Re: Hemostatic Dressings and tourniquets for pre-EMS

[Guest guest]

My primary suggestion is to teach the basics, and back it up with the widely

available research on LEO & related shootings. While tourniquets are amazing and

are certainly saving lives in combat zones, what I've read/seen shows the most

LE are taking chest/head wounds that aren't appropriate for tourniquet usage.

The " advanced skill " that is most useful is needle thoracostomy, but it's a hard

sell to get that approved. Tourniquets should be included, but I wouldn't

emphasize them as much as most " tactical " or combat casualty-style classes do.

We're not seeing a lot of IEDs or mines for law enforcement (and hopefully never

will), which is really where tourniquets shine.

Hemostatic dressings are a sexy topic, and there is something to be said for

them, but you also have to consider cost, shelf life and expiration. A lot of

people can be saved with direct pressure and a couple rolls of gauze that will

certainly work past their 'expiration date'. It's also going to be easier to

remember under pressure.

Austin

>

> We're looking into teaching a bit more to some of our dedicated

> pre-EMS providers (like law enforcement, dedicated response teams,

> plant security, etc.). We're looking at tourniquet use and also

> maybe hemostatic dressings.

>

> Anyone have any thougts about this, and which tourniquets and

> hemostatic dressings do you like?

>

> Steve

>

> Steve , LP

> AlertCPR Emergency Training

> 1278 FM407, Suite 1090-B9

> ville, TX 75077

>

>

>

[Guest guest]

Tourniquets are becoming more mainstream in pre-hospital civilian EMS.  Lessons

learned during the current conflicts in the desert have provided much literature

as to the efficacy of these devices.  I think it is a great life saving tool

that should be taught to all LE!  Tourniquet choice is subjective but there is

a lot to choose from.  You can find allot of Youtube videos for the SOF-T and

CAT styles.  Most LE wear some sort of soft body armor while on patrol.  Bleed

out from extremity wounds has been the number 1 killer of our soldiers in

combat!  As far as hemostatics go....we use the Combat Gauze because it is very

simple to use and is not subject to being blown around on a windy day!  Very

easy to apply as well.  Not endorsing any company here at all but

Tacmedsolutions.com has some really good videos for class room use!

Subject: Hemostatic Dressings and tourniquets for pre-EMS

To: texasems-l

Date: Wednesday, December 21, 2011, 11:40 AM

 

We're looking into teaching a bit more to some of our dedicated

pre-EMS providers (like law enforcement, dedicated response teams,

plant security, etc.). We're looking at tourniquet use and also

maybe hemostatic dressings.

Anyone have any thougts about this, and which tourniquets and

hemostatic dressings do you like?

Steve

Steve , LP

AlertCPR Emergency Training

1278 FM407, Suite 1090-B9

ville, TX 75077

[Guest guest]

We go around teaching industrial rescue and we address the different types of

injuries associated with the industrial environment. Even for the “emergency

rescue teamsâ€, prioritizing injuries and addressing them accordingly is

important. No more waiting on 911. Prioritize the injuries in what will kill

the patient in 10 minutes, then go to the next set of injuries and continue

until 911 or call-out arrives. Getting away from the ABC’s and moving towards

BAT – an idea with the military - the “B†stands for Bad bleeds –

(shown a transected artery might bleed out in 2-3 minutes) and should be

addressed first (airway is 4-6 minutes) and the CAT and combat gauze are great

tools to use in conjunction of well-aimed direct pressure. It has already been

shown that pressure points and elevation are a waste of time. Another tool that

works great are Israeli bandages (basically ACE with 4x4).

The idea of using the (dare I say) tourniquet should be pushed. Back when a

trauma center to adequately address an injury that warranted the TK in the first

place might have been hours and hours away. Now, with the use of helicopters,

we are looking at minutes. The TK is also very beneficial if dealing with a bad

bled that is not accessible due to location (confined space, cat walk…).

Place the TK and re-assess when in a better place. It either allowed the bleed

to clot or if it begins again, tighten it up.

Different studies are out there for the times a TK can be in place before

ischemia occurs. Short as 90 minutes and up to avg 360 minutes.

