page 33: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/33.jpg)
• Mental state – confused/lethargic
• Radial pulse – weak
• Heart Rate – 120+
• Systolic blood pressure – decreased
• Respiratory rate – >35
• Is he going to die from this? MAYBE
2000cc Blood Loss
![Page 34: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/34.jpg)
2.5 Liters Blood Volume
2500cc Blood Loss
![Page 35: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/35.jpg)
• Mental state – unconscious
• Radial pulse – absent
• Heart rate – 140+
• Systolic blood pressure – markedly decreased
• Respiratory rate – over 35
• Is he going to die from this? PROBABLY
2500cc Blood Loss
![Page 36: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/36.jpg)
Normal Adult Blood Volume
• Approximately 5 liters of blood in an average size adult
• Casualty can bleed out in as little as 3 minutes
![Page 37: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/37.jpg)
![Page 38: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/38.jpg)
Controlling Bleeding
Direct Pressure or Pressure Bandage
Tourniquet
Wound Packing
Clotting Agents
![Page 39: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/39.jpg)
Wound Patterns
Accidents and Injuries
Law Enforcement and Some Assaliants
General Citizens
![Page 40: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/40.jpg)
![Page 41: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/41.jpg)
Tourniquets
“Because the rate of complications is low and the rate of hemostasis is high, first aid providers may consider the use of a tourniquet when standard first aid hemorrhage control does not control severe external limb bleeding” –Singletary, 2015
![Page 42: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/42.jpg)
Major Blood Vessels
• Major blood vessels can be found on the medial side and high on the extremities.
• These areas are the best place to control massive bleeding from extremities.
![Page 43: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/43.jpg)
Distal to Proximal
Most venous hemorrhages or simple arterial hemorrhages from the distal third of an extremity are generally well controlled with an absorbent bandage placed direct over the wound
Direct Pressure
Pressure DressingSharpe D, Barneby E, New Approaches to the management of traumatic external hemorrhage. J trauma. 2011:13:47-55
![Page 44: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/44.jpg)
Distal to Proximal
• The Closer an artery is to the left ventricle, the great the force exerted on the vessel’s wall. The more proximal an arterial is to the heart, the greater amount of force needed to tamponade the vessel and stop hemorrhage
120 lbs of pressure to occlude a proximal to a femoral artery hemorrhage
• Proximal Arterial Hemorrhage is life threatening
Blaivas M, Shiver S, et al. Control hemorrhage in critical femoral or inguinal penetrating wounds- An
Ultrasound Evaluation. Prehosp Disaster Med. 2006;21(6):379-382
![Page 45: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/45.jpg)
Distal to Proximal
• Mangled Extremities and especially junctional wounds must be immediately packed, preferably with gauze impregnated with hemostatic agent
Groin, Axilla, Shoulder, and NeckBulger, E, Snyder D et al. An evidence-based prehospital guideline for external hemorrhage control:
American College of
Surgeons committee on Trauma. Prehosp Emerg Care. 2017;18(2):163-173
![Page 46: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/46.jpg)
The Bottom Line...
Is it bleeding a little or a lot?
When in doubt, use a tourniquet.The Military has studies bleeding control extensively and concluded that early tourniquet
application, before the onset of shock, saves lives with little to no associated complications
In 2009 Kragh, Littrel, Jones et all completed a study of 499 patients with 862 tourniquets on
651 limbs…..
![Page 47: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/47.jpg)
Direct Pressure on Wound Site
![Page 48: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/48.jpg)
Hemorrhage Control
• Assess the situation.
• Expose the wound.
• Attempt to control the bleeding with direct pressure or a pressure dressing.
![Page 49: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/49.jpg)
Bandage Options
Or what is handy!
![Page 50: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/50.jpg)
![Page 51: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/51.jpg)
Tourniquets—Use what’s handyCommercial tourniquets Improvised tourniquet
![Page 52: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/52.jpg)
Bleeding Control
• Control hemorrhage using a tourniquet or an Emergency Trauma Dressing (ETD; Israeli bandage).
Combat Application
Tourniquet
Emergency Trauma Dressing
![Page 53: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/53.jpg)
Tourniquet
• Commercial– CAT
– SOF-T
– SOF-T Wide
– Swat T
• Adaptive
![Page 54: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/54.jpg)
CAT (Combat Application Tourniquet)
![Page 55: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/55.jpg)
Tourniquet
CAT
![Page 56: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/56.jpg)
Tourniquet
CAT Thigh/2 person
Using The Friction Adaptor
![Page 57: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/57.jpg)
SOFTT (Special Operations Forces Tactical Tourniquet)
Screw
Windlass
Triangular Clip
Triangular
Clip
![Page 58: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/58.jpg)
Tourniquet
SOF-T SOF-T (Wide)
![Page 59: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/59.jpg)
Tourniquet
Swat T
![Page 60: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/60.jpg)
Application
• 2-3 inches above the wound
• Watch for other sites of bleeding» above the wound
• Multiple bleeding sites» proximal application
![Page 61: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/61.jpg)
Application
• Should be tight enough to stop bleeding
• The tourniquet should never be placed• Joint (knee or elbow)
• Over an impaled object
• Extremity should be exposed
• Document application time• Write on patient!
