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Keeping It Under Control

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Paramedics save lives, the saying goes, and EMTs save paramedics. That's glib and debatable, but it's certainly true that the role of the EMT-Basic is a vital one, and that there's relatively little out there in the way of information and tools to help him do it better. This new column, which will appear several times a year, is a resource for that EMT-B. It will cover everything from reviews of basic skills to assisting ALS providers with more advanced interventions in a way designed to enhance understanding and develop a more complete provider. As always, we welcome your comments; send thoughts, feedback and ideas for future columns to nancy.perry@cygnusb2b.com.

Profuse bleeding is a common companion of major trauma. However, it can also result from ordinary maladies, such as ruptured varicose veins or nosebleeds. Controlling bleeding is crucial to volume retention and preventing hypovolemic shock, and doing it properly can make all the difference for patients in the prehospital environment.

The biggest and by far most important concern in managing a hemorrhage is the safety of the provider. Infection control and BSI precautions are required. Be sure to wear disposable gloves, as well as a gown and or mask with eye protection, if the situation requires. Be sure to clean up well after the call, including the complete cleaning or disposal of soiled equipment, linens and supplies. Additionally, the provider should approach this type of call with the appropriate equipment, which includes gauze pads, rolled gauze and tape (if needed).

The most commonly accepted and utilized methods of hemorrhage control are direct pressure, elevation and the use of pressure points. All three should be used in order to attempt to control bleeding. As the amount of volume loss increases or the severity of the wound dictates, you may need to employ all three methods.

Direct Pressure
Direct pressure is the most commonly used bleeding-control technique, and it usually controls most external bleeding. Try it first when the need arises.

First place a sterile gauze pad over the wound. Place your gloved hand over the pad and hold pressure until the bleeding is stopped. Use additional pads as needed. Once bleeding has been controlled, bandage the gauze pad in place, making sure to wrap the bandage tight enough to keep the bleeding under control but not limit circulation. For extremity wounds, be sure to check for a distal pulse both before and after bandaging the wound. If a pulse is absent after the bandage has been applied, loosen the bandage a bit. Recheck the pulse at regular intervals during transport.

Remember, once the bandage is applied, it should not be removed in the prehospital environment unless absolutely necessary. Removal of a dressing may do further damage to the affected area and increase the bleeding.1

Elevation
The second method used to control bleeding is elevation of an injured extremity, which is most often done along with direct pressure. The goal is to raise the extremity above the level of the heart, to decrease circulation to that area.

Elevation can be done by the provider or a partner, or by the patient himself, if possible. A sling or some other way of maintaining elevation may be used, but be sure to keep the injury site above the level of the patient's heart.

There are situations where you may want to avoid elevating an extremity, such as with any injury that would restrict mobility (fracture, impaled object, etc.).

Pressure Points
If direct pressure and elevation are ineffective, pressure points should be utilized. Pressure points can be found at the brachial artery (midway down the humerus), radial artery (at the thumb side of the posterior wrist), femoral artery (at the groin) and popliteal artery (on the posterior side of the knee joint). Essentially, pressure points are pulse points-places where the artery is close to bone-except pressure applied to those points controls the flow of blood, as opposed to just measuring it.2 When you hold pressure at the pressure points, the artery is compressed against the bone, and blood flow is halted. Pressure should be constant. If bleeding is severe, it's also advisable to hold firm pressure to the wound area.

Checking to see if bleeding has been controlled should be done by releasing pressure on the pressure point but not the wound. If bleeding has not been controlled, reapply pressure to the pressure point. If the bleeding has stopped, continue to keep the area elevated.

Tourniquets
For a long time, using tourniquets for prehospital hemorrhage control was common. Today, due to the many complications that can arise and the effectiveness of direct pressure, elevation and pressure points, tourniquets are rarely used in the control of bleeding.

Compartment & Crush Syndrome
Among the most prevalent and serious complications in the use of tourniquets are compartment and crush syndromes. Both affect the cells and vessels of the area on which the tourniquet is used, but in different ways.

Compartment syndrome occurs when there is prolonged, continuous pressure on an extremity. Muscle cells and tissue, nerves and vessels are all enclosed within the extremity. When circulation is interrupted, it creates pressure within the extremity, which leads to cell damage from lack of oxygenation.3 The pressure also ruptures vessels, leading to swelling and bleeding. If this process is not corrected, it can lead to permanent damage and possible amputation of the affected area.

Crush syndrome is more related to the crushing of extremities by heavy objects and is not as common with tourniquets. It differs from compartment syndrome in that the actual object is the cause of the damage, as opposed to the lack of circulation. However, the cell damage and rupturing of vessels are similar in both syndromes.4

In either case, the best course of action is to avoid using tourniquets for bleeding control. If a tourniquet is encountered in the prehospital setting, the most appropriate course of action is proper BLS care, including administration of high-flow oxygen, and rapid transport to the closest emergency department. Care should be taken when attempting to remove tourniquets already in place.

Other Treatment Methods
In addition to the methods above, there have been some products introduced to the prehospital setting in recent years that can help control bleeding. Several were first used in the military/combat setting, but have proved applicable elsewhere.

Hemostatic agents, such as QuikClot, have been in the prehospital setting for 4-5 years. These agents work by absorbing the liquid (plasma) from blood, reducing clotting times.5 Caution should be used with these, and patients given hemostatic agents should receive only as much as will control bleeding. Transport them rapidly to the ED for removal of the agent.6

Military medics are currently employing a bandage using chitosan, a substance derived from shrimp shells, which adheres to and seals a wound area. It can clot a bullet wound in roughly one minute.7 Though it is used extensively in the combat setting, it has only recently been introduced into the prehospital setting.8

The military is also working with a compression bandage that works like the Ace-type bandages used for minor orthopedic injuries. This bandage provides constant pressure to the wound, allowing EMS personnel to perform other functions.9

Conclusion
Profuse bleeding is a common companion of major trauma and certain maladies. Controlling bleeding is crucial to volume retention and preventing hypovolemic shock. Using some simple and effective methods, along with some progressive new products, prehospital providers can effectively treat and control significant hemorrhage.

The author gratefully acknowledges the assistance of Jodi Kuhn and Paul Sharpe from the Virginia Office of EMS.

References

  1. Lee JA. Bleeding. MedlinePlus, www.nlm.nih.gov/medlineplus/ency/article/000045.htm.
  2. Harvard Medical School Family Health Guide. www.health.harvard.edu/fhg/firstaid/directPres.shtml.
  3. eMedicine. www.emedicine.com/orthoped/target1.
  4. Wheeless' Textbook of Orthopaedics. Reperfusion Injury/Crush Injury. www.wheelessonline.com/ortho/reperfusion_injury_crush_injury.
  5. Z-Medica. QuikClot. www.quikclot.com/productinfo/default.htm.
  6. U.S. Food and Drug Administration. FDA Public Health Notification: Paralysis from Absorbable Hemostatic Agent. www.fda.gov/cdrh/safety/040204-hemostatics.html.
  7. Lurie K. Battlefield Band-Aids. ScienCentral News, www.sciencentral.com/articles/view.php3?language=english&type=&article_id=218391915.

  8. HemCon Medical Technologies. www.hemcon.com.

  9. Essing D. Israeli Super Bandage Saves Lives. IsraCast/Israeli Technology News, www.isracast.com/Articles/Article.aspx?ID=53.

Timothy J. Perkins, BS, EMT-P, is the EMS systems planner for the Virginia Department of Health's Office of EMS. He has over 17 years of EMS operations and management experience. E-mail him at tjperkins5@yahoo.com.

Tim Perkins is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.

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