Tag Archives: Trauma Care

More (well, some!) evidence to back up hemostatic dressings.

Unlike tourniquets and TXA, both of which have  a robust and growing body of literature to support their use, hemostatic dressings such as Quickclot, Combat Gauze, WoundStat etc have had limited published field experience to support their use.
EMS1 on Hemostatics

Blowout Kit

Blowout Kit

 

In US DoD studies, Combat Gauze was chosen as the agent of choice, but that decision was largely based on animal models, which are great, but provide limited value and don’t always translate well to clinical practice. Some suggest they are about 30% more effective than good wound packing with regular materials.

But here’s a study from Israel that supports their effectiveness in the field about 90% of the time!  Keep in mind that this is a small study, but it’s pretty reflective of this authors experience with hemostatics in the military setting, includes extremity and junctional injuries, and acknowledges where there are gaps in the data.

Hemostatic agents in their current form seem to be a potent addition to the hemorrhage control arsenal, and have lots of cheerleaders in the military health care community, but are not a silver bullet that will stop every source of bleeding.  Here’s hoping one of the many gels, foams, CO2 delivered TXA interventions is THE answer to the bleeding patient!

Rescue Task Force Skill. Tourniquets: Where the science stands

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

If you asked any researcher to name some prehospital interventions that truly proved their worth during the recent conflicts in Iraq and Afghanistan they would, almost universally, include  tourniquets and TXA on their list.  Yet there is still, despite a huge volume of well documented research, widespread resistance and misinformation  about these two interventions.

During an EMA Licensing Exam I recently watched someone take a tourniquet off a complete amputation.   He looked at his watch, said “Ten minutes, time to loosen the tourniquet”, and proceeded to remove it from his patient.  Looking at me he asked “Is it bleeding again?” “Of course it’s bleeding again!” was my reply.

I looked at his instructor, and I was floored.  This is what the first aid groups are teaching people about tourniquets? Something very important has been lost in the knowledge translation.

Here are several published studies which look at tourniquet use in the modern context.

The first one we’ll look at was conducted at a US Army Combat Support Hospital (CSH) outside Baghdad over a 7 month period in 2006.  232 patients had 428 tourniquets applied on 309 injured limbs.  194 patients had tourniquets applied in the prehospital setting.  The remainder had them applied in the CSH.  “The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used.” The most common complication (less than 2% of patient) suffered a transient nerve palsy. Let me say that again.  Less than 2% of patients had complications, and the most common one was that their limb hurt or felt funny from the tourniquet compressing a nerve. And it went away.  There were no amputations associated with tourniquet use in this study.  

While this study isn’t without some problems, most glaringly the use of the quality & presence or absence of a radial pulse as the determinant of shock, it is very noteworthy that early tourniquet placement was associated with a better outcome and such a low complication rate makes it THE prehospital intervention for hemorrhage that can be tourniqueted.

LEO Applied TK

Law Enforcement Applied Tk to upper extremity due to arterial bleeding post stabbing. This required an additional full rotation of torsion bar to achieve hemorrhage control by EMS

The second is a follow up to the first, and when we add another 267 patients we get virtually identical data: an overall 87% survival rate, higher in those who received tourniquets early and lower in those who didn’t receive one at all or until the CSH, with a <2% complication rate and no amputations.

This is not to say that any intervention is without risk.  The use of improvised tourniquets and prolonged application times are associated with worse outcomes, and there are some documented cases, with improvised tourniquets, that DID result in amputations after long (17 hour) application.

It is critical that medical providers train with their tourniquet of choice under all potential conditions.  Application effectiveness does not improve under real world conditions! Lower extremity application continues to have the highest failure rate, likely due to the higher occlusion pressures needed (300mmHg!).

The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training

What is the objective to loosening a tourniquet? To prevent loss of limb? To decrease complications like transient nerve palsies?  If those are your objectives, relax, the tourniquets have this one. Put it on, and don’t take it off.  We’ve got the EMS evidence to back this up.

