Having previously controlled any massive external hemorrhage earlier in Tactical Field Care, attention should now be directed toward a more comprehensive evaluation of all hemorrhage. Potential sources of life-threatening internal hemorrhage must be addressed and prior interventions in external hemorrhage reassessed
Circulation and Hemorrhage Control in TFC
Over the next three modules, we will discuss circulation assessment and management in the Tactical Field Care (TFC) setting. This module will focus on hemorrhage control while the subsequent modules will address shock and fluid resuscitation. The didactic presentation will review several hemorrhage control principles, and skills stations will provide an opportunity to get hands-on practice for the procedures you will need to master.
Some hemorrhage control principles and interventions are taught in All-Service Member or Combat Lifesaver training, so it is important to understand what their training and anticipated skill set are in order to assume care for the casualty and potentially initiate more advanced treatments.
There are 6 cognitive and 5 performance learning objectives for the circulation and hemorrhage control module.
The cognitive learning objectives include describing the progressive strategies and limitations of controlling external hemorrhage, identifying the signs and symptoms of pelvic fractures, and the indications, contraindications, and application methods of pelvic compression devices (PCDs), identifying the principles of wound packing and pressure bandages, and identifying the indications and techniques for both tourniquet (TQ) replacement and tourniquet conversion.
The performance learning objectives are applying both a Committee on Tactical Combat Casualty Care (CoTCCC)-recommended and an improvised PCD, wound packing and pressure bandage application, tourniquet replacement, and tourniquet conversion.
Circulation assessment and management is the “C” in the MARCH PAWS sequence.
This video will recap some of the important concepts of hemorrhage control during circulation management in TFC.
HEMORRHAGE CONTROL IN TFC
A pelvic binder should be applied for cases of suspected pelvic fracture from severe blunt force or blast injury with one or more of the following indications:
Pelvic pain
Any major lower limb amputation or near amputation
Physical exam findings suggestive of a pelvic fracture
Unconsciousness
Shock
If the casualty is not experiencing persistent massive external hemorrhage, the potential for massive internal hemorrhage from a pelvic injury should be assessed. Most pelvic fractures are associated with dismounted improvised explosive device (IED) attacks accompanied by amputations, but they also occur in severe blunt trauma (such as motor vehicle crashes, aircraft mishaps, hard parachute landings, and falls). 26% of service members who died in OEF/OIF had a pelvic fracture, and bleeding pelvic fractures with hemodynamic instability have up to a 40% mortality.
Several major vessels run alongside the pelvic bones that can be disrupted by the sharp edges of a fracture and are in anatomic locations that do not allow for effective direct or indirect pressure to be applied.
Pelvic fracture should be suspected in any casualty who suffers severe blunt force or blast injury and has one or more of the following indications:
Pelvic pain
Any major lower limb amputation or near amputation
Physical exam findings suggestive of a pelvic fracture (for example, laceration or bruising at bony prominences of the pelvic ring, crepitus, a deformed or unstable pelvis or unequal leg lengths)
Unconsciousness
Shock
Additional signs include scrotal, perineal, or perianal bruising, blood at the urethral meatus or massive hematuria, blood in the rectum or vagina, or neurologic deficits in lower extremities.
Many prior courses have taught combat medics (and others) to check for pelvic instability by applying downward pressure on the anterior ilia (also called “opening the book”), but this causes further damage if a pelvic fracture is present and should NOT be done.
If the mechanism of injury raises the suspicion of a pelvic injury (IEDs, blasts, motor vehicle accidents (MVAs), etc.) and/or the five major signs and symptoms we just reviewed are present, then a PCD should be applied.
CoTCCC has evaluated several commercially available PCDs and recommended three of them:
PelvicBinder®
T-POD™ Pelvic Stabilization Device
SAM® Pelvic Sling II
Of note, two of the junctional hemorrhage control devices also provide pelvic stability and could be considered: the SAM Junctional Tourniquet (SJT) and the Junctional Emergency Treatment Tool (JETT™).
Whichever PCD is used, it should be placed at the level of greater trochanters, NOT the iliac crests. In one study, 40% of the pelvic binders were placed too high, resulting in inadequate reduction of the pelvic fracture and possibly increased bleeding.
