wound care management during a mass casualty emergency: an ... · when in doubt, use a tourniquet....

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

Introductions

• Mr. Edward Strapp, TP-C/FP-C, NRP, ATC– Trooper/Flight Paramedic, Maryland State Police

– Rotational Athletic Trainer, US Ski and Snowboard

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.

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

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.

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.

This is why I am here

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.

Background

Athletic Competition

Local Event Coverage

Bus Trips

Active Shooters

• 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

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

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.

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

Critical Interventions

• Take care of yourself

• Take care of others

– Triage

– Critical Interventions

• Use others to help

– Give everyone that is injured a buddy

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?

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.

Click through

Hemorrhage and Shock


• What happens when you start to bleed?

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.


• What happens when you start to bleed? – it depends on how much blood you lose

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.

Recognizing Shock• May be difficult to judge blood loss in an

accident scene

• Look for Signs and Symptoms

– mental status

– radial pulse

Recognizing Shock• mental status

• radial pulse

• heart rate (HR)

• blood pressure (BP)

• respiratory rate (RR)

• likelihood of death

Normal Adult Blood Volume

5 Liters Blood Volume

500 cc Blood Loss

4.5 Liters Blood Volume

• 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

1000cc Blood Loss


• 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

1500cc Blood Loss


• 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

2000cc Blood Loss


• 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


2500cc Blood Loss

• 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

Normal Adult Blood Volume

• Approximately 5 liters of blood in an average size adult

• Casualty can bleed out in as little as 3 minutes

Controlling Bleeding

Direct Pressure or Pressure Bandage

Tourniquet

Wound Packing

Clotting Agents

Wound Patterns

Accidents and Injuries

Law Enforcement and Some Assaliants

General Citizens

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

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.

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

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

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

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…..

Direct Pressure on Wound Site

Hemorrhage Control

• Assess the situation.

• Expose the wound.

• Attempt to control the bleeding with direct pressure or a pressure dressing.

Bandage Options

Or what is handy!

Tourniquets—Use what’s handyCommercial tourniquets Improvised tourniquet

Bleeding Control

• Control hemorrhage using a tourniquet or an Emergency Trauma Dressing (ETD; Israeli bandage).

Combat Application

Tourniquet

Emergency Trauma Dressing

Tourniquet

• Commercial– CAT

– SOF-T

– SOF-T Wide

– Swat T

• Adaptive

CAT (Combat Application Tourniquet)

Tourniquet

CAT

Tourniquet

CAT Thigh/2 person

Using The Friction Adaptor

SOFTT (Special Operations Forces Tactical Tourniquet)

Screw

Windlass

Triangular Clip

Triangular

Clip

Tourniquet

SOF-T SOF-T (Wide)

Tourniquet

Swat T

Application

• 2-3 inches above the wound

• Watch for other sites of bleeding» above the wound

• Multiple bleeding sites» proximal application

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!

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

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.

Various Options for HomemadeTourniquets

REMEMBER…

• Tourniquets can be used for:

– Life threatening extremity hemorrhage

–When direct pressure or pressure dressing can not be applied

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

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.

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

Pressure Dressing

• Emergency trauma dressing:

– Maintains pressure created by itself.

– Used in conjunction with hemostatic dressing.

– Direct pressure in the armpit, groin or neck.

• Bleeding can be controlled utilizing wound packing techniques and direct pressure:

➢Kerlix – rolled gauze

➢Z-Pak – folded gauze

Packing Gauze

Wound Packing

• When a tourniquet won’t work

• Expose the wound

• Locate the bleeder

• Place FOCUSED direct pressure

• Pack the wound

Consider Hemostatic

Dressings

Wound Packing

http://drive.google.com/file/d/1FSexY5VuWgfx2dgmAcywUlpuyegqaqLS/view

Expose & Identify

• Expose the wound

– Clear clothing

– Spread the wound

– Clear out clot and blood within the wound

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

Expose & Identify

• Locate the offending vessel

– Look and Feel

– Find the Vessel

Wound Packing

• Apply Focused Direct Pressure

– Thumb or 2 Fingers, DIRECTLY on the vessel

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

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

• 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

Apply Direct Pressure

• Leave

Combat

Gauze in place

• Wrap to

effectively

secure the

dressing in the

wound

Bandage Over Wound

Bandage Over Wound

• 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

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

Sucking Chest Wound

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

Treatment

• Asherman Chest

Seal makes good

Flutter Valve.

• Gloved Hand

• Occlusive Dressing

• Plastic Bag

Improvise and Overcome

You have options

Hemostatic Agents

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.


• 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.


• 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.


• 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).

******** NOTES ********

• Combat Gauze

• Quick Clot

• Wound Sat (Granules)

• Celox

• Hem Con

• Chitosan vs kaolin

• Pro-coagulant actually causes the blood to clot

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

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

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)

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

QUESTIONS?

Thank you, Have a great day!

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

• 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

• 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

http://www.ems1.com/Columnists/kenny-navarro/articles/2156227-When-to-use-hemostatic-agents-in-EMS/

wound care management during a mass casualty emergency: an ... · when in doubt, use a tourniquet....

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