Wound Care Management During a Mass Casualty Emergency: an Evidence-Based Approach for Triage, Tourniquets, Wound Packing, and Chest Seals

Wound Care Management during a Mass Casualty Emergency: An Evidence-Based Approach for Triage, Tourniquets, Wound Packing, and Chest Seals

The Athletic Trainers Ability to think beyond the basics On Field or Off, you may face the event Introductions

• Mr. Edward Strapp, TP-C/FP-C, NRP, ATC – Trooper/Flight Paramedic, Maryland State Police – Rotational Athletic Trainer, US Ski and Snowboard Provider Disclaimer

• In compliance with continuing education requirements, all presenters must disclose any financial associations with the manufacturers of commercial products, supplies of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use.

• Event committee, and the presenters for this seminar do not have financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters.

• This presentation does not involve the unlabeled use of a product or product under investigational use. • There was no commercial support for this activity.

***Warning*** Some pictures may be graphic in nature. Presenter Conflict

• No Conflict

• The views expressed in these slides and the today’s discussion are ours

• Our views may not be the same as the views of our company’s clients or our colleagues

• Participants must use discretion when using the information contained in this presentation Learning Objectives • Understand the need for the rapid identification and management of gross bleeding in the trauma patient. • Identify the phases of shock and the physiological changes. • Identify the rationale for the application of different advanced wound care interventions. Learning Objectives • Acquire the skills needed for tourniquet and wound packing interventions. • Learn how to adapt common sports medicine equipment for tourniquet applications. • Develop a go bag option for management of acute trauma patients. This is why I am here March 20, 2016

• Northwestern Indiana • A school bus carrying a high school basketball team ended up on its roof • The bus driver swerved after getting sideswiped by another vehicle whose driver had spilled coffee. Background Athletic Competition

Local Event Coverage

Bus Trips

Active Shooters Background

• When tragedy strikes anywhere in this nation, the willingness and capability of everyday citizens to take action instead of being passive bystanders can mean the difference between life or death. • With very little training and equipment, the individuals closest to the scene of an accident or mass casualty situation can control bleeding until first responders arrive to take over treatment. JOE BIDEN Vice-President of the United States (Hartford Consensus) Why this topic?

“As the profession of athletic training continuously evolves and ATs practice in various settings, these healthcare providers must have the ability to maintain a high level of preparation and proficiency in all aspects of immediate and emergency care. This ability is critical to minimizing risk to the injured participant.” – BOC, 2015 According to the National Trauma Institute, hemorrhaging is responsible for almost 35% of prehospital deaths and 40% of deaths in the first twenty-four hours after a traumaticArmy considers event andhemorrhage the U.S. as the number one preventable cause of death on the battlefield. When Direct Pressure Isn’t Enough

• Everything has advantages and disadvantages • Each option can be implemented in a variety of situations There is no “Gold Standard”

Stopping blood loss in a severe hemorrhage is really the Gold Standard Critical Interventions • Take care of yourself • Take care of others – Triage – Critical Interventions • Use others to help – Give everyone that is injured a buddy Initial Care

Where do I focus my Attention: – ABCD – Depending on Triage Criteria – Depending on Resources

• Is Airway management more important? ABC • Is Gross Bleeding most important? Circulation • Evaluation and Recognition is Key

• Basic bandaging of soft tissue injuries is often overlooked by first responders. • These basic concepts are critical to the casualty’s survival. Click through Hemorrhage and Shock Hemorrhage and Shock • What happens when you start to bleed? Understanding Shock

• In 1862 – Samuel Gross described shock as the "rude unhinging" of the machinery of life.

• Inadequate Tissue perfusion with oxygenated blood

• Failure of adequate tissue oxygen delivery and utilization during shock can lead to organ dysfunction and death. Hemorrhage and Shock • What happens when you start to bleed? – it depends on how much blood you lose Hemorrhage and Shock Bleeding from extremity wounds

• How quickly this occurs obviously depends on where and how the damage occurs, but…

• Bleeding out and death can occur in 3 to 5 minutes in the worse case. Recognizing Shock • May be difficult to judge blood loss in an accident scene • Look for Signs and Symptoms – mental status – radial pulse Recognizing Shock • mental status • radial pulse • heart rate (HR) • blood pressure (BP) • respiratory rate (RR) • likelihood of death Normal Adult Blood Volume