Also, external rotation of the lower extremities is commonly seen in casualties with displaced pelvic fractures, which may increase the dislocation of pelvic fragments. Secure the knees and/or feet together to prevent external rotation and improve the effect of the PCD.
If you must move the PCD to access the groin or pelvic area for other critical casualty management purposes, temporarily move it to the upper thighs and replace it as soon as possible.
Contraindication for Pelvic Compression Device
Open Pelvic Fractures
Perineal Lacerations
Intraabdominal injuries requiring surgery
Burns
Severe associated pelvic soft tissue injuries may necessitate external fixation of the pelvis instead of a pelvic binder
Open fracture to the pelvis may lacerate the rectum, perineum, or vagina, and an obvious source of external blood loss may not be readily apparent.
This video will go over the proper techniques for applying a CoTCCC-recommended PCD.
After reassessing bleeding control and applying a PCD, if appropriate, the next step is to expose any wounds, if that has not already been accomplished. Wound exposure should be accomplished using trauma shears rather than an unguarded blade to prevent further injury to the extremity. The objective of this is to determine if the bleeding from the wound might be controlled without a tourniquet and/or to assess whether a tourniquet might be applied closer to the wound to preserve as much viable tissue as possible.
There is no precise set of parameters that will universally help make the determination of whether a tourniquet is necessary, but typical injuries that will continue to require a tourniquet include some obvious injuries like amputations and deep wounds that resulted in severed arteries, whereas more superficial injuries not involving the arteries may be more easily controlled. However, sometimes the extent of the wound isn’t clearly known just based on the external view of the wound.
The tactical considerations during Care Under Fire or the uncertainty of the extent of bleeding during the massive hemorrhage phase in Tactical Field Care will sometimes lead to a bleeding control decision that can be managed differently once the situation is more controlled and more information can be gathered from the exposed wound. We’ll spend the next couple of minutes talking about the indications and processes for replacing tourniquets and for converting tourniquets.
The first step in the strategy we just reviewed was to reassess bleeding control measures from massive hemorrhage management. Hemorrhage control in combat casualties takes precedence over fluid resuscitation, even when treating a casualty who is in shock.
If a tourniquet was applied in the CARE UNDER FIRE phase or earlier in your MARCH sequence, assess for effectiveness. If ineffective, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above the bleeding site. Ensure that bleeding is stopped. If a deliberate tourniquet that was placed in TFC is ineffective, apply a second tourniquet side-by-side with the first.
If the wound was packed, consider repacking the wound and reapplying the pressure bandage or moving to a tourniquet for definitive management. If a tourniquet has already been applied to a wound or previously packed and bandaged but is still bleeding, then tighten the original tourniquet, or if that fails to stop the bleeding and eliminate the distal pulse, consider applying a second tourniquet side-by-side, proximal to the original.
In massive hemorrhage, you learned that tourniquets should be applied more deliberately in the TFC setting to maximize effectiveness and minimize the amount of healthy tissue that might be impacted by a tourniquet placed too high on the limb. So, if a tourniquet is, in fact, necessary, replace high and tight tourniquets or tourniquets applied over the clothing with more deliberate tourniquets.
This is done by placing a replacement tourniquet directly on the skin, 2-3 inches above the wound, and tightening it. Then, slowly release the original tourniquet over one minute while monitoring the casualty for signs of recurrent bleeding or resumption of a distal pulse. Slide originally placed tourniquet(s) down, but leave in place proximal to the newly placed tourniquet. In cases of recurrent bleeding or pulses, the original tourniquet can be retightened and the replacement tourniquet can be tightened further, or repositioned and tightened further.
Afterward, the original tourniquet is slowly released again to confirm bleeding control. It may require a second tourniquet to be placed side-by-side with the replacement tourniquet, as well. Occasionally, an attempt to replace a tourniquet will not be successful, and reverting back to the prior tourniquet location may be needed.
If the initial tourniquet remains tightened in its original position, there is a risk of compartment syndrome developing between the two tourniquets. But rather than removing the original tourniquet completely, it can be slid down the extremity and positioned just proximal to the replacement tourniquet but only partially tightened by having the slack of the tourniquet removed and the strap secured to prevent it from catching or being in the way during casualty assessments or movements.
This video will go over the process of replacing a tourniquet in Tactical Field Care.