![Page 62: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/62.jpg)
Application
• A prehospital tourniquet should not be
removed by EMS personnel without authorization from their EMS Sponsor Hospital/Medical Direction
• If application exceeds six hours, removal should only be done by the physician providing definitive care
![Page 63: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/63.jpg)
Rules for Application
• Over clothing, as high and tight as possible when your in a mass casualty.
• Directly on Skin, 2-3 Inches over the wound when your in a controlled environment.
• Take note of tourniquet time.
![Page 64: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/64.jpg)
Various Options for HomemadeTourniquets
![Page 65: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/65.jpg)
REMEMBER…
• Tourniquets can be used for:
– Life threatening extremity hemorrhage
–When direct pressure or pressure dressing can not be applied
![Page 66: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/66.jpg)
Tourniquet Mistakes
• Not using one when you should
• Using a tourniquet for minimal bleeding
• Not making it tight enough – the tourniquet must eliminate the distal pulse
• Not using a second tourniquet if needed
• Waiting too long to put the tourniquet on
• Periodically loosening the tourniquet to allow blood flow to the injured extremity
![Page 67: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/67.jpg)
Reassessment
• Be sure to reassess all interventions:
– After any movements.
– During patient reevaluation.
• Consider using a second tourniquet for any continued uncontrolled bleeding.
• Perform a rapid full body exam to rule out any additional uncontrolled bleeding.
![Page 68: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/68.jpg)
![Page 69: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/69.jpg)
Non-Extremity Massive Bleeding
• Tourniquets are ineffective in the following areas:
– Neck
– Armpit
– Groin
• Treatment for these areas includes:
– Direct pressure
– Pack wound, if applicable
– Pressure dressing
![Page 70: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/70.jpg)
![Page 71: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/71.jpg)
Pressure Dressing
• Emergency trauma dressing:
– Maintains pressure created by itself.
– Used in conjunction with hemostatic dressing.
– Direct pressure in the armpit, groin or neck.
![Page 72: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/72.jpg)
• Bleeding can be controlled utilizing wound packing techniques and direct pressure:
➢Kerlix – rolled gauze
➢Z-Pak – folded gauze
Packing Gauze
![Page 73: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/73.jpg)
Wound Packing
• When a tourniquet won’t work
• Expose the wound
• Locate the bleeder
• Place FOCUSED direct pressure
• Pack the wound
Consider Hemostatic
Dressings
![Page 75: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/75.jpg)
Expose & Identify
• Expose the wound
– Clear clothing
– Spread the wound
– Clear out clot and blood within the wound
![Page 76: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/76.jpg)
Expose & Identify• Open clothing around wound
• If possible, remove excess
pooled blood from the wound
while preserving any clots
already formed in the wound
• Locate source of most active
bleeding
![Page 77: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/77.jpg)
Expose & Identify
• Locate the offending vessel
– Look and Feel
– Find the Vessel
![Page 78: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/78.jpg)
Wound Packing
• Apply Focused Direct Pressure
– Thumb or 2 Fingers, DIRECTLY on the vessel
![Page 79: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/79.jpg)
Wound Packing• Pack Combat Gauze tightly into wound and directly onto bleeding source
• More than one gauze may be required to stem blood flow
• Combat Gauze maybe re-packed or adjusted into the wound to ensure proper placement
![Page 80: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/80.jpg)
Wound Packing
• Pack the wound
– Don’t release Pressure
– Swapping fingers or Side by each
– Pack all voids
Add, Add,
Add and then
Add some more
![Page 81: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/81.jpg)
• Quickly apply pressure until bleeding stops
• Suggested time is 2 to 3 minutes of continuous contact
• Reassess for proper and effective placement
• Combat Gauze may be repacked if initial use fails to provide hemostasis
Apply Direct Pressure
![Page 82: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/82.jpg)
Apply Direct Pressure
![Page 83: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/83.jpg)
• Leave
Combat
Gauze in place
• Wrap to
effectively
secure the
dressing in the
wound
Bandage Over Wound
![Page 84: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/84.jpg)
Bandage Over Wound
![Page 85: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/85.jpg)
![Page 86: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/86.jpg)
• Penetrating Chest Trauma
○ There is nothing to pack beyond the
rib cage
• Blunt or Penetrating Trauma to the chest
increases your suspicion
•Air Hunger or Air Starving
“I Can’t Breath”
We can’t Pack EVERYTHING
![Page 87: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/87.jpg)
Open Pneumothorax
• •Penetrating mechanism– May be “sucking” or “bubbling chest wound
• Respiratory distress– Mild to severe
Optimal method of field management has not been demonstrated
![Page 88: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/88.jpg)
Sucking Chest Wound
![Page 89: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/89.jpg)
Treatment
• ABC’s with c-spine control as indicated
• High Flow oxygen
• Listen for decreased breath sounds on
affected side
• Apply occlusive dressing to wound
• Notify Hospital and ALS unit as soon as
possible
![Page 90: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/90.jpg)
Treatment
• Asherman Chest
Seal makes good
Flutter Valve.
