# Wound Packing



## STXmedic (Oct 24, 2012)

Quick background: Our police department is experimenting with teaching all of their officers, not just the tactical medics, on treatment of trauma with immediate life threats (for example, all of the officers are now carrying a tourniquet). 

The question was brought up about high groin/axilla arterial hemorrhages where a tourniquet would be ineffective. These guys will not be given hemostatic agents, but will be given pressure dressings. It was suggested to initially pack the wound with gauze, and then apply a pressure dressing- the idea being to get a little more directionalized pressure and absorbant gauze on the wound. There was an uproar from several of our Medical Control nurses and docs of "Absolutely not, what are you thinking". When brought up to our head Medical Director (military EM physician), his response was "Sure, why not."

So of course, I get tasked with the research. Well, after perusing all of my related texts at home, and browsing PubMed and Ovid, I'm turning up empty. My google-fu is failing me :sad:

Does anybody have any experience with this? Especially our military guys out there; what are you guys being taught (besides QuickClot or Celox)? I'd especially prefer something backed by evidence. The obvious cons I see is introduction of bacteria deep into the wound (but this is prehospital, so we run that risk anyway) and potentially making the wound worse by forcefully packing a coarse material into the wound. However, the directed pressure does seem to be a nice benefit considering the effected area.

Thoughts?


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## JPINFV (Oct 25, 2012)

If you're going to be using 4x4s, just make sure you moisten them first. It's not like wound packing isn't done all the time post op, or in emergencies in the trauma bay. Heck, it isn't uncommon to just staple head lacks in the trauma bay when they're found.


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## STXmedic (Oct 25, 2012)

JPINFV said:


> It's not like wound packing isn't done all the time post op, or in emergencies in the trauma bay.



That was my initial thought, too. I've packed surgical wounds myself. Having the nurses and docs blow up on how against it they were, I figured there's something I'm missing.


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## JPINFV (Oct 25, 2012)

I'm just a student, so maybe I'm missing something as well.


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## Veneficus (Oct 25, 2012)

PoeticInjustice said:


> The question was brought up about high groin/axilla arterial hemorrhages where a tourniquet would be ineffective. These guys will not be given hemostatic agents, but will be given pressure dressings. It was suggested to initially pack the wound with gauze, and then apply a pressure dressing- the idea being to get a little more directionalized pressure and absorbant gauze on the wound. There was an uproar from several of our Medical Control nurses and docs of "Absolutely not, what are you thinking". When brought up to our head Medical Director (military EM physician), his response was *"Sure, why not."*



That is my take on it, but I doubt it will work. 

Many providers have been taught never to stick anything into a wound. So when you suggest the opposite, there is going to be a lot of resistance and "nay" saying.

Pressure works great for controlling hemorrhage. Nearly 90% of the time. However, the core of the body is not conducive to pressure. It has major holes we call compartments. Which is why people spend a lot of money trying to develop hemostatic agents that don't rely on pressure for it.

If you pack a bleeding goin wound, likely all you will do is turn external bleeding into internal bleeding.

German trauma surgeons decades ago developed various techniques of applying indirect pressure to stop bleeding. But all of these techniques are well beyond EMS application.

About the only one I can think of that would work is to put somebody on a sponeboard and hope the bleeding raises to the level of the wound and the pressure outside the offending vasculature becomes greater than inside.

But it certainly isn't going to hurt to try your best.

One of the issues you face is the premise of acute care over "best practice." Many physicans are simply not trained or accustomed to "good enough", "the best we can do", or making stuff up as you go.  




PoeticInjustice said:


> So of course, I get tasked with the research. Well, after perusing all of my related texts at home, and browsing PubMed and Ovid, I'm turning up empty. My google-fu is failing me :sad:



Of course you are coming up empty, this is the great dilemma of acute care.

You can't do a randomized triple blinded control of patients you attempt to stop bleeding in compared to those you didn't.



PoeticInjustice said:


> Does anybody have any experience with this? Especially our military guys out there; what are you guys being taught (besides QuickClot or Celox)? I'd especially prefer something backed by evidence



We all would.



PoeticInjustice said:


> The obvious cons I see is introduction of bacteria deep into the wound (but this is prehospital, so we run that risk anyway)



Who cares?

I wouldn't sleep better at night knowing I let somebody bleed to death but they are at lower risk of septic complications from hemorrhage control.

Besides, if the wound is in that location or that bad, they are probably going to surgery anyway, and it will be cleaned.