Combat gauze, another great tool – used to be stuffed into the wound bowl, not

as KERLEX. Combination of combat gauze and an Israeli bandage is quite

effective – even on amputations.

Green

Texas Rope Rescue

From: texasems-l [mailto:texasems-l ] On Behalf

Of

Sent: December 21, 2011 2:03 PM

To: texasems-l

Subject: Re: Hemostatic Dressings and tourniquets for pre-EMS

Tourniquets are becoming more mainstream in pre-hospital civilian EMS. Lessons

learned during the current conflicts in the desert have provided much literature

as to the efficacy of these devices. I think it is a great life saving tool

that should be taught to all LE! Tourniquet choice is subjective but there is a

lot to choose from. You can find allot of Youtube videos for the SOF-T and CAT

styles. Most LE wear some sort of soft body armor while on patrol. Bleed out

from extremity wounds has been the number 1 killer of our soldiers in combat!

As far as hemostatics go....we use the Combat Gauze because it is very simple to

use and is not subject to being blown around on a windy day! Very easy to apply

as well. Not endorsing any company here at all but Tacmedsolutions.com has some

really good videos for class room use!

From: Steve , LP paramedic1@...

>

Subject: Hemostatic Dressings and tourniquets for pre-EMS

To: texasems-l

Date: Wednesday, December 21, 2011, 11:40 AM

We're looking into teaching a bit more to some of our dedicated

pre-EMS providers (like law enforcement, dedicated response teams,

plant security, etc.). We're looking at tourniquet use and also

maybe hemostatic dressings.

Anyone have any thougts about this, and which tourniquets and

hemostatic dressings do you like?

Steve

Steve , LP

AlertCPR Emergency Training

1278 FM407, Suite 1090-B9

ville, TX 75077

[Guest guest]

We go around teaching industrial rescue and we address the different types of

injuries associated with the industrial environment. Even for the “emergency

rescue teamsâ€, prioritizing injuries and addressing them accordingly is

important. No more waiting on 911. Prioritize the injuries in what will kill

the patient in 10 minutes, then go to the next set of injuries and continue

until 911 or call-out arrives. Getting away from the ABC’s and moving towards

BAT – an idea with the military - the “B†stands for Bad bleeds –

(shown a transected artery might bleed out in 2-3 minutes) and should be

addressed first (airway is 4-6 minutes) and the CAT and combat gauze are great

tools to use in conjunction of well-aimed direct pressure. It has already been

shown that pressure points and elevation are a waste of time. Another tool that

works great are Israeli bandages (basically ACE with 4x4).

The idea of using the (dare I say) tourniquet should be pushed. Back when a

trauma center to adequately address an injury that warranted the TK in the first

place might have been hours and hours away. Now, with the use of helicopters,

we are looking at minutes. The TK is also very beneficial if dealing with a bad

bled that is not accessible due to location (confined space, cat walk…).

Place the TK and re-assess when in a better place. It either allowed the bleed

to clot or if it begins again, tighten it up.

Different studies are out there for the times a TK can be in place before

ischemia occurs. Short as 90 minutes and up to avg 360 minutes.

Combat gauze, another great tool – used to be stuffed into the wound bowl, not

as KERLEX. Combination of combat gauze and an Israeli bandage is quite

effective – even on amputations.

Green

Texas Rope Rescue

From: texasems-l [mailto:texasems-l ] On Behalf

Of

Sent: December 21, 2011 2:03 PM

To: texasems-l

Subject: Re: Hemostatic Dressings and tourniquets for pre-EMS

Tourniquets are becoming more mainstream in pre-hospital civilian EMS. Lessons

learned during the current conflicts in the desert have provided much literature

as to the efficacy of these devices. I think it is a great life saving tool

that should be taught to all LE! Tourniquet choice is subjective but there is a

lot to choose from. You can find allot of Youtube videos for the SOF-T and CAT

styles. Most LE wear some sort of soft body armor while on patrol. Bleed out

from extremity wounds has been the number 1 killer of our soldiers in combat!

As far as hemostatics go....we use the Combat Gauze because it is very simple to

use and is not subject to being blown around on a windy day! Very easy to apply

as well. Not endorsing any company here at all but Tacmedsolutions.com has some

really good videos for class room use!

