Hemorrhage Control COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

Hemorrhage ControlHemorrhage Control

COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

CMASTCMAST 22

IntroductionIntroduction

Review methods of hemorrhage control in Review methods of hemorrhage control in a tactical environment.a tactical environment.

Hemorrhage is the leading cause of Hemorrhage is the leading cause of preventable death on the battlefield.preventable death on the battlefield.

Hemorrhage control save lives.Hemorrhage control save lives.

New Hemostatic agents available.New Hemostatic agents available.

CMASTCMAST 33

Cardiovascular SystemCardiovascular System

CMASTCMAST 44

Blood VesselsBlood Vessels

ArteriesArteries ArteriolesArterioles CapillariesCapillaries VenulesVenules VeinsVeins

CMASTCMAST 55

PulsesPulses Left ventricle contracts.Left ventricle contracts. Peripheral pulses:Peripheral pulses:

– RadialRadial– Brachial Brachial – Posterior tibialPosterior tibial– Dorsalis pedisDorsalis pedis

Central pulses:Central pulses:– CarotidCarotid– FemoralFemoral

CMASTCMAST 66

BloodBlood Adult body:Adult body:

– Contains approximately 5 to 6 liters of bloodContains approximately 5 to 6 liters of blood– Loss of 1 pint of blood without harmful effectsLoss of 1 pint of blood without harmful effects– Loss of 2 pints may cause shockLoss of 2 pints may cause shock

Three phases of hemostasis:Three phases of hemostasis:– Vascular spasmVascular spasm– Platelet plug formationPlatelet plug formation– Blood clotting Blood clotting

(coagulation cascade)(coagulation cascade)

CMASTCMAST 77

HemorrhageHemorrhage Pulse vs. Blood Pressure.Pulse vs. Blood Pressure. How long until there are changes?How long until there are changes? Young healthy adults compensate for long Young healthy adults compensate for long

periods, then decompensate rapidly.periods, then decompensate rapidly. At what blood pressure do casualties lose At what blood pressure do casualties lose

consciousness? consciousness?─ @ 50 mm Hg@ 50 mm Hg

CMASTCMAST 88

Clinical Signs of Acute HemorrhageClinical Signs of Acute Hemorrhage

ClassClass % Blood % Blood LossLoss

Clinical SignsClinical Signs

II Up to 750 ml Up to 750 ml (15%)(15%)

Slight increase in HR; no change in BP Slight increase in HR; no change in BP or respirationsor respirations

IIII 750-1500 ml 750-1500 ml (15-30%)(15-30%)

Increased HR and respirations; Increased HR and respirations; increased diastolic BP; anxiety, fright or increased diastolic BP; anxiety, fright or hostilityhostility

IIIIII 1500-2000 1500-2000 ml (30-40%)ml (30-40%)

Increased HR and respirations; fall in Increased HR and respirations; fall in

systolic BP; significantsystolic BP; significant AMSAMS

IVIV >2000 >2000 (>40%)(>40%)

Severe tachycardia; severe lowering of Severe tachycardia; severe lowering of BP; cold, pale skin; severe AMSBP; cold, pale skin; severe AMS

CMASTCMAST 99

Sources of HemorrhageSources of Hemorrhage

External:External:

– Visible blood is hard to estimateVisible blood is hard to estimate

Internal:Internal:

– May be hidden within the torso or even in May be hidden within the torso or even in

the extremities secondary to fracturesthe extremities secondary to fractures

CMASTCMAST 1010

Sources of External BleedingSources of External Bleeding Arterial:Arterial:

─ Rapid, profuse and pulsatingRapid, profuse and pulsating─ Bright red in colorBright red in color

Venous:Venous:─ Steady flowSteady flow─ Dark red or maroon in colorDark red or maroon in color

Capillary:Capillary:─ Slow and oozingSlow and oozing─ Often clots spontaneouslyOften clots spontaneously

CMASTCMAST 1111

Extremity HemorrhageExtremity Hemorrhage

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CMASTCMAST 1212

Internal Signs of HemorrhageInternal Signs of Hemorrhage

Soft tissue bruising.Soft tissue bruising. Abdominal tenderness.Abdominal tenderness. Hemoptysis.Hemoptysis. Hematemesis.Hematemesis. Melena.Melena.