PoeticInjustice said:


> and potentially making the wound worse by forcefully packing a coarse material into the wound.



I don't think this is going to be of major concern either. If there is an artery bleeding, it is unlikely you will make it worse. YOu could cause some increased capilary bleeding, but in the grand scheme, any increase in capilary bleed is going to be moot.



PoeticInjustice said:


> However, the directed pressure does seem to be a nice benefit considering the effected area.
> Thoughts?



Direct pressue is the best option. It is just a question of trying to actually apply pressure to the bleed.


When you are talking about SWAT injuries to the chest, axilla, and groin, you are talking about major penetrating trauma. GSW, stab wounds, blast wounds, etc. 

Lateral projectile tracts have incredibly poor outcomes. Short of an open chest on scene, I don't think you will find much improvement.

Always remember, the body doesn't magically bleed. That bleeding has a source. That source has a name. A very specific name. Like axilary artery, pulmonary artery, decending aorta, etc. 

You must address the source of the bleeding at the name. Not at the hole.

Without a scalpel or a hemostatic agent, I would advocate giving packing a try. I would even advocate to soak the packing in epi to help.

But I still doubt it will do anything other than make an external bleed internal.


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## mycrofft (Oct 25, 2012)

*This is sort of like extinguisher class against Godzilla.*

We need a MASH or ROLE 2 surgeon to answer this one.

Never equilibrate postop dressing with field dressing if the issue is life or limb.

The projectile has already screwed your sterile area, just try to slow stop the bleeding, and get them to surgery posthaste and forthwith.  Buy a SKED and use it to SKEDaddle out of there didimau.

Axillary entrances can lead to all  sorts of roundabout tracks in the thorax and even into the abdomen, but axillary artery, lungs and heart sort of pop into the fore. Airway issues may surface as you are trying to address bleeding.  (Could tamponade of unlocated external axillary bleeding potentially speed haemothorax?).

By "high groin" I imagine you are speaking of the inguinal and public regions (the "peri-naughty bits", to coin a phrase). Not as much immediate structure to worry about immediately, but fragmentation and ricochets (sacro/ pelvis) can make things tricky.

Oh, you stepped on one of my clincial sore toes when you said "absorbent". Our deep monkey brains want us to cover up and make neat any bleeding so we throw Kotexes (Combine trademark dressings/ABD's) onto bleeding. The clot is being wicked into the dressing and the cushioning might diffuse local pressure. Throw some gauze on/in to help promote a clot. Good old gauze roller ought to be handy.


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## JPINFV (Oct 25, 2012)

mycrofft said:


> Never equilibrate postop dressing with field dressing if the issue is life or limb.


Except I've seen packing done pre-op in the trauma bay when the patient didn't require emergency surgery. 



> *The projectile has already screwed your sterile area*, just try to slow stop the bleeding, and get them to surgery posthaste and forthwith.  Buy a SKED and use it to SKEDaddle out of there didimau.


It's a bit more complicated than that. Sure, it might not be "clean," but there's more choices than "clean" and "dirty." A gun shot wound would probably fall into the "clean contaminated" category, which is one step down from clean.


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## RocketMedic (Oct 25, 2012)

Poetic, the answer to this is almost too easy (San Antonio, after all).

Packing the wound is relatively effective with Kerlex, slightly moreso with quickclot on the gauze. 4x4s are not optimal, you want big, clean rolls and Ace wraps 4'' or larger for pressure. It's not perfect, but it's way better than nothing. Although the EMSA Academy has me pretty tasked out, off the top of my head, http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=8&cad=rja&ved=0CFMQFjAH&url=http%3A%2F%2Fwww.ifem.cc%2Fsite%2FDefaultSite%2Ffilesystem%2Fdocuments%2FWeb_Resources%2FBattlefield%2520Trauma%2520Lessons%2520from%2520Afghanistan.PPT&ei=69OJUND7DtG42gXZi4GQCg&usg=AFQjCNFPVHxJUVbx5JIvfuK3-jGNnigYZQ&sig2=-8pw7Zq1l0WBIDyfnTTNJw may be able to help you. Fort Sam is a literal wealth of knowledge as well.

Can you get ahold of AMEDD Center & School on Fort Sam Houston for some research and support? They're available and would love to work with civilians (career builder for a junior officer). The 32nd Medical Brigade runs training on Fort Sam, with the 232nd Battalion owning 68W training. I'm utterly certain that they'd love to help SAFD/PD with some training and literature, and possibly even facilities to run trauma lanes in. There's plenty of infrastructure on Fort Sam and Camp Bullis begging to be used.