From: Steve , LP paramedic1@...

>

Subject: Hemostatic Dressings and tourniquets for pre-EMS

To: texasems-l

Date: Wednesday, December 21, 2011, 11:40 AM

We're looking into teaching a bit more to some of our dedicated

pre-EMS providers (like law enforcement, dedicated response teams,

plant security, etc.). We're looking at tourniquet use and also

maybe hemostatic dressings.

Anyone have any thougts about this, and which tourniquets and

hemostatic dressings do you like?

Steve

Steve , LP

AlertCPR Emergency Training

1278 FM407, Suite 1090-B9

ville, TX 75077

[Guest guest]

We go around teaching industrial rescue and we address the different types of

injuries associated with the industrial environment. Even for the “emergency

rescue teamsâ€, prioritizing injuries and addressing them accordingly is

important. No more waiting on 911. Prioritize the injuries in what will kill

the patient in 10 minutes, then go to the next set of injuries and continue

until 911 or call-out arrives. Getting away from the ABC’s and moving towards

BAT – an idea with the military - the “B†stands for Bad bleeds –

(shown a transected artery might bleed out in 2-3 minutes) and should be

addressed first (airway is 4-6 minutes) and the CAT and combat gauze are great

tools to use in conjunction of well-aimed direct pressure. It has already been

shown that pressure points and elevation are a waste of time. Another tool that

works great are Israeli bandages (basically ACE with 4x4).

The idea of using the (dare I say) tourniquet should be pushed. Back when a

trauma center to adequately address an injury that warranted the TK in the first

place might have been hours and hours away. Now, with the use of helicopters,

we are looking at minutes. The TK is also very beneficial if dealing with a bad

bled that is not accessible due to location (confined space, cat walk…).

Place the TK and re-assess when in a better place. It either allowed the bleed

to clot or if it begins again, tighten it up.

Different studies are out there for the times a TK can be in place before

ischemia occurs. Short as 90 minutes and up to avg 360 minutes.

Combat gauze, another great tool – used to be stuffed into the wound bowl, not

as KERLEX. Combination of combat gauze and an Israeli bandage is quite

effective – even on amputations.

Green

Texas Rope Rescue

From: texasems-l [mailto:texasems-l ] On Behalf

Of

Sent: December 21, 2011 2:03 PM

To: texasems-l

Subject: Re: Hemostatic Dressings and tourniquets for pre-EMS

Tourniquets are becoming more mainstream in pre-hospital civilian EMS. Lessons

learned during the current conflicts in the desert have provided much literature

as to the efficacy of these devices. I think it is a great life saving tool

that should be taught to all LE! Tourniquet choice is subjective but there is a

lot to choose from. You can find allot of Youtube videos for the SOF-T and CAT

styles. Most LE wear some sort of soft body armor while on patrol. Bleed out

from extremity wounds has been the number 1 killer of our soldiers in combat!

As far as hemostatics go....we use the Combat Gauze because it is very simple to

use and is not subject to being blown around on a windy day! Very easy to apply

as well. Not endorsing any company here at all but Tacmedsolutions.com has some

really good videos for class room use!

From: Steve , LP paramedic1@...

>

Subject: Hemostatic Dressings and tourniquets for pre-EMS

To: texasems-l

Date: Wednesday, December 21, 2011, 11:40 AM

We're looking into teaching a bit more to some of our dedicated

pre-EMS providers (like law enforcement, dedicated response teams,

plant security, etc.). We're looking at tourniquet use and also

maybe hemostatic dressings.

Anyone have any thougts about this, and which tourniquets and

hemostatic dressings do you like?

