Locate the Bleed & Pack the
Stop the Bleeding and Prevent
You are awakened by the sound of breaking glass. You grab your firearm and flashlight and make your way through the house, clearing as you go. In the first room, you notice a figure crouched down in the corner. You spotlight the subject with your light, and shots ring out. You engage the subject with three well placed shots, eliminating the threat. Your light blinded the armed intruder, and his startle response sent his shots far-right off-target. The intruder’s rounds breached the wall behind you, wounding your spouse that was sitting on the edge of the bed awaiting your return. She is lying next to the bed, alert/orientated with a GSW to the right shoulder. You ask if she is hurt anywhere else – she assures you that she is not. You inspect the wound and clearly see that she has entry and exit wounds with an arterial bleed. You activate EMS, grab the blowout kit you keep in the nightstand, and go to work. You have two minutes or less to save her life. What do you do?
Military Case Study:
Historically, 20% of all injured combatants die in battle. Of battlefield casualties who die, approximately 65% die of massive, multiple trauma and are probably not salvageable. On the basis of data collected from the Vietnam War, almost 50% of battlefield causalities died of exsanguinations (bleeding out) within 3 to 5 minutes and could have been salvaged with timely intervention.
In order to continue to decrease these statistics, we must be able to rapidly identify and manage both internal and external hemorrhages. The Tactical Trauma Care Provider must recognize the type of bleeding (Arterial, Venous, and Capillary) and apply the appropriate hemorrhage-control techniques (e.g. direct pressure, pressure points, clamping, or tourniquets). We must also understand the varying degrees of risk associated with types of hemorrhage and how to estimate blood loss.
In previous articles, we discussed the three levels of care in TCCC. In review, they are: (1) Care Under Fire (2) Tactical Field Care, and (3) CASEVAC Care. Your three levels of treatment are: (1) Self Aid (2) Buddy Aid, and (3) Medic Aid. These articles are written in the “buddy aid” prospective, but keep in mind that you can always perform “self-aid” using your blowout kit – that is what it’s designed for. Today we are shifting from “Care Under Fire” to “Tactical Field Care”. This level of care takes place when you have broken contact with hostile forces and are no longer taking accurate hostile fire. You now have the time to shift from mitigating the threat to patient care. Do we give up security? Absolutely not! Position yourself where you can still scan and pull security as needed. A good example would be drag your patient to one corner of the room with the walls to your back. This allows you to see all of the room and the entry point. If your patient is conscious, alert/orientated, and has no existing head injury, tell them to pull security while you patch them up.
We will continue in our series with the items used in our blowout kit. We will discuss types of injuries associated with these items and treatment modalities. Keeping with the same order from the previous March edition of Tactical Combat Causality Care (TCCC), our first focus will be major hemorrhages. In our first article, we talked about the Combat Application Tourniquet (CAT) and its effectiveness in stopping major extremity arterial bleeds. This month, we are going to focus on bleeds that are located in areas of the body that make tourniquet application impossible. Let’s face it; you can’t put a tourniquet around a neck to stop a throat or head bleed. I don’t think your patient would appreciate it, and the outcome is very obvious.
There are other ways to stop major bleeds, and that is going to be our focus today. One of the more advanced techniques is clamping. This is a very good method to help with arterial bleeds, but there are degrees of training, skill, and licensure associated with clamping, so that method will not be covered in this article. Anyway, we should always crawl before we run, so learning how to pack a wound is just as important and effective if done right. You’re going to have to get to the bleed source and pack the wound, followed by a good pressure dressing to get effective hemorrhage control accomplished. In your blowout kit you should have 1-2 combat gauzes and at least one compression dressing (pressure dressing) of some sort. A very good addition to your compression dressing would be a 2” wide roll of kerlix gauze, or some sort of crinkle gauze that is pre-packed or vacuum-sealed in the original manufacturer’s packaging. These items are very small and will fit in your blowout kit with ease. With these simple tools we can stop or slow down most bleeds located in areas not accessible by a tourniquet.
First, let’s look at what a major hemorrhage is and how it affects the body. The average adult’s cardiovascular system contains 5-6 liters (5000-6000cc) of blood. Like we mentioned in our first article, the cardiovascular system is comprised of the heart, arteries/vessels, and blood (pump, container, fluid). The cardiovascular system has a high-pressure side and a low-pressure side. Arteries supply higher pressure oxygenated (bright red) blood and nutrients to tissue and cells to help sustain life. Veins are the plumbing system that supplies the lower pressure non-oxygenated (dark red) blood back to the heart and lungs, exchanging waste for oxygen and nutrients. Any disruption within this system ultimately results in shock and then death. Our four main phases of shock are: (1) compensated (2) moderately decompensated (3) decompensated, and (4) irreversible. Our main goal is to stop, or slow down, the disruption in the cardiovascular system (bleeding), allowing us the time to transport a person to definitive care. We seem to always focus on the arterial side of things because of the rate in which a person can lose blood volume due to the higher pressure. Do not let slow venous bleeds go unattended for any length of time. Slow oozing bleeds over time equate to severe volume loss as well.