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## RocketMedic (Oct 25, 2012)

Heck, they'd do it for free. The simulation centers on military posts are generally underbooked and looking for people to train, military or civilian. It's just that many agencies never follow through. They even provide training material.


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## jwk (Oct 25, 2012)

JPINFV said:


> If you're going to be using 4x4s, just make sure you *moisten them first*. It's not like wound packing isn't done all the time post op, or in emergencies in the trauma bay.



Why?


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## JPINFV (Oct 25, 2012)

jwk said:


> Why?




Ever have the pleasure of removing a 4x4 or kerlex that has been incorporated into the clot instead of being there to help provide pressure? Granted, this is post-op packing, but packing for post-op wounds that aren't closed are moist so they don't stick.


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## mycrofft (Oct 25, 2012)

Quote:
Originally Posted by mycrofft  
Never equilibrate postop dressing with field dressing if the issue is life or limb. 

Except I've seen packing done pre-op in the trauma bay when the patient didn't require emergency surgery. 

Sure, preop packing is good as it can prevent there being clots and loose "old" blood in the op site, not to mention any haemostatis will help prevent the need for more blood preop. 

I meant the niceties of wound packing postop are mostly to promote evacuation of secretions and healing from the bottom up, since you aren't supposed to leave surgery without haemostasis. First on scene wound packing is to stop bleeding and maybe seal a sucking wound, not nice. No intimate distribution of packing material throughout the wound as in postop packing.


Quote:
The projectile has already screwed your sterile area, just try to slow stop the bleeding, and get them to surgery posthaste and forthwith. Buy a SKED and use it to SKEDaddle out of there didimau.  

It's a bit more complicated than that. Sure, it might not be "clean," but there's more choices than "clean" and "dirty." A gun shot wound would probably fall into the "clean contaminated" category, which is one step down from clean. 

You're right, GSW _*is*_ a wide category. A GSW, especially high velocity, potentially has contaminants from the projectile, any intervening material, and any airborne contaminants (including dust) as well as any internal bleeding and nonvital tissue created by impact, circulatory disconnect, and cavitaion. Pretty dirty, and if on the ground, just filthy. If very close, also powder and maybe wadding. Abdominal penetrations get bowel contents, maybe even bile if you're lucky There are worse (tusked by a boar, punji stakes, bitten by a large reptile) but GSW's pretty darned dirty if it's anything besides a standup .25cal to the arm or upper chest.

I meant that dinking around when seconds CAN count (for a change) and especially if you are still in the danger zone trying to promote a sterile or less-septic situation is not reasonable. I wouldn't grab a handful of mud and slap it on to stop bleeding, but I'm not going to stop, wash, wash the site, use sterile technique to dress and secure the dressing. I'm going to rapidly strip the covering off anything I have that will possibly caulk the hole and shove it on while screaming GO GO GO (unless it's sucking, then the covering stays on to seal it).


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## mycrofft (Oct 25, 2012)

JPINFV said:


> Ever have the pleasure of removing a 4x4 or kerlex that has been incorporated into the clot instead of being there to help provide pressure? Granted, this is post-op packing, but packing for post-op wounds that aren't closed are moist so they don't stick.



Yeah, the compress was included in the clot (deep traumatic incision into the bicep near the shoulder), and it was basically office surgery to get it out. But the emergent bleeding had been stopped. If it is in a significant area (torso, neck, any area with  *mucho* bleeding), the patient has to go to surgery anyway, just be ready to run in blood when you go to debride that compress. Come to think of it, usually the surgeon will want to debride the clot if they cannot assure the bleeding is definitively ended and the site is CLEAN, so have the O neg or whatever ready to play.

SIDETRACK: speaking of postop packing, we had a guy who never went back for dressing change after GSW to abdomen and reconstruction of the rectus abdominis. Had fibers protruding, then an abcess which opened to reveal dark green bowel-smelling funk and more fibers.:wacko:


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## mycrofft (Oct 25, 2012)

*Moisten the compress*



jwk said:


> Why?


 If you can, as JPINV says, it can help delay it being glued into place by fibrin and albumen glue and greatly facilitates debridement. Just don't get preoccupied looking for sterile solution for a fast bleed at inguinum, pubis, or axilla, especially with respiratory decomp.

