The Importance of Tourniquets

A New Decade

&

A New Approach

to

Rural Trauma Care* * *

Military Trauma Care as the model

Norman McSwain MD FACS, NREMT-P

Professor Tulane School of Medicine

Trauma director Charity Hospital

Thanks for including me in the summit

Interactive lecture

with yourselfHow can I change

my state?

How can I change Rural Trauma Care as a national system

Do we need a change in Rural Trauma Care

• Effect of War on prehospital care

• Effect from current conflicts– Iraq, Afghanistan and others

• CoTCCC & TCCC

• Specific treatment techniques

• Military -> Rural benefits

• Louisiana Rural Trauma Care system

This Summit should set in motion Rural Trauma Care

into next decade

Connectionthrough

PreHospital Trauma Life support&

Tactical Combat Casualty Care

6

Understanding patient care

• Principle – medical standard that is necessary for good patient care

• Preference – how the standard is achieved– Conditions– Circumstances– Knowledge, Skill , Ability, & Affect of the operator– Resources available

Science

Art

Goals of Prehospital care• Improve survival

– Arrival on the scene– Arrival at the hospital– At worst “do no further harm”

• Reduce pain– Stabilization– Medication

• Reduce hemorrhage– Stop on the scene– Prevent additional hemorrhage– Stabilize Fractures– Deliver to correct hospital

Principles

• Do no further harm

• Preserve and improve energy production

• Airway/Ventilation management

• Hemorrhage control

• Transport patient to correct hospital

• Do not transport dead patients

• Appropriate resuscitation

• Reduce pain

Proof based patient care

Prominence based patient care

Perceptive based patient care

Evidence based medicine

Eminence based medicine

Understanding based medicine

Understanding

If you cannot answer the question

“WHY”

then you do not understand.

Impact of Warson EMS

Changes of the Wars

• Napoleon Wars – Dominique-Jean Larrey– Foundation elements of prehospital care– Rapid response– Trained attendants– Close hospitals

• War of Northern Aggression (1861)– Development of Ambulance services

Changes of the Wars

• WWI – Thomas Splint– Ground evacuation

• WWII – Training of corpsmen in early management of injured soldiers– Plasma

• Korea – Use of helicopter for rapid transportation– Front line hospitals (MASH)

Changes of the Wars

• Viet Nam – advanced scene care by corpsmen– IV– Airway– Bypass CAS for MASH– Large volumes of crystalloid resuscitation

• Iraq/Afgahnistan– Advanced care en route to the next medical care– Damage control Surgery– Damage control Resuscitation– Military Echelon of Casualty Management– Tourniquets/hemostatic agents– Interosseous vascular access

Larrey’s Principles

EMS Changes in Current Conflicts

• CoTCCC• TCCC• Military Echelon Casualty Management (MECM)• Medical Evacuation (CCAT)• Hemorrhage control

– Tourniquets– Hemostatic agents

• Resuscitation• Surgical management• Interosseous Access• Field Assessment• Field trauma management

Committee on

(CoTCCC)

18

CoTCCC Members – Recent and Present

• U.S. Surgeon General• Chairman – ACS Committee on Trauma• Trauma consultants for Army, Navy, and Air Force

Surgeons General• 5 Trauma Directors for Level 1 Trauma Centers• White House Medical Officer• 2 Command Surgeons, U.S. Special Operations

Command (USSOCOM)• Command Surgeon for the Army Rangers• Senior Enlisted Medical Advisor, USSOCOM• Senior Medic for the Army Rangers

20

Changes to the TCCC Guidelines

CoTCCC

Research Facilities

Service MedicalLessons LearnedCenters

Direct InputFrom Combat MedicalPersonnel

PublishedPrehospital TraumaLiterature

Unclassified

Committee onTactical Combat Casualty Care

Defense Health Board

Trauma and Injury Subcommittee

Assistant Secretary of DefenseHealth Affairs

Surgeons General

22

TCCC Changes 2008/2009

• No hemostatics in Care Under Fire

• Updated tourniquet use plan

• Combat Gauze

• Mgt of Tension Pneumothorax

• Mgt of Sucking Chest Wound

• Mgt of Penetrating Eye Trauma

• TCCC Casualty Card

• Third phase of care: “Tactical Evacuation Care”

