Just got back from a military training course on trauma this weekend. Had lots of good info, but thought I'd distill some of it down for those of you into FAK's.

1. Celox, QuickClot, and the like are being phased out of military stocks. Apparently, in addition to the exothermic issues, there are reports of soldiers dying 1-2 years out from pulmonary emboli, attributed to the product. So, they're using their remaining stock, and using the Israeli bandage and the H-bandage (http://www.galls.com/style.html?assort=general_catalog&style=FA216)

2. Tourniquets are being used in a BIG way in Iraq/Afghanistan. And apparently causing a big percentage drop in fatalities due to exsanguination. So a few of them might be worthwhile, since trends from military medicine eventually trickle into the civilian world. A couple styles are being used, but in a pinch, a belt or a 'kerchief with a stick can do the job. Combat first aid isn't ABC's, it's CAB.

3. If you can get into the course, PreHospital Trauma Life Support would be a worthy use of money. I know a few community colleges offer these types of courses. Some might be open to enrollment of pre-health students only, but maybe one could audit the course. If nothing else, buy the book. Lots of good info. I took the Advanced version, but wouldn't recommend that unless you're real comfortable with your skills (have the PHTLS book from a decade back). It's also a good course cuz it distills lots of basics without having to go through an EMT course (another worth the price course)

4. Burns and compartment syndrome really suck. I'll be adding a few scalpels to my big kit.

Hope some of you get use from this info.

Hi MDinana,
Thanks for sharing!

good information, thanks for posting

Do you have any reference for this? While certain hemostatics (WoundStat) use has been discontinued, hemostatics and specifically hemostatic bandages are still recommended when pressure dressings won't control the bleeding in situations where tourniquets would not be effective or cannot be applied.

I can not attest for what is currently being taught in CLS courses or other military medical classes, but I do know that the most recent set of TCCC Guidelines still recommend the use of CombatGuaze or similar hemostatic dressings. Other military and non-military studies recommend the use of Chitosan based hemostatics like Celox and Hemcon, especially the hemostatic dressings with Chitosan.

I would personally recommend against the use of hemostatic powders simply because they are pain in the arse to use and can cause complications if used incorrectly or when not necessary. Hemostatic bandages are still an outstanding adjunct to bleeding control when other methods don't work.

If there is a study or data supporting the discontinuation of ALL hemostatics, I would be interested in see it.



Tourniquets have even made their way back into civilian EMS. We recently did a mini-study to choose a tourniquet to place into service locally, an article discussing the results of the study should be up on equipped.org soon.

I can't point to any specific source (yet) for the info, other than my instructors - most of whom were Army or AF medics, or Navy corpsmen. We were taking PHTLS, TNCC, or ATLS depending on our provider level, so a higher echelon of care (for the most part) than what the medics are getting. I'll see if I can dredge up some references in the next couple of days on this info.

One thing I realized - there's something called "Combat gauze" still being used by the military that's apparently a QuickClot product with impregnated propriarity anticoagulant. That's still in use/approved. This is probably what you're talking about.

I have yet to see a tourniquet in civvie use, but in all fairness I've been off the streets about 5 years now.

Sometime last year, National Registry changed the "Bleeding, Wounds and Shock" practical skills sheet to include tourniquets for all levels or EMT providers. I would guess that it will take a few years before it trickles into actual widespread use in the field.

Interestingly, while CombatGuaze is a QuickClot product it appears that it uses a different hemostatic agent rather then the older QuickClot formula that produced heat and subsequently caused burns. I have not used it at all, but to quote a medic who has "it is the s#!t, night a day difference compared to the old stuff".

Hemostatics work, loose granules can be a problem when miss used. WoundStat is garbage and should be thrown away, this specific agent HAS been found to travel through the blood stream and cause emboli and was removed from TCCC guideline and military service in 2008/2009.

If there is anything worse than a loose cannon on the decks, it would be a rusty loose cannon..

So, I am a rusty loose cannon, seeking enlightenment...

Years ago, as an EMT primarily doing mountain SAR we treated numerous major wounds doing just fine with direct pressure and pressure points. At no time did we need to resort to a tourniquet. This included one situation involving an amputated arm (bad mistake with a rear rotor).

