Hemorrhage control and trauma patient management are some of the fundamental aspects of a first responder or EMT curriculum.
We’re taught from Day One to expose the wound, apply pressure and continue to Plan B if needed. We practice with bandages, roll gauze, triangle bandages, tourniquets and even medications in some ALS systems.
So what makes your average Stop the Bleed course different than an EMT or paramedic course focusing on trauma? Hemorrhage control requires protocols and supplies for Plan B: what to do if the bleeding doesn’t stop, where to transport your patient to receive definitive care, and what to do if a tourniquet isn’t indicated.
EMS trauma education goes beyond first aid kits and looks instead at trauma bags.
To cover the basics and expand into some of the advanced aspects of hemorrhage control, we have four primary methods of managing bleeding for some of the more typical traumatic injuries (excluding abdominal evisceration and tension pneumothorax).
Focusing on the training aspects for each of these methods, here are some ideas to help your crews train for and perform better hemorrhage control.
1. Direct pressure, elevate, apply cold
Still topping the charts as the primary method for bleeding control in any ambulance is direct pressure. Aside from the obvious amputation, direct pressure will be your likely go-to method for controlling bleeding both at the extremities and the trunk.
What’s important to focus on here is where to apply the direct pressure. To start, directly at the site is the obvious choice, but don’t forget about proximal pressure points for extremity injuries as well.
In addition, if one bandage doesn’t do the trick to stop your bleeding, your next step should be to add more dressings and push harder. Setting up your bags and ambulance for success plays a big role in this. If your crews need to dig through cabinets to readily find assorted bandages, roll gauze, tape, trauma shears and triangle bandages, then you’re setting them up for failure.
Organize your equipment so it’s easily accessible, identifiable and plentiful. By no means does this mean that you need a 100-count of full trauma dressings. It does, however, equate to “enough” to handle the probable injuries that you may encounter on a call, whether it’s in the back of the ambulance, on scene at a trailside incident or at the patient’s side while inside their residence.
2. Hemostatic agents
Hemostatic gauze agents have gained popularity in the EMS setting over the past few years, as well as in the civilian market. What’s important with these products is to follow the manufacturer’s recommendations.
Training with these products should focus on how they can be used both individually and in conjunction with other bleeding control options. Does the hemostatic gauze get inserted into the wound? Do you have to tear open the inside packaging? Can you apply additional dressings over them?
Regardless of which brand you choose, it’s important to know how to properly use these supplies. (Be sure to communicate changes to your crews if you switch brands.)
3. Tranexamic acid
One option to control both internal and external hemorrhage for some ALS systems is the administration of tranexamic acid, also known as TXA.
TXA doesn’t necessarily form new clots – rather, it prevents the breakdown of fibrin, which is formed within the bloodstream to hold clots together. The drug is not indicated for all trauma patients, but for those with recent trauma, a declining blood pressure and suspected hemorrhagic shock or exsanguination, it may be the patient’s saving grace.
We can’t perform surgery in the back of an ambulance (at least not in the U.S.), and simply flooding the patient with normal saline doesn’t do them any good either (blood products might be a better option, but that’s an entirely different article). With TXA, we can at least take a shot at trying to chemically control bleeding within the confines of ALS patient care if mechanical means won’t do the trick.
Because its use is one fitting the low-frequency, high-acuity category, training on TXA administration regularly is a necessity. Better yet, developing a checklist for its administration will help to decrease administration errors, increase familiarity with the medication and improve provider comfort with its indication.
4. Tourniquets
Contrary to popular civilian belief, tourniquets aren’t indicated in all bleeding situations. They don’t work on abdominal injuries, and I’m pretty sure they’re not indicated for head injuries, either.
The technology in these devices has improved significantly over the past decade, largely due to their effectiveness in combat environments. What is taught as a tight belt or bandana with a pencil for winding traction in the Scouts transitioned to a blood pressure cuff in the ambulance and is now a commercialized device with a manageable price tag industry-wide.
Each EMS provider should be familiar with the application of these devices, their maintenance and monitoring needs, and their protocols related to transfer of care with these devices applied. When should EMS apply a tourniquet or remove one? These questions should be addressed through training sessions and agency protocols.
Regardless of your method to stop the bleed, it’s imperative that you’re comfortable with the tools in your toolbox and that you know where to find them quickly when needed.