Steve

Steve , LP

AlertCPR Emergency Training

1278 FM407, Suite 1090-B9

ville, TX 75077

[Guest guest]

Tourniquet use isn't at all controversial now, but I would advise not to teach

releasing the tourniquet (particularly to lay persons). As you say, definitive

care is very accessible domestically, so I recommend that any tourniquets

applied remain so until removed by a physician or surgeon. I've heard a lot of

different information regarding the " safe " time that tourniquets should be

applied for, but 90-120 minutes is extremely reasonable, and most of the time

the patient should either be at definitive care or at least advanced care by

then. I can think of very few situations (again, domestically) where a layperson

would need to remove/reassess a tourniquet. As a paramedic or intermediate,

particularly in parts of more rural areas (transporting by ground) it could be

considered, but at that point you should have the ability to consult with

command. I really hate " passing the buck, " but tourniquet time seems to be very

subjective. I've heard anywhere from a " maximum of 60 minutes " (too short) to

" worry about it after 6 hours " (too long). I think about it at two hours and

would want to address it for sure within four.

I also will take (brief) issue with the comment that " pressure points and

elevation are a waste of time " though I understand the sentiment. Both were in

response to a morbid fear of misuse of tourniquet, and both are effective

techniques--just more difficult and less effective then a tourniquet. All the

way back to '95-ish, people were seriously discussing increasing tourniquet use

for extremity injury, but there was quite a bit of baggage at the time. The last

decade of combat operations have proven the efficacy of tourniquets and removed

much of the fear. For a basic provider, I agree that direct pressure ->

tourniquet is the way to go. An advanced level provider should understand the

limitations and benefits of each and use the least potentially damaging that is

effective. As an example, I had an open radial-ulnar fracture offshore a number

of years back. Evacuation ended up taking roughly eight hours (due to weather

and limited helos able to do night ops.) This would have put me in quite a bind

if I'd jumped straight to the tourniquet. He managed quite fine with direct

pressure so long as his arm was elevated above the heart, but bled like a stuck

pig whenever it was below. He kept his arm, and would not have done so if I'd

been overly aggressive with a tourniquet.

Don't let that part of your brain that gets overly excited by black gear with

velcro shut off the " good thinking " EMS part, as I think there is a strong

tendency to do. There are a lot of lessons worth teaching from the combat

experiences in the sandbox, but too many are currently losing the forest for the

trees. All the high-speed low-drag gear doesn't change EMS, it's still the same

job (just now with more black velcro!)

Israeli combat bandages are swank though.

Austin

> We go around teaching industrial rescue and we address the different types of

injuries associated with the industrial environment. Even for the “emergency

rescue teams”, prioritizing injuries and addressing them accordingly is

important. No more waiting on 911. Prioritize the injuries in what will kill the

patient in 10 minutes, then go to the next set of injuries and continue until

911 or call-out arrives. Getting away from the ABC’s and moving towards BAT – an

idea with the military - the “B” stands for Bad bleeds – (shown a transected

artery might bleed out in 2-3 minutes) and should be addressed first (airway is

4-6 minutes) and the CAT and combat gauze are great tools to use in conjunction

of well-aimed direct pressure. It has already been shown that pressure points

and elevation are a waste of time. Another tool that works great are Israeli

bandages (basically ACE with 4x4).

>

> The idea of using the (dare I say) tourniquet should be pushed. Back when a

trauma center to adequately address an injury that warranted the TK in the first

place might have been hours and hours away. Now, with the use of helicopters, we

are looking at minutes. The TK is also very beneficial if dealing with a bad

bled that is not accessible due to location (confined space, cat walk…). Place

the TK and re-assess when in a better place. It either allowed the bleed to clot

or if it begins again, tighten it up.

>

> Different studies are out there for the times a TK can be in place before

ischemia occurs. Short as 90 minutes and up to avg 360 minutes.

>

> Combat gauze, another great tool – used to be stuffed into the wound bowl, not

as KERLEX. Combination of combat gauze and an Israeli bandage is quite effective

– even on amputations.

>

> Green

>

[Guest guest]

OMG Austin,

You advocate THINKING?

No future for you, my friend!

GG

Re: Hemostatic Dressings and tourniquets for pre-EMS

Tourniquet use isn't at all controversial now, but I would advise not to teach

releasing the tourniquet (particularly to lay persons). As you say, definitive

care is very accessible domestically, so I recommend that any tourniquets

applied remain so until removed by a physician or surgeon. I've heard a lot of

different information regarding the " safe " time that tourniquets should be

applied for, but 90-120 minutes is extremely reasonable, and most of the time

the patient should either be at definitive care or at least advanced care by

then. I can think of very few situations (again, domestically) where a layperson

would need to remove/reassess a tourniquet. As a paramedic or intermediate,

particularly in parts of more rural areas (transporting by ground) it could be

considered, but at that point you should have the ability to consult with

command. I really hate " passing the buck, " but tourniquet time seems to be very

subjective. I've heard anywhere from a " maximum of 60 minutes " (too short) to

" worry about it after 6 hours " (too long). I think about it at two hours and

would want to address it for sure within four.