5 Liters Blood Volume 500 cc Blood Loss

4.5 Liters Blood Volume 500 cc Blood Loss • Mental state – alert • Radial pulse – full • Heart rate – normal or somewhat increased • Systolic blood pressure – normal • Respiratory Rate – normal • Is he going to die from this? NO 1000cc Blood Loss

4.0 Liters Blood Volume 1000 cc Blood Loss • Mental state – alert • Radial pulse – full • Heart rate – Slightly Elevated 100 + • Systolic blood pressure – Normal if Lying, • Respiratory Rate – normal • Is he going to die from this? NO 1500cc Blood Loss

3.5 Liters Blood Volume 1500cc Blood Loss • Mental state – alert but anxious • Radial pulse – may be weak • Heart rate – 100+ • Systolic blood pressure – may be decreased • Respiratory rate – 30 • Is he going to die from this? PROBABLY NOT 2000cc Blood Loss

3.0 Liters Blood Volume 2000cc Blood Loss • Mental state – confused/lethargic • Radial pulse – weak • Heart Rate – 120+ • Systolic blood pressure – decreased • Respiratory rate – >35 • Is he going to die from this? MAYBE 2500cc Blood Loss

2.5 Liters Blood Volume 2500cc Blood Loss • Mental state – unconscious • Radial pulse – absent • Heart rate – 140+ • Systolic blood pressure – markedly decreased • Respiratory rate – over 35 • Is he going to die from this? PROBABLY Normal Adult Blood Volume • Approximately 5 liters of blood in an average size adult • Casualty can bleed out in as little as 3 minutes

Controlling Bleeding Direct Pressure or Pressure Bandage

Tourniquet

Wound Packing

Clotting Agents Wound Patterns

Accidents and Injuries

Law Enforcement and Some Assaliants

General Citizens

Tourniquets

“Because the rate of complications is low and the rate of hemostasis is high, first aid providers may consider the use of a tourniquet when standard first aid hemorrhage control does not control severe external limb bleeding” – Singletary, 2015 Major Blood Vessels

• Major blood vessels can be found on the medial side and high on the extremities.

• These areas are the best place to control massive bleeding from extremities. Distal to Proximal Most venous hemorrhages or simple arterial hemorrhages from the distal third of an extremity are generally well controlled with an absorbent bandage placed direct over the wound Direct Pressure Pressure Dressing Sharpe D, Barneby E, New Approaches to the management of traumatic external hemorrhage. J trauma. 2011:13:47-55 Distal to Proximal

• The Closer an artery is to the left ventricle, the great the force exerted on the vessel’s wall. The more proximal an arterial is to the heart, the greater amount of force needed to tamponade the vessel and stop hemorrhage 120 lbs of pressure to occlude a proximal to a femoral artery hemorrhage • Proximal Arterial Hemorrhage is life threatening

Blaivas M, Shiver S, et al. Control hemorrhage in critical femoral or inguinal penetrating wounds- An Ultrasound Evaluation. Prehosp Disaster Med. 2006;21(6):379-382 Distal to Proximal • Mangled Extremities and especially junctional wounds must be immediately packed, preferably with gauze impregnated with hemostatic agent

Groin, Axilla, Shoulder, and Neck

Bulger, E, Snyder D et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons committee on Trauma. Prehosp Emerg Care. 2017;18(2):163-173 The Bottom Line...

Is it bleeding a little or a lot? When in doubt, use a tourniquet. The Military has studies bleeding control extensively and concluded that early tourniquet application, before the onset of shock, saves lives with little to no associated complications

In 2009 Kragh, Littrel, Jones et all completed a study of 499 patients with 862 tourniquets on 651 limbs….. Direct Pressure on Wound Site Hemorrhage Control

• Assess the situation. • Expose the wound. • Attempt to control the bleeding with direct pressure or a pressure dressing. Bandage Options

Or what is handy!

Tourniquets—Use what’s handy

Commercial tourniquets Improvised tourniquet Bleeding Control • Control hemorrhage using a tourniquet or an Emergency Trauma Dressing (ETD; Israeli bandage).