Unclassified

23

2 Special Operations UnitsExperience with TCCC

• Kotwal – TCCC First Responders Conf 9/08– 75th Ranger Regiment– 482 casualties – 37 fatalities

• Pennardt – CoTCCC meeting 2/09– Army Special Forces unit– 201 casualties – 12 fatalities

• Neither unit identified any preventable deaths

• Both units train all combatants in TCCC

PracticePractice Practice

Tactical Combat Casualty Care

The Course

25

PHTLS Seventh Edition• Introduction – Frank Butler• Care Under Fire – Shawn Johnson• Tactical Field Care – Frank Butler• CASEVAC – Jay Johannigman, Tom Rich• Triage – Paul Cordts • CASEVAC, MEDEVAC, and Aeromedical Evacuation – Jay Johannigman, Tom Rich• Injuries from Explosives – Howard Champion• Medical Support of Urban Ops – Bob Mabry • Ethical Considerations – Frank Anders• Burns in TCCC – Booker King• Theater Medical Care – Brian Eastridge• Pre-Mission Medical Planning – Russ Kotwal, Harold Montgomery

26

Revised TCCC Curriculum Completed • Powerpoint presentations (5)

• Skill sheets (9)

• Instructor guides (5)

• Training videos (16)

• Maintain on websites – public domain

–MHS

– PHTLS

• Update with each change in guidelines

27

TCCC Training Options

• Use curriculum from PHTLS website

• Military-to-Military

• PHTLS – like structure

• Commercial TCCC Training Vendors

• Other options?

28

Requests for TCCC Training

• Sweden

• Spain

• Portugal

• Argentina

29

PHTLS support of TCCC

• Certification card

• TCCC Registry

• Instructor qualifications

• Test

• Curriculum used

• Skills sets trained

Combat Trauma Care

31

Civilian Trauma Care

Is this rural/wilderness

or military

Principles vs Preferences

• Situation

• Conditions

• Skill, Knowledge, Ability, & Affect

• Resources

Military Field TriageTCCC

Stages of Medical Care

• Care Under Fire

• Tactical Field Care

• Tactical Evacuation

• Field Hospital– FST

– CSH

• MedEvac

• Definitive medical care

• Echelon I

• Echelon II

• Echelon III

• Echelon IV

• Echelon V

36

Questions?

Care under Fire

Care Under Fire Guidelines

1. Return fire and take cover.

2. Direct or expect casualty to remain engaged as a combatant if appropriate.

3. Direct casualty to move to cover and apply self-aid if able.

4. Try to keep the casualty from sustaining additional wounds.

37

Care Under Fire Guidelines

5. Airway management Deferred Tactical Field Care phase

6. Stop life-threatening external hemorrhage if tactically feasible:– Direct casualty to control bleeding self-aid . – tourniquet for hemorrhage control

– Tourniquet – proximal to the bleeding site,

– over the uniform, tighten,

–move the casualty to cover.38

Care Under Fire

• Prosecuting the mission and caring for the casualties may be in direct conflict.

• What’s best for the casualty may NOT be what’s best for the mission.

• When there is conflict – which takes precedence?

Care Under Fire• Suppression of hostile fire

minimize the risk of both new casualties additional injuries already injured

• The firepower – essential to tactical fire superiority.– medical personnel – the casualties themselves may be

• The best medicine on the battlefield is Fire Superiority.

40

The Number OneMedical Priority

Early control of severe hemorrhage is critical.– Extremity hemorrhage is the most frequent

cause of preventable battlefield deaths.– Over 2500 deaths • Vietnam • extremity wounds.

– Injury to a major vessel can quickly lead to shock and death.

– Only life-threatening bleeding warrants intervention during Care Under Fire.

41

Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. These casualties had no other injuries.

Vietnam. Medical Evacuation. Marines of Company E, 2nd Battalion, 9th Marines, while under heavy firefight with NVAs within the DMZ on Operation Hickory III, are carrying one of their fellow Marines to the H-34. 07/29/1967

Vietnam

43

Tourniquets – Kragh et alAnnals of Surgery 2009

• Ibn Sina Hospital, Baghdad, 2006 • Tourniquets are saving lives on the battlefield • 31 lives saved in this study by applying tourniquets prehospital rather than in the ED• Author estimates 2000 lives saved with tourniquets in this conflict (Extrapolation provided to MRMC)

Unclassified

C-Spine Stabilization

Penetrating head and neck injuries do not require C-spine stabilization

–Gunshot wounds (GSW), shrapnel

– In penetrating trauma, the spinal cord is either already compromised or is in relatively less danger than would be the case with blunt trauma.

