We’ve Got a

Emergency Hemorrhage Control

Joe SherrellEMS Officer

Tulsa Fire Department(918) 596-9808

jsherrell@cityoftulsa.org

The student shall be able to effectively recognize uncontrolled hemorrhage and immediately provide the indicated treatment.

Upon completion of this course, the student will be able to:

1. Recognize uncontrolled hemorrhage2. Identify the proper method of treatment3. Discuss the indication for tourniquet use4. Demonstrate the proper use of a tourniquet

Objectives5. Discuss the indication for the use of Combat Gauze6. Demonstrate the proper use of Combat Gauze7. Discuss the indication for the use of Phenylephrine8. Demonstrate the proper use of Phenylephrine9. Discuss the indication and use of TXA

LacerationsPenetrationsAmputations

AssessmentScene Safety & PPEPrimary SurveyHospital Notification

Primary Survey CareControl Arterial BleedingOpen and Maintain Airway

Minimize on scene time

En Route CareReassessOxygenation/VentilationVascular AccessSecondary Survey

BLS SkillsIdentificationTourniquetHemostatic AgentHospital Notification

BLS Before ALS

http://en.wikipedia.org/wiki/File:Petit_tourniquet_-_Savigny_1798.jpg

Battlefield testedEndorsed by PHTLSAssociated complications <1.5%

Uncontrollable Hemorrhage

How long does it take for death to occur due to complete femoral artery and vein dissection?

As little as

3 minutes

Combat Application Tourniquet(C-A-T)

Apply just proximal to the bleeding wound Route the band around the extremity

Pass the band through the outside slit of buckle The friction adaptor buckle locks the band in place

Pull the self-adhering band tight and secure

Twist the rod until the bleeding has stopped.

Lock the rod in place with the windlass clip

Secure the rod with the strapIndicate the time of tourniquet applicationLeave area uncovered

TK 0945

Video

Eliminate distal pulseDo not loosenSecond tourniquet may be required

Conscious patients may experience painUtilize pain management protocol

Combat Gauze

Mechanism of ActionImpregnated with Kaolin

Promotes activation of Factor XIIInitiates the clotting cascade

IndicationHemorrhage not controllable with tourniquet or

other meansC-A-T ineffectiveWound location does not allow use of a C-A-T

ApplicationRemove pooled bloodPack gauze into woundHold pressure over bleeding source

3 minutes or hemostasisApply pressure bandage

The Newest Kid on the Block

274 Hospitals40 Countries20,211 adult trauma patients

With, or risk of, significant bleedingHR > 110, SBP <90, clinical judgement

Treatment within 8 hours of injuryTXA or placebo

Death in hospital within 4 weeksBleedingVascular Occlusion (MI, Stroke, PE)Multiorgan FailureHead InjuryOther

Vascular Occlusive EventsNeed for blood/surgery

All Cause Mortality9.1% Increase in survival

Bleeding8.5% Increase in survival

Did Not reduce the need for bloodthe need for surgery

Did increase survival

TXA is SafeTXA Makes a DifferenceTXA Increases SurvivalTXA doesn’t create clots in bad places

RetrospectiveCombat Casualties in AfghanistanBritish Helo PhysiciansTXA vs No TXA

1+ unit(s) PRBC10+ units of PRBC

896 Patients293 received TXA

Characterize TXA use in combat injury careEffect of TXA on

Blood Product UseBad ClotsMortality (24 hrs., 48hrs., 30 days)

~7 times more likely to survive with TXA

Slight increase in DVT & PE formation

Higher Injury = Increase Risk of ClotsMilitary Theater – penetrating/orthoSurvival allows DVT/PE to be diagnosed

Increase SurvivalMassive Transfusion

TXA independent predictor of survivalBenefit shown after 48 hours

Possible anti-inflammatory componentEarlier is Better

If a casualty is anticipated to need significant blood transfusion:

presents with hemorrhagic shockone or more major amputationsPenetrating torso traumaEvidence of severe bleeding

Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury.

Begin second infusion of 1 gm TXA after Hextend or other fluidtreatment.

Formulary

Anti-Fibrinolytic

Promotes clot formation

Hemorrhagic shock Trauma < 3 hours oldSuspected need for massive blood transfusion

In metropolitan Tulsa:sustained tachycardia ≥ 110

AND sustained hypotension systolic BP≤ 90

Non-hemorrhagic shock Non-traumatic hemorrhagic shock Hemorrhagic shock stabilized with other hemostatic

agents/measures

Onset of action within 4 hours after IV administrationDelayed effects up to 48 hours consistent with anti-

inflammatory actions.

While a theoretical concern, TXA has not been shown to cause significant increase in:deep venous thrombosispulmonary embolismmyocardial infarctionstroke

1 gram IVPB over 10 minutes. Administer in 100 mL or 250 mL NS.

The CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with signifcant hemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23–32.

Jonathan J. Morrison; Joseph J. Dubose; Todd E. Rasmussen; Mark J. Midwinter. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2011

Medical Control Board. EMS Protocols for Metropolitan Oklahoma City and Tulsa. 2013.

Tactical Combat Casualty Care Guidelines. Prehospital Trauma Life Support. 2012.