It isn't the absorbency (alone) of the compress that promotes clotting, it is the static accumulation of damaged blood, especially with a scaffold (hence spider web or chitin proteins to staunch bleeding). That's why I get rid of teflon (Telfa) compresses from kits except bandaids, and limit Combine trademark dressings.

Can ANYONE get a ROLE 2 surgeon or MASH doc to get in this thread? :unsure:

PS: just saw I originally referred to the pubic area (anterior superior groin) as the "public" area.:blush:


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## JPINFV (Oct 26, 2012)

mycrofft said:


> I meant that dinking around when seconds CAN count (for a change) and especially if you are still in the danger zone trying to promote a sterile or less-septic situation is not reasonable. I wouldn't grab a handful of mud and slap it on to stop bleeding, but I'm not going to stop, wash, wash the site, use sterile technique to dress and secure the dressing. I'm going to rapidly strip the covering off anything I have that will possibly caulk the hole and shove it on while screaming GO GO GO (unless it's sucking, then the covering stays on to seal it).


 

The funny thing is that post-op dressing changes aren't 100% sterile either (i.e. sterile gloves, gown, hat, mask, field, etc). Clean? Sure, but clean can easily be obtained in the field by not ****ing around between opening the package and putting it in the wound (before someone claims otherwise because in the field is "in the field"). Why are we concerned about sterile technique when time is of the essence when day 2 surgery kids (med students) are allowed to poke around and repack post op wounds when time is plentiful?


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## Veneficus (Oct 26, 2012)

mycrofft said:


> Can ANYONE get a ROLE 2 surgeon or MASH doc to get in this thread? :unsure:



I am not sure it is possible or that it would really add anything. I have seen military doctors do some outright assinine stuff to patients under the guise of "this is war."

I also fight a rather impossible battle trying to show civilian surgeons that there is benefit to damage control surgery and not treating all patients like somebody you preselected for outpatient. 

I can also tell you that surgeons are nearly as difficult to convince as aesthesiologists.

Not realy different from EMS providers doing the same and claiming "in the field things are different."

One of the craziest things I ever saw working in a trauma center was one of the trauma surgeons pulling out a foley catheter sticking it in the lumen of a incised caratid artery, inflating the baloon and typing off the end. Then simply taking off his gloves and with an annoyed sigh ask somebody bring the patient to surgery in 15 minutes. 

I saw the some doc create a temporary graft with off the shelf IV tubing in another patient at a later time.

I thought this guy was the epitomy of fast thinking being able to improvise that in the moment. 

Then a couple years later, I read about both of those techniques in a textbook. (It was sort of a let down to find out everyone knew that stuff)

The military also has a vastly more efficent system for combat casualty care than the civilians do. At the Role III we are familiar with, and I am sure elsewhere, trauma patients never stop at the ED. They never make it out of the trauma area. They are recieved by trauma surgeons and are taken right to surgery or right to the ICU.

A highly respected ED doc, who is also a colonel in the army medical corp, I know likes to say the only business an EM has in severe trauma is to wave "goodbye" to the patient on their way to surgery. He advocates the ED not even try to help those patients as it is just a waste of time.

It is the same way with Field treatment. Like I said above, if the person bleeds out, we can all sleep better knowing they didn't get septic or the dressing didn't become part of the clot and was more complicated to remove. I am sure pathology is appreciative of the later too.

In a life threatening hemorrhage the only goal is to stop the bleeding. If it is neat, clean, and doesn't make things more complicated down the pike, that is a bonus.


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## RocketMedic (Oct 26, 2012)

So basically, go forth to the Fort.


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## JPINFV (Oct 26, 2012)

Veneficus said:


> The military also has a vastly more efficent system for combat casualty care than the civilians do. At the Role III we are familiar with, and I am sure elsewhere, trauma patients never stop at the ED. They never make it out of the trauma area. They are recieved by trauma surgeons and are taken right to surgery or right to the ICU.


 

Shrug, that's how it is at the hosptial I'm currently at. Trauma patients (unless it's really minor) go to the trauma bay and the trauma team (gen surg). Alerts and activations get help from EM residents and attendings, but the trauma team is still primary.


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## Ace 227 (Oct 26, 2012)

Pack and wrap is pretty standard in the military.  Especially for inguinal wounds. I could see where some axial wounds might be better treated with an occlusive dressing but packing to stop bleeding is certainly an option.  You've got to stop the hemorrhage, however you can. 