Emergency Trauma Dressing Combat Application Tourniquet Tourniquet

• Adaptive • Commercial – CAT – SOF-T – SOF-T Wide – Swat T CAT (Combat Application Tourniquet) Tourniquet CAT Tourniquet CAT Thigh/2 person

Using The Friction Adaptor SOFTT (Special Operations Forces Tactical Tourniquet) Screw

Triangular Windlass Clip

Triangular Clip Tourniquet SOF-T SOF-T (Wide) Tourniquet Swat T Application

• 2-3 inches above the wound

• Watch for other sites of bleeding » above the wound

• Multiple bleeding sites » proximal application Application

• Should be tight enough to stop bleeding • The tourniquet should never be placed • Joint (knee or elbow) • Over an impaled object • Extremity should be exposed • Document application time • Write on patient! Application

• A prehospital tourniquet should not be removed by EMS personnel without authorization from their EMS Sponsor Hospital/Medical Direction • If application exceeds six hours, removal should only be done by the physician providing definitive care Rules for Application • Over clothing, as high and tight as possible when your in a mass casualty. • Directly on Skin, 2-3 Inches over the wound when your in a controlled environment. • Take note of tourniquet time. Various Options for Homemade Tourniquets REMEMBER… • Tourniquets can be used for: – Life threatening extremity hemorrhage –When direct pressure or pressure dressing can not be applied Tourniquet Mistakes • Not using one when you should • Using a tourniquet for minimal bleeding • Not making it tight enough – the tourniquet must eliminate the distal pulse • Not using a second tourniquet if needed • Waiting too long to put the tourniquet on • Periodically loosening the tourniquet to allow blood flow to the injured extremity Reassessment

• Be sure to reassess all interventions: – After any movements. – During patient reevaluation. • Consider using a second tourniquet for any continued uncontrolled bleeding. • Perform a rapid full body exam to rule out any additional uncontrolled bleeding.

Non-Extremity Massive Bleeding

• Tourniquets are ineffective in the following areas: – Neck – Armpit – Groin • Treatment for these areas includes: – Direct pressure – Pack wound, if applicable – Pressure dressing

Pressure Dressing

• Emergency trauma dressing: – Maintains pressure created by itself. – Used in conjunction with hemostatic dressing. – Direct pressure in the armpit, groin or neck. Packing Gauze

• Bleeding can be controlled utilizing wound packing techniques and direct pressure: ➢Kerlix – rolled gauze ➢Z-Pak – folded gauze Wound Packing

• When a tourniquet won’t work • Expose the wound • Locate the bleeder • Place FOCUSED direct pressure • Pack the wound

Consider Hemostatic Dressings Wound Packing Expose & Identify

• Expose the wound – Clear clothing – Spread the wound – Clear out clot and blood within the wound Expose & Identify

• Open clothing around wound

• If possible, remove excess pooled blood from the wound while preserving any clots already formed in the wound

• Locate source of most active bleeding Expose & Identify

• Locate the offending vessel – Look and Feel – Find the Vessel Wound Packing

• Apply Focused Direct Pressure – Thumb or 2 Fingers, DIRECTLY on the vessel Wound Packing

• Pack Combat Gauze tightly into wound and directly onto bleeding source

• More than one gauze may be required to stem blood flow

• Combat Gauze maybe repacked or adjusted into the wound to ensure proper placement Wound Packing • Pack the wound – Don’t release Pressure – Swapping fingers or Side by each – Pack all voids

Add, Add, Add and then Add some more Apply Direct Pressure

• Quickly apply pressure until bleeding stops

• Suggested time is 2 to 3 minutes of continuous contact

• Reassess for proper and effective placement

• Combat Gauze may be repacked if initial use fails to provide hemostasis Apply Direct Pressure Bandage Over Wound • Leave Combat Gauze in place • Wrap to effectively secure the dressing in the wound Bandage Over Wound

We can’t Pack EVERYTHING • Penetrating Chest Trauma ○ There is nothing to pack beyond the rib cage • Blunt or Penetrating Trauma to the chest increases your suspicion •Air Hunger or Air Starving “I Can’t Breath” Open Pneumothorax

• •Penetrating mechanism – May be “sucking” or “bubbling chest wound

• Respiratory distress – Mild to severe

Optimal method of field management has not been demonstrated Sucking Chest Wound Treatment

• ABC’s with c-spine control as indicated • High Flow oxygen • Listen for decreased breath sounds on affected side • Apply occlusive dressing to wound • Notify Hospital and ALS unit as soon as possible Treatment

• Asherman Chest Seal makes good Flutter Valve. • Gloved Hand • Occlusive Dressing • Plastic Bag Improvise and Overcome