I recall talking with a fairly new paramedic friend and colleague, about the number of times he had used a tourniquet on the street. Drawing on about three years experience, he said he had never needed to use one.

Now I see a lot of excitement over the new clotting agents. I have no doubt they have value in a battlefield environment, but I, like many of us, am not on a battlefield.

Is it really worth carrying any of the clotting materials in a standard FAK, given that the vast majority of situations can be handled with direct pressure, and, in extremis, with the big T?

I'm in hikermor's boat - always willing to learn new lessons from deployment medicine learned the hard way, but for WFA scenarios we see pretty much the same lesson, direct pressure treats most major bleeding wounds (every one in my less than universal experience). That's not to say a tourniquet can't be applied in other scenarios, but I will be curious to see how or if the tourniquet advice could be applied in scenarios where you are 24 hours from better medical care. Meantime I would have a high level of confidence in stopping bleeding using non-TQ methods.

That said, I still stuck a tourniquet in the trauma bag kept in the car, but in 99% of auto accidents I would not be inclined to apply it.

A tourniquet is like a firearm, you never need one until you need it very badly and you need it RIGHT NOW!

I can think of 5 incidents of the top of my head where I would have used hemostatics if I had them and 3 cases where I had hemostatics and used them very effectively. All but one of those incidents were gunshot wounds. As for tourniquets, what we have been finding is that EMS providers working in an urban or suburban setting underestimate the need applying a tourniquet due to the proximity of hospitals.

It is not uncommon to see trauma patients brought into the ED with stacks of soaked through dressings. Pressure dressings are not always effective. They work for the majority of bleeds we encounter, especially the new dressings like Cinch-Tight, H-Dressing and Israeli dressings but sometimes a "bigger hammer" is needed.

I look at both these adjuncts (tourniquets and hemostatics) as some of the drugs we carry in our drug box... you use them rarely but when your patient needs them there is no replacement. They take up very little space and weigh next to nothing.

I have never thought there was a need for me to have quikclot or similar agents, in large part because of some of the downsides. I had also read a couple places where a number of EMS units had purchased these items and ended up never using them so decided to stop carrying them when they expired. I gather the proper application for them is very, very limited. There is also the issue that my opinion of an appropriate sized FAK is something that will fit in a sandwich sized zip lock bag. Quikclot will fit in such a bag, but not much else will, and I think there are more important things to have in a FAK.

For extremity bleeding issues, I have always felt if direct pressure did not work it is best to transition to the big T. I would give a major spurter about 20 seconds of direct pressure and if I could not stop it that way, it is on to something effective. The important thing IMO is that the guy does not bleed out before someone more competent gets there, or alternately you get the injured party to someone more competent.

I have never felt that I needed a fancy tourniquet either. The chance of me needing one is so low that I am willing to go with a piece of paracord and a pen. I can tie the ends of the paracord together in about five seconds and use a pen or something similar as a windlass to tighten it up. I know it is not ideal but it is better than letting someone, especially me, bleed to death before someone more competent and presumably better equipped is able to help.

I am intrigued somewhat by combat gauze. It appears to be something useful for deep penetrating wounds to the abdomen that you can't put a tourniquet on and direct pressure is pretty tough to apply. But these kind of injuries are very rare so I think I will pass on it for now, although I suppose I could be convinced.

I am not much of a FAK guy. My idea of a FAK starts with a couple of clean hankies (I am only sort of kidding about this). I rarely cover minor wounds with a bandage. They seem to heal faster if left open. I will use a bandage to protect a wound that might otherwise get further damage, or to keep it clean or dry.

I agree that not every trauma/bleeder needs a tourniquet. I've never used one.

But, I bet most folks haven't had the same combat conditions, where there isn't just 1 patient at a time, and there isn't an entire ambulance and fire engine team reporting. Usually, it's 1 medic and a crap-load of casaulties happening all at once. He can't spend 5 minutes with each holding pressure, and he can't have the battle buddy do it for him - someone needs to be shooting back.

This is also why hemostatics and (more importantly) tourniquets are great tools in the back country or survival situations. While you probably won't need to be shooting back, you could easily find yourself in a situation where evacuation is a LONG time off and you may be the only person able to provide aid. You may even be the only patient as well as the only care giver. The quicker you stop bleeding the more blood you retain... it really is that simple.