I also will take (brief) issue with the comment that " pressure points and

elevation are a waste of time " though I understand the sentiment. Both were in

response to a morbid fear of misuse of tourniquet, and both are effective

techniques--just more difficult and less effective then a tourniquet. All the

way back to '95-ish, people were seriously discussing increasing tourniquet use

for extremity injury, but there was quite a bit of baggage at the time. The last

decade of combat operations have proven the efficacy of tourniquets and removed

much of the fear. For a basic provider, I agree that direct pressure ->

tourniquet is the way to go. An advanced level provider should understand the

limitations and benefits of each and use the least potentially damaging that is

effective. As an example, I had an open radial-ulnar fracture offshore a number

of years back. Evacuation ended up taking roughly eight hours (due to weather

and limited helos able to do night ops.) This would have put me in quite a bind

if I'd jumped straight to the tourniquet. He managed quite fine with direct

pressure so long as his arm was elevated above the heart, but bled like a stuck

pig whenever it was below. He kept his arm, and would not have done so if I'd

been overly aggressive with a tourniquet.

Don't let that part of your brain that gets overly excited by black gear with

velcro shut off the " good thinking " EMS part, as I think there is a strong

tendency to do. There are a lot of lessons worth teaching from the combat

experiences in the sandbox, but too many are currently losing the forest for the

trees. All the high-speed low-drag gear doesn't change EMS, it's still the same

job (just now with more black velcro!)

Israeli combat bandages are swank though.

Austin

> We go around teaching industrial rescue and we address the different types of

injuries associated with the industrial environment. Even for the �emergency

rescue teams�, prioritizing injuries and addressing them accordingly is

important. No more waiting on 911. Prioritize the injuries in what will kill the

patient in 10 minutes, then go to the next set of injuries and continue until

911 or call-out arrives. Getting away from the ABC�s and moving towards BAT

� an

idea with the military - the �B� stands for Bad bleeds � (shown a

transected

artery might bleed out in 2-3 minutes) and should be addressed first (airway is

4-6 minutes) and the CAT and combat gauze are great tools to use in conjunction

of well-aimed direct pressure. It has already been shown that pressure points

and elevation are a waste of time. Another tool that works great are Israeli

bandages (basically ACE with 4x4).

>

> The idea of using the (dare I say) tourniquet should be pushed. Back when a

trauma center to adequately address an injury that warranted the TK in the first

place might have been hours and hours away. Now, with the use of helicopters, we

are looking at minutes. The TK is also very beneficial if dealing with a bad

bled that is not accessible due to location (confined space, cat walk�). Place

the TK and re-assess when in a better place. It either allowed the bleed to clot

or if it begins again, tighten it up.

>

> Different studies are out there for the times a TK can be in place before

ischemia occurs. Short as 90 minutes and up to avg 360 minutes.

>

> Combat gauze, another great tool � used to be stuffed into the wound bowl,

not

as KERLEX. Combination of combat gauze and an Israeli bandage is quite effective

� even on amputations.

>

> Green

>

[Guest guest]

Steve,

I will weigh in here as well. We did this same thing a few years back and here

is how we made the choice.

1. What is the transporting EMS carrying on their ambulances? If the " first

responder " uses a device that the transporting medics are not familiar with, it

can cause some issues during care transfer and during transport and handing off

at the ED.

2. What is the receiving trauma center familiar with and desiring to work with?

We decided we didn't want any surprises when we were turning the patient over to

the trauma team. This being said, we are fortunate that our primary trauma

center is a military trauma center, so they recommended the CAT tourniquet (with

the metal bar, not plastic) and the combat gauze. We already were using the

Israeli bandage.

Both of these help zero in on what you will recommend or use. This will also

help save some dollars and be more efficient working with limited dollars.