44

4545

Berator

46

Tactical Field Care Guidelines

2. Airway Managementb. Casualty with airway obstruction or impending airway

obstruction:- Chin lift or jaw thrust maneuver- Nasopharyngeal airway- assume position that best protects the airway- Place unconscious casualty in recovery position.- If previous measures unsuccessful:

- Surgical cricothyroidotomy (with lidocaine if conscious)

47

IV Access – Key Point

• NOT ALL CASUALTIES NEED IVs!– IV fluids not required for minor wounds– IV fluids and supplies are limited – save them

for the casualties who really need them– IVs take time– Distract from other care required–May disrupt tactical flow – waiting 10 minutes

to start an IV on a casualty who doesn’t need it may endanger your unit unnecessarily

48


Shock management6. Fluid Resuscitation

• Assess for hemorrhagic shock; – altered mental status (in the absence of head injury)

– weak or absent peripheral pulses • best field indicators of shock.

Not in shock:

- No IV fluids necessary

- PO fluids permissible if conscious and can

swallow

49


Shock management

6. Fluid Resuscitation

b. If in shock:

- Hextend, 500ml IV bolus

- Repeat once after 30 minutes if still

in shock.

- No more than 1000ml of Hextend

50

Hypotensive Resuscitation

Goals of Fluid Resuscitation Therapy• Improved state of consciousness (if no TBI)• Palpable radial pulse–Corresponds roughly to systolic blood

pressure of 80 mm Hg• Avoid over-resuscitation of shock from torso

wounds.• Too much fluid volume may make internal

hemorrhage worse by “Popping the Clot.”

51

Pulse Oximetry Monitoring

• Pulse oximetry – – heart rate – percent of oxygenated blood (“O2 sat”)

• Sea Level– 98% or higher

• 12,000 feet• 86% = normal

Resuscitation

Resuscitation

• Damage Control Surgery (DCS)– Control of hemorrhage– Shunt vascular injury– Staple bowel injuries– Stabilize fractures– Vac Pac Dressing

• Follow up surgery– 24-48 hours– Definitive vascular care– Repair bowel injuries– Assure hemostasis

Does NOT have tobe done in same hospital

Damage Control Resuscitation• Replace what is lost• Whole blood– PRBC– Plasma– Platelets– Cryoprecipitate

• Ratio– 1 PRBC : 1 plasma : ?– 1 platelets : 1 Cryoprecipitate – No crystalloid

Damage Control Resuscitation

Military – Holcomb, Rhee and others

Civilian – Duchesne & others

Damage Control ResuscitationPrehospital Rural Care

Restricted Fluid Resuscitation (Mattox)

Indicators - Pulse character & mentation (Holcomb)

Short transports - Minimal Crystalloid

Future

Long transports - colloid plus hypotensive care

Resuscitation

Replace what is lost

WITH

what is lost

Resuscitation

• Blood is lost – replace blood

• Crystalloid is lost – replace crystalloid

• Presser agents are lost – replace pressor agents

What happened to blood?

Military uses it why can’t we?

Next best option- Reconstitute blood -

• Packed Red Blood Cells

• Plasma– Frozen

– Liquid

• Platelets

• Cryoprecipitate

Where is this available?

Uncontrolled hemorrhageHypotensive, hypovolemic

Uncontrolled hemorrhageHypotensive, hypovolemic

Raising blood pressure Pressure Gradient

blood loss blood pressure

*********************************

Add more fluids Hematocrit

Oxygen delivery Anaerobic metabolism

Energy (ATP) Production

Raising blood pressure Pressure Gradient

blood loss blood pressure

*********************************

Add more fluids Hematocrit

Oxygen delivery Anaerobic metabolism

Energy (ATP) Production

FatalCycle

Fluid administrati

on without

easy vessels

William Blaisdale, MDScudder Orator 1982

Sternal Screw for IV fluids

Alex Haller, MDScudder Orator 1994

Intraosseous IV fluids in pediatric patients

Walter Estell Lee, MD Scudder Orator 1941

Intraosseous fluids done by Tocatins in Philadelphia.