• Gloved Hand
• Occlusive Dressing
• Plastic Bag
![Page 91: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/91.jpg)
Improvise and Overcome
You have options
![Page 92: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/92.jpg)
Hemostatic Agents
![Page 93: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/93.jpg)
Mechanisms of Actions
• Mucoadhesives
– Hemcon bandage, Chitogauze, Celox gauze
• They become sticky, the shrimp shell based products, primarily chitosan based, and work by cross-linking cellular blood components to form a mucoadhesive barrier.
![Page 94: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/94.jpg)
Mechanisms of Actions
• Factor Concentrators
– Quick Clot
• Rapidly absorb water from the blood at the injury site, which concentrates platelets and other intrinsic clotting factors resulting in faster clot formation.
![Page 95: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/95.jpg)
Mechanisms of Actions
• Procoagulant supplements
– Combat Gauze
• Procoagulant supplements deliver additional clotting factors to the wound which then combine with clotting factors already present. Together, these clotting factors increase the rate of blood clot formation.
![Page 96: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/96.jpg)
Mechanisms of Actions
• A side-by side comparison of four hemostatic dressings – in an animal model of arterial hemorrhage
• Demonstrated survival superiority associated with the use of Combat Gauze™
(Kheirabadi, Scherer, Estep, Dubick, & Holcomb, 2009).
![Page 97: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/97.jpg)
******** NOTES ********
• Combat Gauze
• Quick Clot
• Wound Sat (Granules)
• Celox
• Hem Con
• Chitosan vs kaolin
• Pro-coagulant actually causes the blood to clot
![Page 98: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/98.jpg)
What do you need?Create a Go Bag
– Cat Tourniquets
– Chest Seals
– Pressure Dressings
– Clotting Agents
Can I improvise
• Tourniquets
– Exercise Bands
– Wide “string”
• Chest Seals
– Plastic Bags
– Ice Bags
– Saran Wrap
– Tape
• Pressure Dressings
– ABD Pads and Elastic Wraps
![Page 99: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/99.jpg)
At Minimum, kit should contain:
Tourniquet- Commercial or ImprovisedPressure Bandage (Ace and Gauze)Plastic patch or zip lock bag for use
with Tension pneumothoraxTape of some kindGloves
![Page 100: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/100.jpg)
CMAST 100
Improved First Aid Kit
Combat Application
Tourniquet (CAT)
MOLLE Type
Pouch
Weight: 1.08 lbs. Cube: 128 ci
Emergency Trauma
Dressing
(Israeli Bandage)
4”
Kerlix
14g
Needle
Nasopharyngeal
Airway (NPA)
2” Tape
Exam Gloves
(4)
![Page 101: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/101.jpg)
What do you need……….
…….. Something you have access to
…….. Something you are comfortable using
…….. Something you can use in a hurry
…….. Something you can Get/Create/Replace
![Page 102: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/102.jpg)
QUESTIONS?
![Page 103: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/103.jpg)
Thank you, Have a great day!
![Page 104: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/104.jpg)
Sources• Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., Sanddal, N. D., Butler, F. K., Fallat, M., Taillac, P., White,
L., Salomone, J. P., Seifarth, W., Betzner, M. J., Johannigman, J., & McSwain, N. Jr. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173. doi:10.3109/10903127.2014.896962
• Granville-Chapman, J., Jacobs, N., & Midwinter, M. J. (2011). Pre-hospital haemostatic dressings: A systematic review. Injury, 42(5), 447–459. doi:10.1016/j.injury.2010.09.037
• Burkatovskaya, M., Tegos, G. P., Swietlik, E., Demidova, T. N., P Castano, A., & Hamblin, M. R. (2006). Use of chitosan bandage to prevent fatal infections developing from highly contaminated wounds in mice. Biomaterials, 27(22), 4157–4164. doi:10.1016/j.biomaterials.2006.03.028
• Kozen, B. G., Kircher, S. J., Henao, J., Godinez, F. S., & Johnson, A. S. (2008). An alternative hemostatic dressing: Comparison of CELOX, HemCon, and QuikClot. Academic Emergency Medicine, 15(1), 74-81. doi:10.1111/j.1553-2712.2007.00009.x
• Li, J., Cao, W., Lv, X. X., Jiang, L., Li, Y. J., Li, W. Z., Chen, S. Z., & Li, X. Y. (2013). Zeolite-based hemostat QuikClot releases calcium into blood and promotes blood coagulation in vitro. Acta Pharmacologica Sinica, 34(3), 367-372. doi:10.1038/aps.2012.159
• Rall JM, Cox JM, Songer AG, et al. Comparison of novel hemostatic gauzes to QuikClot Combat Gauze in a standardized swine model of uncontrolled hemorrhage. J Trauma Acute Care Surg. 2013; 75(2 Suppl 2):S150-6.
