# Hemorrhage Control



## Molon Labe (Nov 6, 2008)

I would like to provide the most current information regarding hemorrhage control. This information is based on the evidence coming out of Iraq and Afghanistan in treating our soldiers.

The Committee on Tactical Combat Causality Care has revised their recommendations for the 2008 Guidelines. See the info below.

2008 TCCC Updates
The 2008 TCCC Update has a Chart on page 21 showing the major Hemostatic Agents

Here are the important notes for the changes in Hemostatic Agents in TCCC. This is from a memo from Capt. Frank Butler the Chairman of CoTCCC.

2. A number of new hemostatic agents have recently become available. These new agents have undergone testing both at the U.S. Army Institute for Surgical Research (USAISR) and the Naval Medical Research Center (NMRC). The findings from these studies were presented to the Committee on TCCC (CoTCCC) on 1 April 2008. Three different swine bleeding models were used: a 6mm femoral artery punch model at USAISR and both a 4mm femoral artery punch model and a femoral artery/vein transaction model at NMRC. Both the NMRC and the USAISR studies found Combat Gauze and Woundstat to be consistently more effective than the hemostatic agents HemCon and QuikClot previously recommended in the 2006 TCCC guidelines. No significant exothermic reaction was noted with either agent. Celox was also found to outperform the current agents, although it performed less well than WoundStat in the more severe USAISR model, where 10 of 10 Woundstat animal survived, 8 of 10 Combat Gauze animals survived, and 6 of 10 Celox animals survived. The reports detailing this research will be available shortly from USAISR and NMRC.

3. In light of these findings, the CoTCCC voted to recommend Combat Gauze as the first line treatment for life-threatening hemorrhage that is not amenable to tourniquet placement. Woundstat is recommended as the backup agent in the event that Combat Gauze does not effectively control the hemorrhage. The primary reason for this order of priority is that combat medical personnel on the committee expressed a strong preference for a gauze-type hemostatic agent rather than a powder or granule. This preference is based on field experience that powder or granular agents do not work well in wounds where the bleeding vessel is at the bottom of a narrow wound tract. A gauze-type hemostatic agent is more effective in this setting. Combat Gauze was also noted to be more easily removable from the wound site at the time of surgical repair. Woundstat might, however, be very useful in circumstances where the first-line agent has been ineffective or where the characteristics of the wound make a granular agent preferable.

You can get Combat Gauze and WoundStat from North American Rescue Products or Chinook Medical
The disadvantage to Combat Gauze and WoundStat is cost. Both are between $30 and $40 per package.

If you want Celox I would go Calvery Arms

I would stay away from QuickClot as the new versions just do not work as well as Combat Gauze, WoundStat, or Celox. In fact in the USAIR and NMRC study referenced in the above memo, 0 out of 10 animals survived with QuickClot. But if you want it, try L.A. Police Gear

Before you set out to buy Hemostatic Agents be sure you understand the proper wound management and packing. Direct pressure is the first line treatment. The American College of Surgeons and the Pre-Hospital Trauma Life Support Guidelines no longer recommend elevation and pressure points for severe bleeding. There is no evidence that these techniques work and you may be wasting precious time. It is possible to bleed out from a femoral artery injury in as fast as 3 minutes. If direct pressure does not work, for extremity trauma go directly to a tourniquet. *No they will not lose the limb.* See the links below for the studies. For bleeding that is not amenable by a tourniquet such as a high femoral artery injury go to your hemostatic agents. Apply the agent and pack the wound with gauze and apply constant pressure for 2-3 minutes. Wrap with compression bandage to keep pressure on the wound.

*The most important step is to pack the wound and fill the void. Go HERE scroll down and click on Videos to view proper wound packing.
*
Like many traditional beliefs, the tradition is strong, but the evidence is weak. Here is the evidence supporting tourniquet use

February 2008 Journal Of Trauma - Tourniquet Use
This is an overview of the article. I have the PDF of this that I can email if you would like

Here is an article from JEMS
Tourniquet First

Another JEMS Article
Return of the Tourniquet

If you are looking for the best Tourniquet available look for the C-A-T or SOF Tourniquet both are approved by the CoTCCC for use by the military and both provide complete blood flow stoppage in the femoral artery. Both can be placed one handed and just plain work. The C-A-T is the current issue to US Special Operations Soldiers.