The needles were 15 gauge and initially made by

George Piling Company in Philadelphia

Intraosseous Fluid Administration

• Tibia

• Sternum

• Humerus

FAST - 1

B I G

EZ - IO

Cook

Success rates95%

90 seconds

Intraosseous Fluid Administration

Hemorrhage Control

Hemorrhage control

• Compression bandages

• Tourniquets

• Hemostatic agents– Cutaneous/local

– Systemic

• Factor XIV

Where is factor XIV available?

TourniquetsDo they belong in civilian

EMS ?

YES!

Tourniquets

• Why were we wrong?– Don’t confuse me with no data, my mind is

made up?– The data does not support their use– Data? What data?–Well if you put them on, that determines the

level of the amputation. They distal extremity will die.

– If they are too tight, the artery will be damaged.– If they are too tight, the nerve will be damaged.

Hemorrhage control

• Iraq – most common cause of preventable death– 10% of deaths distal to axilla or groin

• Compressible– Tourniquet-able

– Non-tourniquet-able

• Non-compressible Champion & HolcombSOMA 2005

Factor XIV• Suture

• Ligature

• Hemostat

Can be applied in the ORTherefore the importance to deliver the patient

to the Hospital with a trauma team that can and will immediately place the patient in an OR

Open the abdomen/chestand

FIX THE HEMORRHAGE

Tourniquet

• Triangle bandage & windless

• Commercial devices

• Blood pressure cuff

• Used in military since 1674

Swartz , Surg ‘58

Albert Sidney JohnstonGeneral, Confederate Army

• Gun shot would to thigh

• Blood ran down into boot

• Directed medic to another solder

• Exsanguinated

• Tourniquet would have saved his life

• Reportedly in his pocket.

TourniquetsClinical experience

• Kandahar AFB - 4 months (2006)• 134 patients treated• 6 patients – 8 tourniquets• Lives saved = 4 patients – 5 tourniquets• Misuse = 1 venous tight only => Bleeding• Prolonged use = 1 (4 hours) no complications

Tien et alJACS ‘08

TourniquetsClinical application

• Combat operations => delay in transport

• 16 hours = no complications

• Patient life saved

Kragh et alJ Ortho Trauma ‘07

TourniquetsClinical Experience

• UK Joint Trauma Registry

• 66 months

• 1375 patients

• Tourniquets = 70 (5%) patients

• Tourniquets used = 107

• 2 or > = 24%

• 87% survival Brodie et alJR Army Med corps ‘07

TourniquetsClinical Experience

• Vietnam KIA exsanguination = 9%• OTF 31st Combat Support Hospital• 12 months = 3444 patients• Major vascular, traumatic amputation, tourniquet• 165 patients • Prehospital tourniquet = 67 (TK)• Severe extremity injury no tourniquet = 98 (No TK)• Bleeding control = TK=83% vs No TK-60%• Secondary amputation = TK=6% vs No TK =9%• Potentially preventable deaths = 57%

Beekley et alJ Trauma ‘08

Tourniquets

Clinical Experience

• Israeli Defense Forces

• 550 patients

• 91 prehospital tourniquets (16%)

• Injury to application 15 minutes

• Ischemia time = 83 minutes

• 78% effectiveLakstein et alJ Trauma ‘03

Special Operation Forces Tactical Tourniquet

SOFT-T

Combat Applied Tactical Tourniquet

CATT

Application of CATT

Emergency Medical TourniquetEMT

85

Cravat/Windlass

Tourniquets

86

Tourniquets in WWIIWolff AMEDD J April 1945

“We believe that the strap-and-buckle tourniquet in common use is ineffective in most instances under field conditions…it rarely controls bleeding no matter how tightly applied.”

