Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Hemostatic Agents and Tourniquets

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This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was a session entitled “Tourniquet and Hemostatic Agent - Workshop.” It was delivered by Brad L. Bennett, PhD, who is a Fellow of the Academy of Wilderness Medicine, US Navy Captain (retired), and a member of the Committee on Tactical Combat Casualty Care, and Lanny Littlejohn, MD, LCDR, MC, USN.

In this workshop, the instructors discussed hemostatic agents (HA) and tourniquets (TQ). The HA discussed were HemeCon Bandage, QuikClot Granules, QuikClot Combat Gauze, and Celox products. The TQ discussed were C-A-T, SOF Tactical Tourniquet, MET, TK-4, and NATO.

I will mention a few of the observations made in the workshop. QuikClot Combat Gauze is an excellent example of a product that can save lives. It comes packaged as 4 yards of 3-inch non-woven kaolin-coated gauze. Kaolin causes rapid blood coagulation into a stable blood clot, is not absorbed into the body, is safe to leave in a wound until further medical care is obtained, does not produce heat, and has a shelf live of 3 years. To use this product, first remove clothing as needed to visualize the wound. Next, if possible, remove excess pooled blood from the wound while preserving any blood clots that have already formed. Try to locate the most active source of bleeding, which is where the Combat Gauze will be applied. The Combat Gauze is packed directly into a bleeding wound, then may be used to apply pressure directly over the source of bleeding. Once the bleeding has slowed or stopped (generally, in 3 to 5 minutes if the application is successful), the wound is wrapped with a bandage to maintain pressure. Depending on the source and activity of the bleeding, it may be necessary to use more than one Combat Gauze, or to re-pack and adjust the gauze in the wound to ensure proper placement.

By example, the Combat Application Tourniquet (C-A-T) is a small and lightweight tourniquet that can be applied with one hand. It can completely occlude arterial blood flow in a limb, and thus save a life if there is severe bleeding. It can be carried in its one-handed configuration, with the free-running end of the self-adhering band passed through the buckle, forming a loop for the arm to pass through. Then, one pulls the self-adhering band tightly and securely fastens it back upon itself. The windlass rod is twisted until bleeding has stopped. To maintain the tightness, the windlass rod is locked in place with the windlass clip. Then, the self-adhering band is wrapped over the windlass rod. To complete the application, the windlass rod and self-adhering band are secured with the windlass strap. Obviously, one should be practiced in this technique before having to deploy it in the field. EXTENSIVE ANNUAL TRAINING WITH HEMOSTATIC AGENTS AND TOURNIQUETS ARE NEEDED FOR COMPETENCY AND CONFIDENCE.

Other points made by the instructor team included that a second tourniquet might need to be applied between the first tourniquet and the heart (e.g., “proximal” to the first tourniquet) if the first tourniquet is not effective. One should not put a tourniquet directly over the knee or elbow, or over a pocket that contains bulky items. Whenever a tourniquet is applied, it is important to clearly expose the application site and to record the time of application with an indelible marker. If the purpose of applying a tourniquet is to stop torrential (e.g., life-threatening) bleeding, do not periodically loosen it to allow circulation to return to the limb, as this usually causes unacceptable additional blood loss.

For the medical professionals reading this post, here are a few pointers about removing a tourniquet:

1. Do not remove the tourniquet if the victim will arrive at medical treatment within two hours after the time of application, the limb beyond the tourniquent has been amputated, the victim is in shock, or the tourniquet has been applied for more than 6 hours.
2. If you decide to remove the tourniquet, loosen it slowly and observe for bleeding, so that it may be promptly re-applied if necessary.
3. Once the tourniquet is loosened, apply a hemostatic agent to the wound and cover it with a pressure dressing. Leave the loose tourniquet in place in case it needs to be urgently re-applied.
4. If bleeding is not controlled without the tourniquet, re-tighten it.

MY SINCERE THANKS TO DRS. BENNETT AND LITTLEJOHN FOR THIS TREMENDOUSLY USEFUL SESSION.

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Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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