 And for what its worth, the current generation of hemostatic agents(Combat Gauze, chitogauze, celox, etc.) still require as much pressure as kerlix to be effective and they've shown that, properly applied, kerlix works just as well.


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## Veneficus (Oct 26, 2012)

JPINFV said:


> Shrug, that's how it is at the hosptial I'm currently at. Trauma patients (unless it's really minor) go to the trauma bay and the trauma team (gen surg). Alerts and activations get help from EM residents and attendings, but the trauma team is still primary.



That is how a lot of civilian trauma centers work. 

Some with EM as the primary or a rotating basis for experience. 

The military has several mechanisms in place that I have not seen in any civilian trauma system. 

Not least of which is a surgeon at a forward position that can enact immediate temporizing repair so the soldier can be moved to the main trauma center.

Then there is the specifics of damage control surgery, which I have not seen or even heard of in a civilian hospital. 

Hemostasis or temporizing repair prior to aggresive resus. Followed by evac to yet an even higher level of care in Germany or the US for definitive, cosmetic, etc treatment

That chain and the techniques involved were developed over the last 10+ years of war. 

Generally in the civilian world, all life saving surgery is definitively finished prior to closure. 

Like in many events, for a variety of reasons, not least of all is money, and convenience of the facility/providers, the newly demonstrated effective ways are not adopted. It might be "the standard of care" after another 50 years of study and arguments over "this is not the military."

In my 4+ years in a major US trauma center, I have always seen an attempted resuscitation prior to surgery. If the patient is "stabilized" in the trauma bay, then they go to surgery.

That is exactly the opposite of what the military is doing. (with outstanding results)


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## Brandon O (Oct 26, 2012)

mycrofft said:


> Yeah, the compress was included in the clot (deep traumatic incision into the bicep near the shoulder), and it was basically office surgery to get it out. But the emergent bleeding had been stopped.



To me, this seems like a good thing. Presumably by the time somebody's going in to debride the site, they're in a position to enact more definitive control of the bleeding.


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## mycrofft (Oct 26, 2012)

I think the "Everybody stops at the Emergency Room" deal is an outgrowth of triaging civilain ills, and the practice in the old days of MASH that once incoming were triaged, those headed for surgery needed some fluid resuscitation or a chest tube or such to be able to survive anesthesia and surgery. This allowed them to pace their entry into Surgery, and any iffy cases would die and not waste their time.


Not exactly the goal of modern civilian ED's!


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## Doczilla (Nov 8, 2012)

Regular kerlix is 80% as effective as hemostatic gauze. 

Also consider that if the ENTRANCE is high inquinal, theres a good chance that the wound tracked into the pelvis. 

Not saying it does no good to pack it, but if you're gonna do it, don't do it half a$$ed. Either pack it or dont. 

Don't mess around with it in lieu of getting them to bright lights and cold Steel though.


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## mycrofft (Nov 8, 2012)

Amen.


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## DPM (Oct 24, 2014)

Resurrecting an old thread here I know, but I'm seeing some faces in here whose opinions I would like to hear. 

http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2011.01036.x/full 

That is a link to a study on wound packing using some commercially available hemostatics, and the results are quite interesting. We used Z-fold Celox gauze when I was last in Afghan, as well as CAT tourniquets, Israelis pressure dressings and a few different types of chest seals. 

I've see how successful hemostatic gauze can be on non-compressible and 'junctional' bleeds first hand.  

So my point is thus- in light of current operational success with hemostatics and wound packing, what is the civilian consensus? Do we have a better way of managing catastrophic bleeding when urgent evacuation isn't possible?


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## Mtoone (May 11, 2016)

Im no expert by any means (military CLS is all) but the first rule we are taught is any primary artery severance typically causes death within 5 minutes of inital trauma, with that in mind, what are the odds of a ambulance arriving within 5 minutes of a i flicted wound? Applying an exterior bandage with pressure wont stop the bleeding of those cavities of the wounds being described. 
Theres alot of room to bleed into. Applying a bandage on the inside forcing the artery to stay in place were pressure can be applied will keep it from moving, and then applying more gauze to fill the cavity will create a "wicking" effect, giving the moisture some where other then the insides of the body to travel to. A little statistics from a field surgeon from my division, nearly 87% of axillary and inguinal wounds that are treated by packing gauze and improvising a pressure dressing are livable wounds. 
Alas thats not the actual civilian world, thats military, but if you are intrested in "field expedient" medical care, try getting in touch with a military componet and ask them about it, 9/10 times they have a wealth of knowledge and personal experience of matters of this sort.