CMASTCMAST 1313

Injured Internal OrgansInjured Internal Organs

CMASTCMAST 1414


Assess the tactical situation.Assess the tactical situation. Expose the wound.Expose the wound. Attempt to control the Attempt to control the

bleeding with direct bleeding with direct pressure or a pressure pressure or a pressure dressing.dressing.

CMASTCMAST 1515

CMASTCMAST 1616


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CMASTCMAST 1717


Life-threatening arterial bleeding Life-threatening arterial bleeding (amputation) may require early use of a (amputation) may require early use of a tourniquet.tourniquet.

If under enemy fire or in a dangerous If under enemy fire or in a dangerous position rapidly apply a tourniquet and position rapidly apply a tourniquet and move casualty to cover.move casualty to cover.

CMASTCMAST 1818

TourniquetsTourniquets

Several new tourniquets have been Several new tourniquets have been selected as primary means to control selected as primary means to control hemorrhage in combat.hemorrhage in combat.

CMASTCMAST 1919

Combat Application TourniquetCombat Application Tourniquet

WINDLASS

SELF ADHERING BANDWINDLASS STRAP

The C-A-T was selected as the primary The C-A-T was selected as the primary tourniquet tourniquet for every soldier.for every soldier.

C-A-T Step 1C-A-T Step 1

Place the wounded extremity through the loop of the Self-adhering Band


Place tourniquet above the injury

site


Pull the free-running end of the Self-adhering Band tight and securely fasten it back on itself.


Adhere Self-adhering Band completely around the limb until the clip is reached.


Twist the Windlass Rod until the bleeding has stopped.


Lock the Rod in place with the Windlass Clip


For small extremities, continue to adhere the Self-adhering Band around the extremity and over the Windlass Rod.


Grasp the Windlass Strap, pull it tight, and adhere it to the velcro on the Windlass Clip.

C-A-T TourniquetC-A-T Tourniquet

The C-A-T Tourniquet is now ready for transport.


NOTE:

The friction adaptor buckle is not necessary for proper C-A-T application to an arm. It MUST be used with two hands when applying to a leg.

C-A-T: Lower ExtremityC-A-T: Lower Extremity

To use, wrap the Self-adhering Band through the friction adaptor buckle.


This prevents the Self-adhering Band from loosening during transport.

CMASTCMAST 3232



CMASTCMAST 3333



SOFTT

CMASTCMAST 3535

SOFTT ApplicationSOFTT Application

Similar to the CAT: Similar to the CAT: ─ Slide loop over extremitySlide loop over extremity─ Pull strap tightPull strap tight─ Twist windlass until Twist windlass until

bleeding stopsbleeding stops─ Latch the windlass Latch the windlass

with one of the with one of the tri-ringstri-rings

─ Tighten the safety Tighten the safety screwscrew

CMASTCMAST 3636

SOFTT ApplicationSOFTT Application

One-handed application Two-handed application

CMASTCMAST 3737

Improvised TourniquetImprovised Tourniquet

Place cravat between heart and wound.Place cravat between heart and wound. Tie a half-knot on upper surface.Tie a half-knot on upper surface. Place a short stick on half-knot.Place a short stick on half-knot. Tie a square knot on top of Tie a square knot on top of

stick.stick. Twist stick (windlass) to Twist stick (windlass) to

tighten.tighten. UNTIL BLEEDING STOPS.UNTIL BLEEDING STOPS. Secure windlass to prevent unwinding.Secure windlass to prevent unwinding.

CMASTCMAST 3838

Improvised TourniquetImprovised Tourniquet

CMASTCMAST 3939

Tourniquet PrinciplesTourniquet Principles

Never cover a tourniquet.Never cover a tourniquet. Mark a “T” on the casualty's forehead or Mark a “T” on the casualty's forehead or

somewhere obvious (sharpie pen).somewhere obvious (sharpie pen). In combat when the tactical situation In combat when the tactical situation

allows, loosening a tourniquet is allows, loosening a tourniquet is appropriate. appropriate.