Of course you need to balance how much your carrying vs. what could happen in what your doing. My FAK for wildland firefighing is beefier then the FAK I carry for day hiking.

Thank you very much. Most helpful.

While I am sure that this would work better then nothing, paracord is way too thin and will cause significant damage. I have use a triangular bandage as a tourniquet using a similar technique quite effectively. A cut up a shirt or other piece of clothing before using a piece of paracord.

I'm up for recertifying my WFA this year, and may step up the longer 5 day WAFA, depending on schedule: it will be interesting how the instructor deals with tourniquets and hemostatics, or if they deal with them at all. A couple years ago the response was there's no real place for tourniquets in the backcountry, they identified all sorts of issues with releasing pressure and restoring circulation after having it on for ~an hour or more: in short they said if you commit to a tourniquet you may be committing to losing a limb. And they also said the majority of bleeding is stopped with direct pressure, which is true - and when there isn't the pressure to evacuate a casualty right away as there may be with an EMT and close transportation, you can apply direct pressure much better by yourself or putting a confident Scout on the task for you. I will agree the game is to prevent blood loss and keep the patient out of shock, so it makes sense that a tourniquet may have a place on a serious bleeder. I imagine though that will probably come as a result of a fall, and they may have much more serious wounds to deal with. Anyway, I'll follow whatever protocol I'm trained in, but may carry the tourniquet on longer hikes - I think the two I have are SOFT-T types.

Perhaps something wider is in order. I still think a tourniquet is not something I am likely to need and its fairly easy to improvise. We are talking about dead versus not dead here. Thats when I would be using one. I am not going to quibble over some minor tissue damage caused by the use of a less then ideal tourniquet if the other option is dead.

I would be interested in hearing what they tell you. WMS has come out supporting both hemostatics and tourniquets but there is some controversy as to what should be taught at the level.

I agree that for most people a dedicated tourniquet would be not necessary, but pre-planning how to go about making an improvised tourniquet and knowing how and when to use one would be good knowledge to have.

I've always been taught that a tourniquet needs to be 1.5-2 inches wide. But the ones I saw (about 5 types) were all 1 inch nylon webbing.

I guess 1 inch is fine. Paracord might work in a pinch, but you're going to cause lots of local trauma, including potentially cutting into flesh in an attempt to get it tight enough.

But a nylon belt or something similar, and you're set.

Ok have to chime in again. I agree with the "its a better option then dead", comment. In my bag that I carry in the jeep, I have an Isreali tourniquet. I hope to God that I never have to use it, but like said - it is a better option then dead. The space it uses in neglegible, but it gives me just 1 more option. YMMV. I am a big fan of the H-bandage - again hoping that I never have to use it.

There is nothing worse then having run out of options. It is a bad feeling standing there trying to think of what else you can do and realize that you have exhausted all your resourses and still cant save the patient. Just my .02.

BINGO!

I have had the unfortunate luck (profession) to have been in that posistion but if I am standing there I want to know there ARE NO MORE OPTIONS. I still hate that feeling. I think thats why during and emergency situation, people that I work with / hang out with beat themselves up so badly when we loose a soul. Hell - if I thought it would do any good, I would dance naked (ewwww) in the middle of a field to save a life. Some of my buddies that see my kit, look at me like I lost my mind, but they always like to have me around when things get bad.

Nice to be wanted but damn...

One point of dissent - the Israeli bandage isn't intended as a tourniquet.

That being said, some interesting articles/further reading:
http://www.jems.com/resources/supplements/the_war_on_trauma/tourniquet_first.html
http://www.jems.com/resources/supplement...niquet_use.html

The orange tourniquet shown is the same as the standard issue USGI one, but that's in tacticool black.

I'm at work right now, but will be trying to find some other resources to support my initial post.

I guess I should have been more clear on what I use: an Isreali issue tourniguet. It looks just like the tourniquet in the Jems artical but in tacti-cool black. I am glad that you sent me that link because I now have the instructions in English (since I cant read Isreali).

Correct, but technically the specific powders that were phased out were the old formula of QuickClot and WoundStat.

