Tuesday, June 13, 2017

Stop bleeding to death

DISCLAIMER: Instructions here are not a substitute for professional medical care and treatment. If you are having a medical emergency call 911 or your local emergency number for assistance.

When I was a flight medic for the army, some of my buddies and I had a saying, “stop the bleeding and start the breathing.” Little did we know that this would in a roundabout kind of way become what the American Heart Association teaches during CPR and in other advanced classes. In 2010 the AHA changed the guidelines for CPR. Once upon a time everyone was taught their A-B-C’s-Airway, Breathing, and Circulation. Now that has changed to C-A-B for Chest compressions, Airway, Breathing1.
Now follow me here, emergency situations are all about assessment, diagnosis, planning, implementation and evaluation. All of these must happen in rapid succession and you will probably have to repeat the process several times in an emergency situation.

What will kill you or your buddy the fastest? Answer: BLEEDING2, 3. A person can bleed out in less than 3 minutes from a femoral artery injury. So let’s step back for a second to C-A-B. How can we expect for an injured person to recover from not breathing by starting chest compressions when there is not enough circulating volume to oxygenate anything? We must stop the bleeding and start the breathing.


Now the question is-How do we stop the bleeding? My hope is that I can provide answers that anyone can understand. I explain to Boy Scouts and infantrymen that there are two types of bleeding.

Band-Aid bleeding
Hospital bleeding


These should be pretty self-explanatory. Band-Aid bleeding is what I define as bleeding that can be stopped with the simplest of dressings and minimal pressure.


Hospital bleeding I tell people makes your pucker factor go up. You realize quickly that you will not be able to take care of this on your own and need more help. I use the term hospital bleeding as a name only. Utilize your resources- to include people and supplies to control bleeding.
In the above diagram both capillary and venous bleeding can be considered Band-Aid bleeding. Venous and arterial bleeding are Hospital Bleeding. Notice the overlap with venous bleeding. Venous bleeding can go either way, remember that we have to constantly keep assessing, because a venous Band-Aid bleed can turn into a holy crap Hospital Bleeding situation very fast. Arterial bleeding is always a hospital-grade emergency.

If you have never seen an arterial bleed, I suggest you YouTube it. Arterial bleeding, as stated before is ALWAYS Hospital Bleeding. To be more clear, arterial bleeding is an emergency and requires advanced medical treatment, call 911 or your local emergency services for assistance.
While you are waiting for emergency services or heaven forbid that you have no other help available, what can you do? We already know that anything more than a simple bandage or dressing with minimal pressure is Band-Aid bleeding. How do we go from a simple bandage and minimal pressure to controlling Hospital Bleeding?

***DIRECT PRESSURE AND TOURNIQUETS***

Direct pressure is tricky at best and impossible at worst. Lots of people want to just put their palm on a site that is bleeding and just lean on it for all their worth. This usually ends in frustration and the inability to stop the bleeding. Direct, pinpoint pressure, is what is needed to stop bleeding when attempting to use pressure4. Direct pressure alone is not enough; it has to be teamed with something. i.e. plain gauze, hemostatic dressing such as QuikClot or other chitosan infused dressing.


These types of dressings are best used in places where tourniquets won’t. i.e. head, neck, trunk, and groin. For the extremities there is the good old fashioned tourniquet. Which has seen many upgrades on the design but the principles remain the same.

The tourniquet has saved more lives on the battlefield than any medicine ever will. It is fast to apply but not very easy. Too many people rely on the windlass (the stick) of a tourniquet to get enough pressure to occlude arterial blood flow. Ideally arterial flow is staunched by use of straps or bands and secured with the windlass. Below are a few tourniquets.




Tourniquets are not placed willy nilly. Their application should be painful and the person receiving a tourniquet should tell you that it’s painful if they are able. Please do not think that painful application of a tourniquet means you are doing it wrong. The idea is to stop blood flow and to not be able to feel pulses below where a tourniquet is applied.

Ideally tourniquets are placed four to six finger widths above an injury and not directly over a joint like the elbow or knee. Many times a second or third tourniquet are required to attain enough pressure to block arterial flow of the affected area. Additional tourniquets should be placed below the original tourniquet so as not to damage more tissue above the original site. Let’s remember that the primary application of pressure with the tourniquet is with the straps or bands and then by twisting the windlass and securing it. After application of a tourniquet the date and time must be noted somehow. I don’t care how you make this happen but it is important to note the time when it comes to removal.

In a two-part study on outcomes with tourniquets the numbers show 862 tourniquets were applied on 651 limbs. Survival was 87% for both study periods. Morbidity rates for palsies at the level of the tourniquet were 1.7% for study 1 and 1.5% for study 2; major limb shortening was 0.4% for both. Survival was associated with prehospital application (89% vs. 78% hospital, p < 0.01) and application before the onset of shock (96% vs. 4% after)5.

There are a few takeaways from the study.           
      
                  Tourniquets save lives
Subsequent damage without limb removal is small
 Limb removal rates are low


This is important information. To know that you can apply a tourniquet and still maintain a viable limb after tourniquet removal plays huge mentally. You can worry about staying alive and less about if your leg or arm is going to need cut off.

Tourniquet removal should always be done in the hospital setting by a qualified medical professional. Removal or conversion of a tourniquet to a standard dressing must be controlled and monitored.
It wasn’t that long ago that the Boston Marathon Bombing happened. Many of those survivors credit the use of tourniquets in saving their lives. Commercially available tourniquets are not terribly expensive. Really what is the cost of a tourniquet compared to saving life and limb?







References:
1.     Hazinski, M. F., & Field, J. M. (2010). 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation, 122(Suppl), S639-S946.
2.     Jenkins, DH. (June 22, 2011.) National Trauma Institute. [Testimony before the U.S. Senate Committee].
3.     Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, Pons PT: Epidemiology of trauma deaths: a reassessment. J Trauma. 1995, 38: 185-193.
5.     Kragh, J. F., Littrel, M. L., Jones, J. A., Walters, T. J., Baer, D. G., Wade, C. E., & Holcomb, J. B. (2011). Battle casualty survival with emergency tourniquet use to stop limb bleeding. The Journal of emergency medicine, 41(6), 590-597.