You have options Hemostatic Agents Mechanisms of Actions • Mucoadhesives – Hemcon bandage, Chitogauze, Celox gauze • They become sticky, the shrimp shell based products, primarily chitosan based, and work by cross-linking cellular blood components to form a mucoadhesive barrier. Mechanisms of Actions • Factor Concentrators – Quick Clot • Rapidly absorb water from the blood at the injury site, which concentrates platelets and other intrinsic clotting factors resulting in faster clot formation. Mechanisms of Actions

• Procoagulant supplements – Combat Gauze

• Procoagulant supplements deliver additional clotting factors to the wound which then combine with clotting factors already present. Together, these clotting factors increase the rate of blood clot formation. Mechanisms of Actions • A side-by side comparison of four hemostatic dressings – in an animal model of arterial hemorrhage • Demonstrated survival superiority associated with the use of Combat Gauze™

(Kheirabadi, Scherer, Estep, Dubick, & Holcomb, 2009). ******** NOTES ******** • Combat Gauze • Quick Clot • Wound Sat (Granules) • Celox • Hem Con • Chitosan vs kaolin • Pro-coagulant actually causes the blood to clot What do you need? Create a Go Bag Can I improvise – Cat Tourniquets • Tourniquets – Chest Seals – Exercise Bands – Pressure Dressings – Wide “string” – Clotting Agents • Chest Seals – Plastic Bags – Ice Bags – Saran Wrap – Tape • Pressure Dressings – ABD Pads and Elastic Wraps At Minimum, kit should contain:

Tourniquet- Commercial or Improvised Pressure Bandage (Ace and Gauze) Plastic patch or zip lock bag for use with Tension pneumothorax Tape of some kind Gloves Improved First Aid Kit Emergency Trauma Dressing 4” Kerlix (Israeli Bandage)

Combat Application Nasopharyngeal Tourniquet (CAT) Airway (NPA)

14g 2” Tape Needle

MOLLE Type Exam Gloves Pouch (4) Weight: 1.08 lbs. Cube: 128 ci

CMAST 100 What do you need………. …….. Something you have access to

…….. Something you are comfortable using

…….. Something you can use in a hurry

…….. Something you can Get/Create/Replace QUESTIONS? Thank you, Have a great day! Sources

• Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., Sanddal, N. D., Butler, F. K., Fallat, M., Taillac, P., White, L., Salomone, J. P., Seifarth, W., Betzner, M. J., Johannigman, J., & McSwain, N. Jr. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173. doi:10.3109/10903127.2014.896962 • Granville-Chapman, J., Jacobs, N., & Midwinter, M. J. (2011). Pre-hospital haemostatic dressings: A systematic review. Injury, 42(5), 447–459. doi:10.1016/j.injury.2010.09.037 • Burkatovskaya, M., Tegos, G. P., Swietlik, E., Demidova, T. N., P Castano, A., & Hamblin, M. R. (2006). Use of chitosan bandage to prevent fatal infections developing from highly contaminated wounds in mice. Biomaterials, 27(22), 4157–4164. doi:10.1016/j.biomaterials.2006.03.028 • Kozen, B. G., Kircher, S. J., Henao, J., Godinez, F. S., & Johnson, A. S. (2008). An alternative hemostatic dressing: Comparison of CELOX, HemCon, and QuikClot. Academic Emergency Medicine, 15(1), 74-81. doi:10.1111/j.1553-2712.2007.00009.x • Li, J., Cao, W., Lv, X. X., Jiang, L., Li, Y. J., Li, W. Z., Chen, S. Z., & Li, X. Y. (2013). Zeolite-based hemostat QuikClot releases calcium into blood and promotes blood coagulation in vitro. Acta Pharmacologica Sinica, 34(3), 367-372. doi:10.1038/aps.2012.159 • Rall JM, Cox JM, Songer AG, et al. Comparison of novel hemostatic gauzes to QuikClot Combat Gauze in a standardized swine model of uncontrolled hemorrhage. J Trauma Acute Care Surg. 2013; 75(2 Suppl 2):S150-6. • Satterly S, Nelson D, Zwintscher N, et al. Hemostasis in a noncompressible hemorrhage model: An end-user evaluation of hemostatic agents in a proximal arterial injury. J Surg Educ. 2013;70(2):206-11. • Watters JM, Van PY, Hamilton GJ, et al. Advanced hemostatic dressings are not superior to gauze for care under fire scenarios. 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