CMASTCMAST 4040

Tourniquet RemovalTourniquet Removal Once the tactical situation allows, Once the tactical situation allows,

tourniquets should be loosened and other tourniquets should be loosened and other methods to stop bleeding applied.methods to stop bleeding applied.─ Direct pressure - pressure dressingDirect pressure - pressure dressing─ HemCon Chitosan BandageHemCon Chitosan Bandage─ QuikClot powder QuikClot powder

CMASTCMAST 4141

Tourniquet RemovalTourniquet Removal When loosening a tourniquet, do not When loosening a tourniquet, do not

remove it from the limb.remove it from the limb. If the tourniquet has been in place for If the tourniquet has been in place for > 6 hours, do not remove.> 6 hours, do not remove. If fluid resuscitation is required, it should If fluid resuscitation is required, it should

be accomplished before the tourniquet is be accomplished before the tourniquet is removed.removed.

Tourniquets are very painful, provide Tourniquets are very painful, provide pain medications as needed.pain medications as needed.

CMASTCMAST 4242

Tourniquet RemovalTourniquet Removal If tourniquet has been in place for only 1-If tourniquet has been in place for only 1-

2 hours, loosening and using other 2 hours, loosening and using other methods to control hemorrhage can methods to control hemorrhage can salvage limbs.salvage limbs.

Remember: if unable to control Remember: if unable to control hemorrhage by other means, re-tighten hemorrhage by other means, re-tighten the tourniquet.the tourniquet.

It is better to sacrifice the limb than to It is better to sacrifice the limb than to lose a life to hemorrhage.lose a life to hemorrhage.

CMASTCMAST 4343

AmputationAmputation

Apply a pressure dressing to cover the Apply a pressure dressing to cover the end of the stump.end of the stump.

Kerlix and 6” Ace wrap for effective Kerlix and 6” Ace wrap for effective pressure dressing.pressure dressing.

Rinse amputated part free of debris. Rinse amputated part free of debris. Wrap loosely in saline-moistened sterile Wrap loosely in saline-moistened sterile

gauze.gauze.

CMASTCMAST 4444

Preservation of Amputation PartsPreservation of Amputation Parts

Seal amputated part in a plastic bag or Seal amputated part in a plastic bag or cravat.cravat.

Place in a cool container; do not allow to Place in a cool container; do not allow to freeze. freeze.

Never place an amputated part in water.Never place an amputated part in water. Never place amputated part directly on ice.Never place amputated part directly on ice. Never use dry ice to cool an amputated part.Never use dry ice to cool an amputated part.

CMASTCMAST 4545

Hemostatic AgentsHemostatic Agents

HemConHemCon®® Chitosan Bandage. Chitosan Bandage.

QuikClotQuikClot®® Hemostatic Powder. Hemostatic Powder.

CMASTCMAST 4646

Chitosan Hemostatic DressingChitosan Hemostatic Dressing

Hold the foil over-pouch so that instructions can Hold the foil over-pouch so that instructions can be read. Identify unsealed edges at the top of the be read. Identify unsealed edges at the top of the over-pouch.over-pouch.

CMASTCMAST 4747


Peel open over-pouch by pulling the unsealed Peel open over-pouch by pulling the unsealed edges apart.edges apart.

CMASTCMAST 4848


Trap dressing between bottom foil and non-Trap dressing between bottom foil and non-absorbable green/black polyester backing with absorbable green/black polyester backing with your hand and thumb.your hand and thumb.

CMASTCMAST 4949


Hold dressing by the non-absorbable polyester backing Hold dressing by the non-absorbable polyester backing and discard the foil over-pouch. Hands must be dry to and discard the foil over-pouch. Hands must be dry to prevent dressing from sticking to them.prevent dressing from sticking to them.