The nuts of it is Tourniquets are very effective lifesaving tools that have very few side effects, even when placed incorrectly and left in place for several (greater than 2) hours. Tourniquets are used in surgery everyday with no complications. We must retrain ourselves and remember that Tourniquets work and are safe, just ask the many soldiers who are alive today because of one.

Take Care


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## Blueberry556 (Nov 14, 2008)

*Tourniquets*

*Cavalry Arms* also makes their own tourniquet. Drawing on their vast experience in molded nylon products, they designed their tourniquet to be light like a CAT, but exceptionally strong like the SOF. It has a flat windlass and D-ring made of a nylon similar to a Glock and is self-applicable with one hand on any extremity. It can be seen here:

TheTacticalMedic.com

eBay Store


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## Fn/Form (Nov 6, 2008)

What do you all think about the NATO (webbing/aluminum bar/rings) tourniquet compared to the CAT?

Also, is the "Combat Gauze" you refer to made by Quick Clot?


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## Molon Labe (Nov 6, 2008)

Having never used the NATO Tourniquet I cannot comment on how it compares to the CAT or the SOF-T. But I am sure it was tested by USAISR and TCCC and is not one of the recommended tourniquets for some reason. See the list below to see if fails in any of these points. 

Here are the 7 Absolute Requirements for a Tourniquet:

Ample Capability - Occlusion of arterial flow in a thigh 26.7 inches in diameter
Rapid Application - Apply to upper or lower extremity in less than one minute
Anti-Clip Design - Must not slip during or after application
Adjustable
Small Cube - Weigh less than 230 grams
No Power Requirement
Extended Storage

Here are the 6 Desirable Features:

Wider is Better - Not less than 1" wide
Self Application - One handed self application to an upper extremity
Open Ended Design - To allow use on entrapped limbs
Torque Control - Prevent over tightening
Low Cost
Device Security - Should not allow for accidental release once applied


Yes Combat Gauze is made by Z-Medica, who makes QuickClot


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## Fn/Form (Nov 6, 2008)

Local TCCC medics taught an abbreviated tourniquet/combat care class. They made us use every tourniquet they could lay their hands on, maybe a dozen or so. Time stress only. NATO was one of the simplest and most durable. Probably a bit more easy to fumble than the CAT. I ended up buying one of each.

One of the best recommendations they made was to incorporate injury training into our regular firearms/active shooter training. A "Well, duh!" thing we had not considered.


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## Molon Labe (Nov 6, 2008)

One of the important things to work into your training is increased stress. Add high noise, little or no light, put a drop leg holster on and practice unclipping it to put the tourniquet on without the holster in the way. Get to the point where you can put it on with your non-dominant arm to your shooting arm in under 30 seconds from your kit, and under 45 seconds applied to your thigh. Your goal is to get this skill into your midbrain, just like a pistol failure, what do you do everytime you hear that click, tap and rack, it is now instinct, you should be able to accomplish the skill under survival stress without thinking. This is where you need to be. Take Care and Stay Safe


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## O6nop (Dec 6, 2008)

Is it a myth or do feminine product (inserts and/or pads) work well for bleeding injuries?


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## TakDwn (Oct 30, 2008)

O6nop said:


> Is it a myth or do feminine product (inserts and/or pads) work well for bleeding injuries?


Myth. They do NOT work well for bleeding injuries.


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## Fn/Form (Nov 6, 2008)

Can anyone remember the name of the new course that is supposedly replacing TCCC? I thought it began with an O, but can't remember it...


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## Molon Labe (Nov 6, 2008)

TCCC is not really a "course" but rather a methodology or a standard of care that is included in courses. There are several courses around the county that include TCCC as part of the instruction. It is turning even more into a guiding entity (Tactical Combat Causality Care Committee) that studies the studies and releases standards based on evidence based medicine. 

Once the National Tactical Officers Association (NTOA) finalizes the course, there will be a series of new courses entitled Tactical Rescue Technician. There will be an Operator Course, a Medic Course, and a Medical Director Course as well as one other that I cannot remember. These will include the TCCC standard but will have much more content beyond TCCC.

I do not know which course you are referring to - Sorry


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