Hemostatic Agents

• QuikClot

• Hemcon

• Wound Stat

• Combat Gauze

Mechanism of action

• Absorb water– QuikClot

– Combat Gauze

• Increase clotting– Hemcon

Hemostatic Agents

• Complications

• Vascular damage –WoundStat

• Local hypothermia– QuikClot

• Difficulty in placement– All powder/granular agents

90Courtesy Dr. Bijan Kheirabadi

Combat Gauze

• 3 inch x 4 yard roll of gauze

• Impregnated with kaolin

• Material that causes blood to clot

Kaolin is a white clay used for many purposes, among which is the medication Kaopectate.Also eaten by the ‘clay eaters’ of Georgia and other rural areasTo improve digestion

Factor XIV

Delivery of the patient to the correct hospital is the

MOST IMPORTANTstep EMS can take

Field Hemorrhage Control Non-combat patient care

Direct hand pressure

Pressure Bandage

Torso ExtremityHemostatic Agent Tourniquet

HospitalYes

No

Hospital

Hemorrhage continues

94


2. Airway Management

a. Unconscious casualty without airway obstruction:

- Chin lift or jaw thrust maneuver

- Nasopharyngeal airway

- Place casualty in recovery position

Open chest

wound

Open chest wound

• Re-establish ventilation

• Air movement out airway not chest wall– Close open hole

• Relive compartment syndrome– Needle into pleural cavity

– Needle not stop in chest wall

– 8 cm

– 14 gauge

Open Pneumothorax Mgt

Frank, I finally got to test the open pneumothorax treatment algorithm. We had a SWAT call-up, our second of the day, with a guy threatening to kill himself with two hostages. He finally shot himself at point blank range in the left chest with a .357 magnum hollow point. I was only about 30 feet away and got to him immediately and sure enough he had a hole as big as a golf ball in his left chest. He had an open pneumo so I put my hand over it and it stopped blowing. I asked the medic for some vaseline gauze and he handed me, yes, an Asherman chest seal. Of course it did not stick, but we used it until we got him intubated and then I put on a EKG pad which worked great. He is now in the OR getting whatever fixed. We had another GSW at the same time through the back with no exit who DOW. Now I have to try to get all the blood out of my uniform. See you in a few days, Semper Fi, Mel

98

Pain Control

Pain Control When Able to fight:• Mobic and Tylenol are the medications of

choice• Both should be packaged in a COMBAT PILL

PACK and taken by the casualty as soon as feasible after wounding.

99

Pain Control – FentanylLozenge

Pain Control - Unable to Fight• If casualty does not otherwise

require IV/IO access

– Oral transmucosal fentanyl citrate, 800 µg (between cheek and gum)

– VERY FAST-ACTING; WORKS ALMOST AS FAST AS IV MORPHINE

– VERY POTENT PAIN RELIEF

Trauma Center

Is this a gadget too?

Hemorrhage control timelines

12 10 12 10 25 25 15 10 20

12 10 30 1000125

0 50 100 150

Minutes

CommunityHospital

TraumaCenter

Access

Scene

transport

ED

Surgeon

OR staff

Ready OR

to OR

Hemorrhage control

68 minutes

Indications to bypassSevere trauma

• Physiologic reasons– Shock– Airway & ventilation– Major Hemorrhage

• Anatomic– Penetration - head, neck, torso, proximal limbs– Crush torso– Major fractures

• Mechanism of injury– Major vehicle damage– Fall from height

Failure to fly syndrome

Contra-indications to bypass4Time

• Technical difficulties– Inability to maintain airway

• BVM is not working• Separation of esophagus & trachea required

– Intubation in the field unsuccessful or not trained• Surgical airway necessary

– Uncontrollable hemorrhage• External• Internal

• Critical conditions– Cardiac Arrest– Ventilation compromise

• Tension pneumothorax• Major fail chest

• Medical Control decision – Shock– Transportation time > 50 minutes

Contra-indications to bypass2

Mechanism of injury• How important is it ?