CMASTCMAST 5050


CMASTCMAST 5151


Place the light colored sponge portion of the Place the light colored sponge portion of the dressing directly to the wound area with the dressing directly to the wound area with the most severe bleeding. Apply pressure for 2 most severe bleeding. Apply pressure for 2 minutes or until the dressing adheres and minutes or until the dressing adheres and bleeding stops. Once applied and in contact bleeding stops. Once applied and in contact with the blood and other fluids, the dressing with the blood and other fluids, the dressing cannot be repositioned.cannot be repositioned.

A new dressing should be applied to other A new dressing should be applied to other exposed bleeding sites; each new dressing exposed bleeding sites; each new dressing must be in contact with tissue where bleeding must be in contact with tissue where bleeding is heaviest. Care must be taken to avoid is heaviest. Care must be taken to avoid contact with the casualty’s eyes.contact with the casualty’s eyes.

CMASTCMAST 5252


If dressing is not effective in stopping If dressing is not effective in stopping bleeding after 4 minutes, remove the original bleeding after 4 minutes, remove the original and apply a new dressing. Additional and apply a new dressing. Additional dressings cannot be applied over ineffective dressings cannot be applied over ineffective dressings.dressings.

Apply a battle dressing/bandage to secure a Apply a battle dressing/bandage to secure a hemostatic dressing in place.hemostatic dressing in place.

Hemostatic dressings should only be Hemostatic dressings should only be removed by responsible persons after removed by responsible persons after evacuation to the next level of care.evacuation to the next level of care.

CMASTCMAST 5353

Click on picture for video

CMASTCMAST 5454

CMASTCMAST 5555

CMASTCMAST 5656

QuikClotQuikClot

Warning: Avoid contact with wet skin; Warning: Avoid contact with wet skin; product reacts with small amounts of water product reacts with small amounts of water and can cause burning. and can cause burning.

Stop burning by brushing away granules Stop burning by brushing away granules and flooding area with large volume of and flooding area with large volume of water. water.

If ingested, immediately drink two or more If ingested, immediately drink two or more glasses of water.glasses of water.

CMASTCMAST 5757

QuikClotQuikClot Directions:Directions:1-Apply direct firm pressure to wound using sterile 1-Apply direct firm pressure to wound using sterile

dressing or best available substitutedressing or best available substitute

2-If bleeding is stopped or nearly stopped after 2-If bleeding is stopped or nearly stopped after approximately 1 minute of pressure, wrap and tie approximately 1 minute of pressure, wrap and tie bandage to maintain pressure on woundbandage to maintain pressure on wound

3-If moderate to severe bleeding continues, hold 3-If moderate to severe bleeding continues, hold pack away from face and tear open at tabspack away from face and tear open at tabs

CMASTCMAST 5858

QuikClotQuikClot

4-Use wiping motion to remove gauze and 4-Use wiping motion to remove gauze and excess blood – immediately start a slow excess blood – immediately start a slow pouring of one QuikClot packet directly onto pouring of one QuikClot packet directly onto the wound. Stop pouring as soon as dry the wound. Stop pouring as soon as dry granules cover the wound areagranules cover the wound area

5-Use only enough QuikClot to stop bleeding. If 5-Use only enough QuikClot to stop bleeding. If bleeding continues open a second packet of bleeding continues open a second packet of QuikClot and continue to use as directed QuikClot and continue to use as directed

CMASTCMAST 5959

QuikClotQuikClot

6-Reapply firm pressure to QuikClot covered 6-Reapply firm pressure to QuikClot covered wound using sterile gauze. Wrap and tie wound using sterile gauze. Wrap and tie bandage to maintain pressurebandage to maintain pressure

CMASTCMAST 6060

QuikClotQuikClot


CMASTCMAST 6161

Treatment GoalsTreatment Goals

Hemorrhage control continues to be the Hemorrhage control continues to be the priority in battlefield care.priority in battlefield care.

Hemorrhage is the leading cause of Hemorrhage is the leading cause of preventable death on the battlefield.preventable death on the battlefield.

Our focus must be on stopping soldiers Our focus must be on stopping soldiers from bleeding to death on the battlefield.from bleeding to death on the battlefield.

CMASTCMAST 6262

Questions?Questions?

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Hemorrhage Control COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)