These may vary drastically across your students / response groups which will

make the education piece tougher, but hopefully will be better integrated with

the local health care system.

BTW, talk to the surgeons and then get some samples of various tourniquets and

hemostatic dressings...and play with them repeatedly. Then, if you have a group

that may be leading this change in their community, you can show them what is

out there and let them have hands on...and make the decision that best works for

them.

Hope I understood your question correctly.

Dudley

Hemostatic Dressings and tourniquets for pre-EMS

We're looking into teaching a bit more to some of our dedicated

pre-EMS providers (like law enforcement, dedicated response teams,

plant security, etc.). We're looking at tourniquet use and also

maybe hemostatic dressings.

Anyone have any thougts about this, and which tourniquets and

hemostatic dressings do you like?

Steve

Steve , LP

AlertCPR Emergency Training

1278 FM407, Suite 1090-B9

ville, TX 75077

[Guest guest]

Steve,

I will weigh in here as well. We did this same thing a few years back and here

is how we made the choice.

1. What is the transporting EMS carrying on their ambulances? If the " first

responder " uses a device that the transporting medics are not familiar with, it

can cause some issues during care transfer and during transport and handing off

at the ED.

2. What is the receiving trauma center familiar with and desiring to work with?

We decided we didn't want any surprises when we were turning the patient over to

the trauma team. This being said, we are fortunate that our primary trauma

center is a military trauma center, so they recommended the CAT tourniquet (with

the metal bar, not plastic) and the combat gauze. We already were using the

Israeli bandage.

Both of these help zero in on what you will recommend or use. This will also

help save some dollars and be more efficient working with limited dollars.

These may vary drastically across your students / response groups which will

make the education piece tougher, but hopefully will be better integrated with

the local health care system.

BTW, talk to the surgeons and then get some samples of various tourniquets and

hemostatic dressings...and play with them repeatedly. Then, if you have a group

that may be leading this change in their community, you can show them what is

out there and let them have hands on...and make the decision that best works for

them.

Hope I understood your question correctly.

Dudley

Hemostatic Dressings and tourniquets for pre-EMS

We're looking into teaching a bit more to some of our dedicated

pre-EMS providers (like law enforcement, dedicated response teams,

plant security, etc.). We're looking at tourniquet use and also

maybe hemostatic dressings.

Anyone have any thougts about this, and which tourniquets and

hemostatic dressings do you like?

Steve

Steve , LP

AlertCPR Emergency Training

1278 FM407, Suite 1090-B9

ville, TX 75077

[Guest guest]

Steve,

I will weigh in here as well. We did this same thing a few years back and here

is how we made the choice.

1. What is the transporting EMS carrying on their ambulances? If the " first

responder " uses a device that the transporting medics are not familiar with, it

can cause some issues during care transfer and during transport and handing off

at the ED.

2. What is the receiving trauma center familiar with and desiring to work with?

We decided we didn't want any surprises when we were turning the patient over to

the trauma team. This being said, we are fortunate that our primary trauma

center is a military trauma center, so they recommended the CAT tourniquet (with

the metal bar, not plastic) and the combat gauze. We already were using the

Israeli bandage.

Both of these help zero in on what you will recommend or use. This will also

help save some dollars and be more efficient working with limited dollars.

These may vary drastically across your students / response groups which will

make the education piece tougher, but hopefully will be better integrated with

the local health care system.

BTW, talk to the surgeons and then get some samples of various tourniquets and

hemostatic dressings...and play with them repeatedly. Then, if you have a group

that may be leading this change in their community, you can show them what is

out there and let them have hands on...and make the decision that best works for

them.

Hope I understood your question correctly.

Dudley

Hemostatic Dressings and tourniquets for pre-EMS

We're looking into teaching a bit more to some of our dedicated

pre-EMS providers (like law enforcement, dedicated response teams,

plant security, etc.). We're looking at tourniquet use and also

maybe hemostatic dressings.

Anyone have any thougts about this, and which tourniquets and

hemostatic dressings do you like?

Steve

Steve , LP

AlertCPR Emergency Training

1278 FM407, Suite 1090-B9

ville, TX 75077