TOURNIQUET REPLACEMENT
Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled by other means unless the casualty is in shock, you cannot closely monitor the wound for re-bleeding, or there has been an amputation; however, do not attempt tourniquet conversion if the tourniquet has been on for six or more hours. Also, consider leaving the tourniquet in place if the tactical or medical considerations make transition to other hemorrhage control methods inadvisable.
While the original tourniquet is still in place controlling the bleeding, pack the wound with hemostatic gauze, if available, and hold pressure for three minutes. Then, apply a pressure bandage over the dressing, maintaining pressure. Afterward, slowly release the tourniquet (over at least one minute) while closely observing for bleeding. If the wound packing and pressure bandage do not control the bleeding, retighten the tourniquet or follow the steps to replace the tourniquet if it is above the clothing, like a high and tight tourniquet. In cases where the conversion has failed, it is appropriate to try again within the next two hours, as long as it hasn’t been more than six hours since the original tourniquet was applied.
If the conversion is successful, loosen the tourniquet and move it down to just above the pressure dressing, loose but with no slack in the strap in case it is needed later, and annotate the time of tourniquet removal on the DD Form 1380, TCCC Casualty Card. Periodically reassess the wound for recurrent bleeding and reassess after any casualty movements.
This video will go over the process of converting a tourniquet using wound packing and pressure bandages in TFC.
Tourniquets are not required for all extremity bleeding. Occasionally, some lacerations that can be controlled by hemostatic dressings will have a tourniquet applied during the massive hemorrhage phase. If you assess that a wound is amenable to control without a tourniquet, the wound packing and pressure bandage application skills taught in the massive hemorrhage module can be used.
CoTCCC-recommended hemostatic dressings, including Combat Gauze®, ChitoGauze®, and Celox™ Gauze, are safe and contain active ingredients that assist with blood-clotting at the site of active bleeding. To effectively form a clot and stop bleeding, hemostatic dressing must be packed into the wound to maximize contact at the active source of bleeding with direct pressure applied over the wound for at least 3 minutes.
If bleeding has not been controlled:
If packed with hemostatic dressing, remove prior packing material and repack starting at step 3.
If packed with gauze or other materials, apply additional gauze/materials and pressure (for another 3 minutes) until bleeding has stopped.
All dressings for significant bleeding should be secured with a pressure bandage while maintaining pressure on the wound throughout the process of applying the pressure bandage.
Also, wound packing and pressure bandage application can be used at this stage for larger bleeding wounds that were not previously addressed, but that should be controlled prior to the wound phase (or the “W” of MARCH-PAWS).
This video will review the principles of wound packing and pressure bandage application.
WOUND PACKING & PRESSURE BANDAGES
The first part of circulation management in TFC focuses on hemorrhage control. This includes identifying the progressive strategies for controlling external hemorrhage; identifying the signs and symptoms of a pelvic fracture; understanding the implications for placing a PCD; and identifying the indications and methods for wound packing and pressure bandages, tourniquet replacement, and tourniquet conversion.
The skills that were taught and practiced included the application of both CoTCCC-recommended and improvised PCD, wound packing and pressure bandage application, tourniquet replacement, and tourniquet conversion.
The next two modules will focus on other aspects of the circulation phase of the MARCH-PAWS sequence in the Tactical Field Care environment: recognition and management of shock, and hemorrhagic shock fluid resuscitation.
To close out this module, check your learning with the questions below (answers under the image).
Check on learning
Answers
What are the initial actions that should be taken in the circulation phase of the MARCH-PAWS sequence?
The initial action in this phase should be to ensure that there are no untreated sources of massive bleeding and reassess all previously applied tourniquets and dressings with pressure bandages to ensure bleeding is still being controlled.
What signs or symptoms are suspicious for pelvic instability?
Pelvic pain
Any major lower limb amputation or near amputation
Physical exam findings suggestive of a pelvic fracture
Unconsciousness
Shock
How do you prevent dislocation of pelvic fragments from external rotation of the lower extremities?
Prevent external rotation of the lower extremities by tying the casualty’s knees and/or feet together.
Where should you apply a deliberate tourniquet when replacing one that was placed over the uniform, like a high and tight tourniquet from Care Under Fire?
Place a replacement tourniquet directly on the skin, 2-3 inches above the wound.
What are contraindications to converting a tourniquet to wound packing and a pressure bandage?
Answer: Shock, Inability to closely monitor for rebleeding, or Amputation