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## CANMAN (May 14, 2016)

Dr. Nicholas Senn (Previous president of the AMA and Founder of the Association of Military Surgeons of the United States said in 1898 "The fate of the wounded rests in the hands of the one that applies the first bandage". 120 years later patients are still dying of hypovolemic shock from wounds treated with big bulky dressings. I think the quote should be updated to "The life of the wounded rests in the hands of the one who applies the correct tools to actually stop the bleeding". 

We are currently carrying Quick Clot Z-Fold gauze for wound packing at my service, and will often use it in conjunction with an H bandage for wound compression. We also have tourniquets but like others have pointed out they will not be effective for a groin wound. Quick hemorrhage control, rapid admin of our blood products, and get the patient to the OR as quick as we can...We have seen alot of success deploying the Z-fold gauze with the H bandage on both scene and IFT flights where hemorrhage is still uncontrolled when we get to patient side.


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## ExpatMedic0 (May 15, 2016)

Just to confirm, (excluding commercial hemostatic agents), wound packing is still not part of the national paramedic educational curriculum, nor is it standard practice in civilian EMS scope of practice for most state certifications (excluding regional protocols) correct?


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## EpiEMS (May 15, 2016)

ExpatMedic0 said:


> Just to confirm, (excluding commercial hemostatic agents), wound packing is still not part of the national paramedic educational curriculum, nor is it standard practice in civilian EMS scope of practice for most state certifications (excluding regional protocols) correct?



Couldn't find it in the Instructional Guidelines on the EMS.gov site. Seems like it's PHTLS/TCCC/TECC-approved. Also, looks like it's DHS-sanctioned: https://www.amr.net/solutions/feder...nces-and-resources/dhs-tactical-ems-guide.pdf see page 71


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## Tigger (May 15, 2016)

We were taught into my medic class but there wasn't any sort of reference for it.


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## ExpatMedic0 (May 16, 2016)

I took ITLS last year, there was no mention of it in the class. No mention it of it under the national paramedic scope of practice model, nor any of the states procedural scope of practice models I am certified in. It would appear that this is still an "up and coming" thing for civilian EMS and still regional and agency specific. However, if it was in your PHTLS class I am really surprised it has not became more main stream.


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## NYBLS (May 18, 2016)

We went over it pretty extensively in TCCC and ITLS, but it may be instructor dependent. Its been utilized in the military for years, its silly to not adapt it if it works.


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## Dustoff707 (May 28, 2016)

Army Medic here. We're trained and train all our guys on hemostatic dressings. Wound packing of all neck, axillary, and inguinal wounds. We don't pack groin wounds, no point normally but I suppose it would be case dependent to an extent. Pack as much quikclot in as possible, hold pressure for at least 3 minutes and then wrap it with a pressure dressing of some sort. ETB, ace wrap, etc.. Technique depends on the location of the wound and believe me packing wounds works.


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## gotbeerz001 (May 28, 2016)

Took PHTLS recert yesterday and they addressed hemostatic agents and wound packing as accepted practice. 


Sent from my iPhone using Tapatalk


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## Alex07 (Jan 18, 2017)

So for more so those who find this while searching,  I came across this looking for wound packing slides in hopes I wouldn't have to make them -__-  But anyways reading this thread I think most people are missing the fact that this is being taught for emergency intervention prehospital.  In the hospital they may wound pack or utilize other means. When I deploy I always have several tourniquets on me to include a junctional, if I have uncontrolled bleeding, I would use one of those immediately, even stateside in ambulance services hands down. However, if I don't have a junctional tourniquet or I have a GSW to a weird place, then I would wound pack the hell out of it.  the notion of holding pressure and elevating makes sense on paper but in an emergency or during care under fire (police too) your not gonna sit there with your hand on a wound waiting when you have other things that take precedence which is when wound packing becomes a great alternative.  Idk about others but Civilian Paramedicine does talk about wound packing, at least the school I went to.  Military PHTLS and TCCC go way more in-depth with it as well to include hemostatic agents.  To properly do it, its best to use something like compressed gauze or kerlix so you don't have a bunch of pieces everywhere, but you use what you have.  Also, just packing a wound wont do anything but act like a sponge, the idea of it is if you know your anatomy and can find the source of the bleeding, your initial packing will be on the vessel to help potentiate clotting and then pack the hell out of the wound to give it added pressure.  I cant speak for hospital protocols, but if your teaching policemen or firefighters or medics this is what I've done and seen in my experience both stateside and deployed.