We have two major forms of hemorrhage that can occur from a traumatic incident: (1) external hemorrhage, and (2) internal hemorrhage. External hemorrhage is very evident, because you will be able to visually see the bleeding. Some examples of trauma-related incidents that cause external hemorrhage would be: gunshot wounds (GSWs), stabbings, shrapnel, open fractures, and any puncture wound that causes bleeding. Internal hemorrhage is a totally different animal and is much harder to identify to the untrained eye. This is because both the bleeding and the source are hidden beneath tissue. Some of the key indicators of internal hemorrhage are: swelling, bruising, formation of a hematoma (large lump forming at injury site), distended abdomen that is rigid and not soft upon palpation (to touch), bleeding from body orifices (such as the nose, mouth, ears, and rectum), and altered mental status. Some injuries associated with internal bleeding are blunt force trauma, falls, and blast injuries. There is very little you can do for an internal hemorrhage in the field, so the most important thing to learn is the ability to identify the problem. Internal bleeding requires immediate surgical attention from a higher echelon of care.
Above: A Gunshot Wound (GSW) to the right upper quadrant (RUQ) of the abdomen. Internal bleeding would be a challenge due to the possibilities associated with this wound. The risks would be to the: (1) Liver (2) Inferior Vena Cava (a main inferior artery), if the bullet path is at a downward angle; and (3) a possible sucking chest wound (Tension Pneumothorax), if the bullet path is at an upward angle.
A loss of 25% to 40% of total blood volume can create a life threatening situation, resulting in irreversible shock. The main focus here is aggressive treatment to stop the bleeding. For this we will turn to our combat gauze impregnated with hemostatic agent in our blowout kit. Once you have identified your bleed, you need locate the bleed source and apply pressure directly with your finger. Next, you are going to either use some spare gauze, a t-shirt, or finger to scoop the excess blood out of the wound cavity, while simultaneously feeling to make sure you have identified the bleed source. You will feel the pulsating sensation of an arterial bleed with your finger. Get your first pack of combat gauze ready to deploy. Pull the gauze out enough to wrap it around one or two fingertips (depending on the wound size), or gather enough for an initial pack. Take the finger(s) with the combat gauze wrapped around it and stuff the gauze into the bleed source. Press your fingers, with the combat gauze, into the bleed source and hold pressure for at least a minute. Combat gauze will not be efficient if you do not locate the bleed source and start your packing at the source. If you pack a hemostatic agent above the bleed source, it will form a clot without stopping the bleed. The wound will continue to bleed beneath the formed clot and may possibly conceal the source giving you the false impression that you have controlled the bleed. Once you start packing the combat gauze into the wound cavity, continue doing so until the entire wound cavity is filled (pack it to the bone). If you run out of combat gauze, start packing your second gauze directly on top of the first. If you only have one pack of combat gauze, then this is where the kerlix gauze comes in handy, as I mentioned above. The key here is to pack the entire wound cavity as tightly as possible. I like to actually slightly over-pack wounds so that when I place my pressure dressing on top, it creates a pressure point giving me added value. With kerlix you may have a partial roll left after packing the wound. Lay the remainder on top of the wound cavity, and place your pressure dressing over it to create the added pressure point. I have actually had wound cavities large enough that I had to place entire rolls of kerlix inside without unrolling them. Like I said before, the focus is to pack the entire cavity. If you have an extra set of hands available, you can have them compress the pressure point above the wound to slow the bleed for you while you get your equipment ready. Remember! Always check for an exit wound. If an exit wound is present, then you would complete the exact same process as above. Make sure that your bleed source is completely stopped on your exit wound side as well. Reassess your work every five minutes or so to make sure your interventions are holding. If your first dressing gets blood soaked, do not replace it! Apply another pressure dressing on top of the old one and secure it. I know you are probably thinking that this all seems very uncomfortable to the person that is hurt. The bottom line here is aggressive treatment, not patient comfort. This process will cause temporary pain and discomfort to the patient. They can thank you later for saving their life, which is much better than the outcome that occurs from doing nothing.
Well, I hope you have enjoyed this month’s training. Remember – pack the wound to the bone, get your pressure dressing in place, and always reassess every intervention you perform. Train with your blowout kit and get the muscle memory and skills established to get you through the stressful situations. Next month we will move into the patient assessment side of things and go over blood sweeps, estimating blood loss (EBL), and other assessment skills to help with identifying major bleeds, shock identification, and prevention. I will also include some charts and other goodies for you to laminate and keep in your blowout kit for quick reference guides. That will wrap up bleeds for us, and we will move onto airway emergencies the following month. Remember that firearm and range safety are paramount, so “lead from the front” and set the example to all. Happy shooting, and I look forward to training with you again next month. Until then, this is “Doc” McBryde from Afghanistan ……I’m Oscar Mike.