• Satterly S, Nelson D, Zwintscher N, et al. Hemostasis in a noncompressible hemorrhage model: An end-user evaluation of hemostatic agents in a proximal arterial injury. J Surg Educ. 2013;70(2):206-11.
• Watters JM, Van PY, Hamilton GJ, et al. Advanced hemostatic dressings are not superior to gauze for care under fire scenarios. J Trauma 2011;70:1413-18.
• Schwartz RB, Reynolds BZ, Shiver SA, et al. Comparison of two packable hemostatic Gauze dressings in a porcine hemorrhage model. Prehosp Emerg Care 2011;15:477-482
![Page 105: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/105.jpg)
• Doyle GS, Taillac PP. Tourniquets: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care. 2008 Apr-Jun;12(2):241-56.
• Granville-Chapman, J., Jacobs, N., & Midwinter, M. J. (2011). Pre-hospital haemostatic dressings: A systematic review. Injury, 42(5), 447–459. doi:10.1016/j.injury.2010.09.037
• Burkatovskaya, M., Tegos, G. P., Swietlik, E., Demidova, T. N., P Castano, A., & Hamblin, M. R. (2006). Use of chitosan bandage to prevent fatal infections developing from highly contaminated wounds in mice. Biomaterials, 27(22), 4157–4164. doi:10.1016/j.biomaterials.2006.03.028
• Lawton, G., Granville-Chapman, J., & Parker, P. (2009). Novel haemostatic dressings. Journal of the Royal Army Medical Corps, 155(4), 309-314 doi:10.1136/jramc-155-04-13
• Kheirabadi, B. S., Mace, J. E., Terrazas, I. B., Fedyk, C. G., Estep, J. S., Dubick, M. A., & Blackbourne, L. H. (2010). Safety evaluation of new hemostatic agents, smectite granules, and kaolin-coated gauze in a vascular injury wound model in swine. Journal of Trauma-Injury Infection & Critical Care, 68(2), 269–278. doi:10.1097/TA.0b013e3181c97ef1
• Li, J., Cao, W., Lv, X. X., Jiang, L., Li, Y. J., Li, W. Z., Chen, S. Z., & Li, X. Y. (2013). Zeolite-based hemostat QuikClot releases calcium into blood and promotes blood coagulation in vitro. Acta Pharmacologica Sinica, 34(3), 367-372. doi:10.1038/aps.2012.159
• Littlejohn, L., Bennett, B. L., & Drew, B. (2015). Application of current hemorrhage control techniques for backcountry care:Part two, hemostatic dressings and other adjuncts [Article in Press]. Wilderness and Environmental Medicine. doi:10.1016/j.wem.2014.08.018
![Page 106: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/106.jpg)
• Kenny Navarro , The Research Review,http://www.ems1.com/Columnists/kenny-navarro/articles/2156227-When-to-use-hemostatic-agents-in-EMS/
• Hasan, Hemorrhage Control in the Battlefield: Role of New Hemostatic Agents, MILITARY MEDICINE, 170, 1:63, 2005
• Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. Journal of Trauma. 2005;59: 217-222.
• Kragh JF, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. Journal of Emergency Medicine. 2009. Article in press.
• Boulton AJ, et al. Prehospital haemostatic dressings for trauma: A systematic review Emerg Med J 2018;25:449-457
• Granville-Chapman J, et al. Pre-Hospital haemostatic dressings: A Systematic Review Injury, Int. J. Care Injured 2011;42:447-459
• Scerbo MH, et al. The Trauma Center is too late: Major Limb Trauma without a Pre-Hospital tourniquet has increased death from Hemorrhagic shock. J Trauma Acute Care Surg 2016;83/6: 4465-1172
• Bulger EM, et al. An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 2014;18/2:163-173
• Kragh JF, et al. U.S. Military Use of Tourniquets from 2001 to 2010. Prehospital Emergency Care 2015;19/2:184-190
![Page 107: Wound Care Management during a Mass Casualty Emergency: An ... · When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet](https://reader033.vdocuments.us/reader033/viewer/2022052019/6033004b46977414094c9f41/html5/thumbnails/107.jpg)