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## ExpatMedic0 (Jan 18, 2017)

I've been a medic since 2006 and in EMS since 2002. I had not been taught wound packing until a couple of years ago. This class was only a "local in-service training" by a commercial hemostatic agent company representative that came to our ambulance HQ. I did ITLS in 2015, and my friend did his last month at a different agency, neither of our courses covered wound packing in the lectures or the practicals. I am shocked that it's not in the ITLS courses.


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## Alex07 (Jan 18, 2017)

I cant speak on ITLS or much on the civilian side.  I know Pima CC's paramedic program incorporates it sparcely, but it is taught pretty in depth in the military.  I know the army paramedic program has it as a skill and so does the air force's medical technician as well.  We go through PHTLS Military and TCCC which also discusses the uses of it and ATLS Military as well.  Its also going to probably depend on the agency you work for too as our ride alongs on the civilian side at Baltimore that's also a skill set for EMT-B and EMT-P.  I mean I haven't had to do it many times in my career I almost always used a tourniquet and if I have time ill pack the wound to prevent foreign matter to get into it. There are several skills that one agencies would use or teach versus others.  As far as the teaching programs it would also depend on the curriculum as well. PCC had more certs and classes than other traditional EMT or paramedic programs I've researched.


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## EpiEMS (Jan 18, 2017)

@Alex07, very informative commentary - thanks!

Do you generally have hemostatic dressings available for wound packing in the tactical setting? Or are you limited to the standard fabric stuff?


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## Alex07 (Jan 18, 2017)

EpiEMS said:


> @Alex07, very informative commentary - thanks!
> 
> Do you generally have hemostatic dressings available for wound packing in the tactical setting? Or are you limited to the standard fabric stuff?



Well...im deployed right now and im fortunate to have both. Combat gauze is amazing and i have compressed gauze too. my previous deployments ive only had compressed gauze ie the ones u get in IFAKs, it just depends. stateside in our ambulance service we have both available as well. I kno besides where im at now, its pretty standard for the military to use combat gauze. we no longer use the powdered quik clot with regular gauze anymore, only plane or hemostatic gauze due to safety hazards.


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## STXmedic (Jan 18, 2017)

EpiEMS said:


> @Alex07,Do you generally have hemostatic dressings available for wound packing in the tactical setting? Or are you limited to the standard fabric stuff?


All of our tactical medics, both on the PD and FD side, have hemostatic agents in our kits. Each of our SWAT operators also have henostatic agents (as well as other equipment of course) in the IFAKs on their kits as well.


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## Summit (Jul 4, 2018)

Bump for the latest discussion.

Our regional protocols now specifically discuss and allow hemostatic gauze and wound packing, and prohibit powdered/granulated hemostatics. Tourniquet first if tourniquet is necessary.

With respect to hemostatics, here is a good overview of the current agents:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869418/

Additional reading tells me that sponges (e.g., Quickclot ACS+) and power/granule hemostatics (e.g., Celox A or Traumadex powder) are inferior to hemostatic gauze

I've also gleaned that if one is going to believe that hemostatics are superior to gauze (there are studies showing nonsuperiority), that Celox Rapid is superior to other Celox or Quickclot products.

I've used a regenerated cellulose gauze in the past (ActCel) and this study shows Bloodstop iX BattleMatrix (mouthfull) as superior to QuickClot Combat gauze (kaolin mineral based): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849001/

I've not found a good study comparing say Celox Rapid to a regenerated cellulose gauze. Cellulose and chitosin products are much easier to remove from a wound than products using kaolin which usually requires surgical debridement.


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## VFlutter (Jul 4, 2018)

Good info. Choosing a hemostatic agent can be daunting. Currently have Celox granules in my kits but that was more so due to cost.


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## Bullets (Jul 5, 2018)

we are using Chitosan z fold gauze, my supplier gets it for like $12 per gauze pack, which is like a third of quick clot. Havent had a chance to use it yet though


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## ExpatMedic0 (Jul 31, 2018)

The z  packs (gauze not antibioitcs lol) we carried had no hemostatic agent, they where just compressed gauze. Maybe that's why it's cheaper?


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