Massive hemorrhage

Task Force 115. I took this photo on my last day at Forward Operating Base Dwyer (2011) after my replacement had arrived. This was a mass casualty where we received multiple Medivacs at the same time following a nasty skirmish between US Marines and Taliban fighters.

I gained plenty of experience with massive hemorrhage during my deployment to Afghanistan in 2011 (see photo at right).  Bleeding from massive extremity hemorrhage was the single largest reversible cause of death during the Vietnam war, but today’s combat medics have learned from these mistakes and gotten really, really good at controlling massive hemorrhage.  You can save a life too by addressing Massive hemorrhage as the first priority on your MARCH mnemonic.

Leatherman Raptor Trauma Shears

As you approach any patient in the wilderness or the trauma bay, look for obvious signs of bleeding like a blood soaked pant leg or blood underneath the patient.  Put on your medical gloves and run your hands around the perimeter of the patient’s body, feeling for blood.  If discovered, it’s time to expose it lickity split. This is a good job for the Leatherman Raptor Trauma Shear.  Use it to slice off any overlying clothing. Find the bleeding and if it’s a gusher, it’s time to stop and place a tourniquet. 

A tourniquet is a strip of fabric wrapped circumferentially around an extremity and then tightened until all blood flow past it stops. An effective tourniquet is tightened by a windlass, a device which when twisted, applies tremendous pressure circumferentially around the extremity.  Commercially made tourniquets come in many shapes and sizes, but most are lightweight and compact. Reputable brands to consider are Combat Application Tourniquet (CAT), SOF Tactical Tourniquet (SOFT-T), and Stretch Wrap and Tuck Tourniquet (SWAT-T).

If you must fashion your own tourniquet during an emergency, tie a cravat or neckerchief around the extremity and insert a makeshift windlass (a stick or large screwdriver) between the tourniquet and the skin.  Now twist it until you can’t twist any more and secure it with tape or another tie.

Beware of any tourniquet which do not have a windlass.

-Dr. Solberg

If the bleeding wound isn’t amenable to a tourniquet (wounds in the armpits or groin, or on the neck or scalp), apply a hemostatic (blood-stopping) dressing over a wound, or stuff hemostatic gauze into the wound, and apply direct pressure over the top with your hands or by wrapping a large, stretchy, elastic wrap.

https://youtu.be/G3TKfdFHAtM

Quick Clot is a mineral powder which has a microscopic, three dimensional, honey-comb structure. When it contacts blood, it absorbs water, leaving behind the blood’s own clotting factors and platelets in a higher concentration to stop bleeding. Quick Clot granules can be poured into a wound, or Quick Clot impregnated gauze can be stuffed into a wound, and then a pressure dressing can be applied.

Hemcon and Celox products contain chitosan, a carbohydrate molecule derived from shellfish.  Chitosan becomes extremely sticky when it contacts blood, sealing a wound to control bleeding.  Initially, it was only available as a firm, foam-like wafer that could be pressed onto an area of external bleeding, but newer formulations called ChitoFlex and HemCon Bandage can be torn and folded to cover or stuff into a bleeding wound. 

In addition to treating combat injuries, hemostatic dressings may also be useful to control minor bleeding in persons who take blood thinners to prevent stroke or treat blood clots.

Some form of hemostatic dressing should be carried by all persons taking blood thinners who travel beyond the geographic limitations of traditional ambulance services. 

 When you’ve finished addressing Massive hemorrhage, it’s time to address the airway!