It should be noted that Celox was never used by the military in it's powered form, at least not service wide (some units may have used it) and Celox has not been linked to any of the complications of the QuickClot or Woundstat.

From a practical point of view, the powders are a poor choice for most applications vs. the impregnated dressings.

i assume the Quick Clot was being breathed in and that caused lung problems years later and not that it was put on an open wound?

Actually, it was WoundStat not QuickClot that had the issues with future PEs... and it isn't from inhaling the powder. One of the problems found with with WoundStat is that could damaged the inside of blood vessels causing allowing clots to form on the dammaged tissue. These clots have the potential of breaking off and lodging elsewhere, like the lungs. I was unable to find a reference to QuickClot or Celox having similar complications and NONE of the hemostatic agent impregnated gauze products have these issues.

The information I have indicates that the next TCCC (2011) will likely have a new powdered hemostatic as a last resort treatment if the Combat Gauze failed to work.

I'm pretty sure the only impregnated gauze still being purchased is the Combat Gauze mentioned earlier. Though I would assume the powder would be worse than the impregnated bandages.

The few articles I could find on it did indicate it damaged vessels, perhaps due to the exothermic reaction (one article mentioned real bad adhesions when it was used intra-operatively)

I said I'd offer some proof... here's a convenient article. From this month's Journal Of Trauma:
"Safety Evaluation of New Hemostatic Agents, Smectite Granules, and Kaolin-Coated Gauze in a Vascular Injury Wound Model in Swine
Kheirabadi, Bijan S. PhD; Mace, James E. MD; Terrazas, Irasema B. MS; Fedyk, Chriselda G. MS; Estep, J. Scot DVM; Dubick, Michael A. PhD; Blackbourne, Lorne H. MD
.....
.....
Results: No differences were found in baseline measurements. Thrombelastography showed similar hypercoagulability of the final blood samples when compared with baselines in all groups. All vessels treated with KX or CG were patent and had no thrombus or blood clot in their lumen. In contrast, seven of eight carotid arteries and six of eight jugular veins treated with WS developed large occlusive red thrombi and had no flow. Small clots and WS residues were also found in the lungs of two pigs. Histologically, significant endothelial and transmural damage was seen in WS-treated vessels with luminal thrombi and embedded WS residues.

Conclusion: WS granules caused endothelial injury and significant transmural damage to the vessels that render them nonviable for primary surgical repair. The granules can enter systemic circulation and cause distal thrombosis in vital organs. More relevant in vitro and in vivo safety tests should be required for clearance of new hemostatic agents."

Obviously edited out the gist of the article. Everything is quoted however. Yeah, small sample size, some small study flaws, but provides some evidence for my original post.

Having never used blood clotting granuals I do have a few questions if I may...
Does the granual completely clot the wound and hemostasis of the vessle or does it just promote platelet aggregation? If these granual were to get into the blood stream, would that not thrombos the closest distal vessel? What I am getting at is that this should have been pulled out of the field a lot sooner then (what I am assuming is) very recently? I mean if all patients that clotting granuals suddenly developed PE or DVT's or even something as benign as echymosis distal to a wound, shouldnt someone have questioned it long before it was adopted into the military theater? I am not trying to be disrespectful asking this, but I am truely concerned as this is not common knowledge as quite a few of my friends carry the granules in their first aid kits.

Any thoughts about BloodSTOP gauze?

I carry the 4x4 BloodSTOP gauze and the 4x6 First Care Emergency Bandage in all my kits.

My thinking is to slap some of the gauze on the bandage before applying.

Thoughts?

-john

I wish I could answer your questions, EpiRider. But I've never used the powder'd stuff either. All the products are supposed to promote clot formation, which I guess could get aggressive and occlude the entire vessel (the article I cited mentions that they were patent in all subjects initially). But you're right, it may occlude distally, or even proximal if it got into a vein, which I assume is how the pigs got the PE's.

JohnN, no personal experience with that brand, but it seems (to my mind, anyway), that an impregnated bandage would work better than the powder.

As a somewhat puzzling aside, our Navy Exchange is still selling the powder'd stuff on their shelves for personal use. Wierd, huh?