Tac Tool Tuesday! Junctional Compression!

The AAT is now the AAJT! This device has been shown to reduce hemorrhage in junctional trauma with lower tissue pressures than other devices.

AAJT

Exciting emerging applications for this device include it’s prospective use in pelvic fractures! Rather than worry about stopping multiple fracture sources of blood loss, just stop blood flow to the affected area altogether until timely surgical repair or embolization.

Here’s a link to the abstract from the research at Madigan Army Medical Centre

Tac Technique Tuesday!

We’ve recently looked at wound packing as one of the more effective methods to control hemorrhage.  This week let’s look at surgical crichoidthyrotomy as an airway option in tactical environments.

Surgical airways are recommended by both C-TECC and CoTCCC relatively early in the airway management flowchart, below NPA and positioning and above placement of an ET tube.  Unlike the civilian setting where equipment is readily available and one monitor/patient is the norm, the Tactical Field Care (TCCC) and Indirect Threat Care (TECC) phase recommendations recognize that time and equipment constraints may not allow us to use tools like ETCO2 waveform capnography to confirm tube placement, or even Direct Laryngoscopy or Video Laryngoscopy to place a tube.  In those settings, a scalpel-bougie crich may be your best bet for definitive tactical airway management.Crich

Watch this video of Dr Dennis Kim demonstrating a very deliberate surgical method on a cadaver, and think about doing this in a dust-storm in Iraq (or a blizzard in the BC Alpine), or in the pitch black with IR illumination and NVG’s while balancing the equipment on the cleanest surface you can find, your jumpkit or your lap.

https://www.youtube.com/watch?v=Kg14kdIycDE

If they are done quickly and smoothly out of prepared stripped-down kits they are significantly easier and safer than ETT placement.  There is no technology to depend upon.  No Laryngoscope, no waveform capnography to confirm placement.

Equipment is simple: A scalpel, a bougie, and a cut down #6 ETT with 10 ml syringe attached.

If necessary, make a vertical incision to mark your midline.  Cut the skin laterally across the neck to expose the crichoid membrane.  Pierce the membrane, extend the incision and do not remove the scalpel.  Insert the bougie over top of the scalpel blade into the tracheal lumen. Remove the scalpel and pass the tube over the bougie.

The technique starts at 2:30 in this video!

https://www.youtube.com/watch?v=BT7KsQN6ANc

If you compare the two techniques, you’ll see that the scalpel-bougie Crich is the easier, safer method.  By keeping the surgical tract open continuously, via scalpel, then bougie, then tube, there is a major reduction in the chance of losing the tract.  Losing the tract in the dark, in the dust, in the snow, isn’t an option. This is your last ditch airway procedure.  It must work!

 

One Step Closer to our Tactical Emergency Casualty Care Course

For the past several days I’ve been working the phone lines and email tree trying to nail down a venue for our next course offering, and I think we’ve found it.  I’ll be stopping by tomorrow to ensure that it meets our needs and is cost effective for our clientele.

Our Tactical Emergency Casualty Care Course is open to paramedics, law enforcement, and Canadian Armed Forces members.  TCCC and TECC teach the same material, but to different target audiences, in a slightly different format.  While sending the 9-Liner CasEvacReq is an essential skill for a deployed soldier, there isn’t much need to teach it to a street level paramedic or police member.

What each of them does have to know is how to handle themselves if they’re injured; how to apply a tourniquet to themselves, their patient, or their partner quickly and efficiently and get back to the job at hand.  How to control hemorrhage with wound packing, direct pressure, and with a variety of bandages.  How to place an airway, on the floor, in the dark, by touch. How to move someone by themselves over smooth terrain, over rough terrain.

Tomorrow, at 1300, I find out if we’ve got our venue!