• > 75 % go home within 6 hours

• 1 year– 641 patients in AR

– 2 deaths

– 59 operations

– 120 admissions

Plan for

Louisiana Trauma Care System

Stages of Medical Care

• Care Under Fire

• Tactical Field Care

• Tactical Evacuation

• Field Hospital– FST

– CSH

• MedEvac

• Definitive medical care

• Echelon I

• Echelon II

• Echelon III

• Echelon IV

• Echelon V

Louisiana Echelon for Trauma Care• Echelon I– EMS system– ALS care– State wide communication

• Echelon II– Critical Access Hospitals– <25 beds– ED Provider in-house– Physician available

• Echelon III– Rural Hospitals 25-60 beds– ED physician staffed– Surgeon available– Orthopedics available– OR staffed– Blood bank

Louisiana Echelon for Trauma Care

• Echelon III– Level III trauma center– Neurosurgeon available– OR rapid access 24 hours– 24 hour blood bank– CT, MRI– Interventional Radiology

• Echelon IV– Level II/I Trauma Center– In house OR– 24 hour everything – 15 minutes– ED physicians & Surgeons dedicated to patient care

SE Louisiana Trauma systemField to Trauma Center

• Physiologic reasons– Shock– Airway & ventilation– Major Hemorrhage

• Anatomic– Penetration - head, neck,

torso, proximal limbs– Crush torso– Major fractures

• < 50 minutes

Rural Trauma Organization System

Patient care movement

• EMS triage– Hospital best able to care for patient

• Minor - closest hospital

• Major

– level III

–DCS

–DCR

• Serious – Trauma Center

–ACS anatomical

–ACS physiological

Rural Trauma Organization System• Trauma patient care

• Critical Access– No serious patients via EMS

– Treat and release

– Understand trauma if walk-in

• Rural– DCR

– DCS

– Rapid assessment & move

• Trauma Center (III, II, I)

• Totally prepared

Rural Trauma Organization System• Trauma Educational System– Critical Access

• RTTCS

• ATLS ?

– Rural• ATLS

• DCR/DCS

– Level III• ATOM

• DCS/DCR

– Level II, I• Teaches above

Rural Trauma Organization System

• Trauma Transportation System

• EMS triage

• ACS Anatomic & Physiologic– Trauma center (within 50 minutes)

– Rural hospital• DCS/DCR

• Immediate transfer to Trauma Center

Tulane Center for Trauma Life Support Education

Regional Medical Center

Regional Medical Center

Acute Access

Hospital

Acute Access

Hospital

Acute Access

Hospital

Acute Access

Hospital

Acute Access

Hospital

Acute Access

HospitalRegional Medical Center

Acute Access

Hospital

Acute Access

Hospital

Acute Access

Hospital

EMS triage Hospital Triage

http://files.vector-images.com/clipart/ambulance1.gif









Trauma Education SystemATLS/PHTLS

Trauma Center

Level III Level III Level III

RuralCritical Access






Trauma Education SystemATOM

Trauma Center








Trauma Education SystemRTTDC

Trauma Center








Summary• Re-assess rural trauma patients needs

• Re-assess rural trauma care– EMS

– Critical Access hospitals

– Rural Hospitals

– Trauma Center

• Re-assess Rural Trauma Training– EMS

– Critical Access hospitals

– Rural Hospital

– Trauma Center

• Re-assess rural trauma transport

• Develop Rural Trauma Patient Care System

PHTLS 6th edition7th edition 2010/11

• Basic principles of patient care– non combat situation

• Tactical principles of patient care– Situation Assessment & management

• Combat situation – Scene– Safety,– Combat contingencies vs non-tactical contingencies

– Patient assessment & management• Unique Primary assessment & care requirements • Unique Secondary assessment & care requirements

Tactical Edition Tactical CombatTactical CombatCasualty CareCasualty Care

committeecommittee

A New Decade

&

A New Approach

to

Rural Trauma Care

Change your mind set

Develop a plan

121

Disarm Individuals with Altered Mental Statues

• Armed combatants with an altered state of consciousness may use their weapons inappropriately.

• Secure long gun, pistols, knives, grenades, explosives.

• Common causes of altered mental status are Traumatic Brain Injury (TBI), shock, and pain medications.

• “Let me hold your weapon for you while the doc checks you out”

Transportation of dead patients is bad

• ~ 40% increased crash when EMS is traveling lights & siren

• Patients who are dead need to be pronounced via radio

• ACS & NAEMSP have a combined policy statement JACS March 2003

• Stop it !!!

Committee on

CoTCCC

Open Pneumothorax Mgt

FrankWhat Mel isn't telling you is that he saved this guys life. I happenedto be in the bay when they got here. The patient is recovering followinga Left upper lobectomy and chest wall reconstructionWould echo Mel's commentsEKG/Defib pad yesAsherman noj

Documents

The Importance of Tourniquets