Sometimes the best care isn’t enough

Tonight, the RCMP announced that Cst David Wynn is unlikely to survive the GSW head injury he suffered yesterday morning in a Edmonton area casino. He’s in an Edmonton hospital receiving the best possible care, but sometimes, far too often, that isn’t enough.

The results of a gun shot wound to the brain are devastating.  Tonight we’re thinking of the families of Cst Wynn, both natural and regimental. We’re praying for the speedy and complete recovery of Aux Cst Bond (unarmed at the time of the shooting, being an Auxiliary), who suffered a grievous limb injury and faces a long difficult recovery ahead of himself.

We have seen one bloody police shooting after another in this country.  We have buried far too many Canadians in red serge and navy blue.

It is time Canada’s police services have access, across the board, top to bottom and coast to coast, to hard armour and suitable patrol carbines.  It will cost more, both in terms of training time, training ammunition, capital expenses to buy the things, but it is worth it.  Time and money spent on training is almost always money well spent.

Yesterday was a good day

Devon, Ian and I spent the day with 10 NSR members working our way through day one of ITLS.  We covered the ITLS Primary Survey and Ongoing Exam. Airway management, hemorrhage control, chest and abdominal injuries.

One of the best things we do in ITLS is almost insidious.  We get people talking the same language.  We take students with qualifications ranging from Wilderness First Aid through to EMR (in this case) who have been trained by the Red Cross, St John’s, JIBC, AET and other training providers, and we get them all using the same terminology.  This means that when teams are communicating and collaborating on scene, the transfer of information is fast, efficient, and leads to shorter scene times and better care.

North Shore Rescue 2 TK

We also try to introduce new equipment, procedures, and techniques to our classes. Comfortable with a CAT? Let’s look at a SOFT too.  Use the SAM Pelvic Sling? Have you looked at the TPOD for your agency?  Asherman Seals work, but how about Hyfin?

We don’t expect our clientele to stay on top of the latest science behind EMS.  That’s what we do.

Our second NSR course!

Tomorrow we start our second contract course, another ITLS for North Shore Rescue.  We’d originally planned this to be our ITLS Site Visit for sign-off as a ITLS Training Centre, but due to scheduling conflicts we won’t be getting our visit done this time around.

Ian’s packing up a his jumpbags, AV kit, and airway mannequins. I’ve got a briefcase full of admin and paperwork, and I’m answering questions from students already. Devon’s looking over his material.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Working with SAR groups is always a bit different than working with EMS or other health care providers.  Medicine is only a small part of the mission, whether you’re a CF SARTECH or a community volunteer, and amidst all of the other critical skills that they work hard to keep sharp, the more difficult it can be to keep the finer nuances of patient care.

Regular review of the material is great, but team based training helps to ensure that the collective knowledge of the team is maintained.  Not every team member needs to be an expert prehospital care provider; every team member does need to know what the goals and fundamentals of care are. That’s what makes a team efficient and effective, that they’re all working towards the same greater goal.

One of the great things about ITLS is it’s focus on a team based approach to caring for the HMMVW Amb on the flight line, KAFinjured.  Concurrent activity and clearly defined and communicated goals keeps scene times to a minimum and allows for superb care even under very austere conditions.

 

 

ITLS site visit

We’re at T-7 days until our second ITLS course for North Shore Rescue.  This course will also mark our site visit for our sign-off as an ITLS Training Centre.  Ian, Devon, and I are all divying up tasks and figuring out a teaching schedules.

We’ve done this before, there have been years where I’ve taught more than one course per week, but the added pressure of our certification as an ITLS Training Centre is putting a certain stress on us.  North Shore Rescue is always a great group to work with!

The power of the meme

There’s a social media site I run, that occasionally post humorous but educational memes.  I love using those in education.  If I can put some pithy saying about Spinal Motion Restriction into Morgan Freeman’s or Oprah’s voice (or someone else with a distinctive voice), why the heck wouldn’t I?

SMR penetrating