Severe hemorrhage

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I know there have been some older threads, but yall mentioned in the past upcoming changes in your management of these calls and I am curious to see how things have changed since. @VFlutter @RocketMedic

We have had two (that I know of or was assisting with) femoral GSW's that led to an arrest prior to crews leaving scene in the past few weeks. Those along with some articles I've read have got me thinking about if there are other things we could be doing with these patients that would be beneficial. I am thinking about finding some resources to pitch to our clinical staff about adding to what we can do for these patients.

For reference with the location of the last one, at best you are looking at about 25 minutes from time of occurrence to arrival at the hospital. There are areas in the city that would be less than that, but there are areas where I am not a 3 minute drive away and are the reason I dislike the "but you're only about 5 minutes away from a hospital" line people fall back on as excuses for some things. All this is assuming a short staging time, you don't have to go far to find the pt, no extrication issues, traffic/weather, and so on.

I've never worked first hand with anything besides tourniquets, so I want to hear yalls experience with what you're using, what was the decision to use it based on, or thoughts on new research that is coming out worth mentioning. Curious to hear about everything, whether it be quickclot, PRBC/plasma vs whole blood, TXA, etc. I know there is a fine line with some patients in the fact that we aren't definitive care, but some of the things I've seen or heard about lately has me wondering if we can do a better job of extending that clock to even make it to that point.
 
I have not used one personally but I think Junctional Tourniquets are the best option and heavily used in the military. Other than that just pack the wound (with quickclot if you got it) and direct pressure. One person keeps their fist in the groin as everyone else works the code. TXA is a good choice. PRBCs are probably the only intervention, other than hemorrhage control, that will make a difference.


If you are trying to pitch a product the Sam Junctional Tourniquet that look similar to their pelvic binders is what I would get.
 
Never even knew that was a thing. I have a feeling the price would make that likely a no, but I'll look at it some tonight. And no, we don't have quickclot or any similar product. Wound packing would just have to be standard gauze.
 
Junctional tourniquets and old-fashioned manual pressure on the descending aorta are the only two reasonable fixes here imo. Your regulatory infrastructure won't allow field transfusions and there's too many financial, operational and clinical barriers to realistically implement that at RAA.
 
When you're marketing it, phrase it towards "could save police lives, etc". The problem with junctional tourniquets is that they're expensive, and I've yet to meet an agency that doesn't gripe about the cost of normal tourniquets, to say nothing of fancy rarely-used ones. Saving Officer Awesome or Sherrif McFriendly is an easier sell than the gangster it'll most likely get used on.
 
VFlutter said:
IRRC they are around $350-500. They should be reusable. Maybe some type of grant or public funding?
https://www.sammedical.com/products/sam-sjt
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Looks like it's dual use, too (as a pelvic binder)?

RocketMedic said:
Junctional tourniquets and old-fashioned manual pressure on the descending aorta are the only two reasonable fixes here imo. Your regulatory infrastructure won't allow field transfusions and there's too many financial, operational and clinical barriers to realistically implement that at RAA.
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Just wait for field REBOA...?
 
EpiEMS said:
Looks like it's dual use, too (as a pelvic binder)?



Just wait for field REBOA...?
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Its closer than you think.



Junctional tourniquets are good. Depending on where the wound is though the best course of action may be to go knuckle deep in the wound, find the artery and manually compress until you can get a clamp in there.
 
TXmed said:
Its closer than you think.



Junctional tourniquets are good. Depending on where the wound is though the best course of action may be to go knuckle deep in the wound, find the artery and manually compress until you can get a clamp in there.
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I disagree. REBOA isn't a skill that is quickly implemented even in a level 1 trauma center, typically takes a few minutes by well trained trauma surgeons. I doubt EMS is close/if at all to getting REBOA in the field for many reasons, mainly being you have a medic screwing around trying to accomplish this task on scene vs. moving patient towards cold steel and bright lights which is what they need anyway. REBOA is a great tool when deployed quickly and executed flawlessly, and I don't know how many you have seen performed or have done, but it's not the easiest skill to do and CONFIRM, now add in doing it in the field. Most of the trauma docs I work with aren't huge fans, and are well versed in placement.
 
If it is reusable, that would be a much easier idea to sell.

I still think we could benefit from adding quickclot, txa, supervisors carrying blood products, or some combination of the above. The other injury I'm thinking of with some of these are the central wounds where there isn't much to compress, pack, clamp, etc.

As far as REBOA in the field, the only way I see that happening is with the docs that ride out with us on occasion. Maybe then. That isn't most days though and I wouldn't be counting on having it available since I never know when those days are.
 
If you don't have immediate access to QuickClot or similar product and you don't have access to a CAT or similar TQ, for lower limb injury, shove a knee into a groin & get weight onto it, and do wound packing. For more central wounds that are just too high even for a "junctional" device, pack what you can, load and go. Place a couple of large bore lines, not for YOU to flood the patient, but so the hospital has 2 large bore lines (at least 18g) to infuse blood via their massive transfusion protocol. Key thing: don't wait around, load and go. This is one instance where doing EMT thinking on scene and any "advanced" stuff en-route is a life-saver.
 
Akulahawk said:
If you don't have immediate access to QuickClot or similar product and you don't have access to a CAT or similar TQ, for lower limb injury, shove a knee into a groin & get weight onto it, and do wound packing. For more central wounds that are just too high even for a "junctional" device, pack what you can, load and go. Place a couple of large bore lines, not for YOU to flood the patient, but so the hospital has 2 large bore lines (at least 18g) to infuse blood via their massive transfusion protocol. Key thing: don't wait around, load and go. This is one instance where doing EMT thinking on scene and any "advanced" stuff en-route is a life-saver.
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This, every word of it.
 
I doubt that REBOA will ever become big in the field; because of the lack of blood flow to the liver, kidney, and mesentary you have about 30-60 minutes to have a definitive surgical outcome or the associated distal ischemia outweighs the benefit of placement.

Akulahawk said:
If you don't have immediate access to QuickClot or similar product and you don't have access to a CAT or similar TQ, for lower limb injury, shove a knee into a groin & get weight onto it, and do wound packing.
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This is what we do even in the ED. Keep pressure and get them up to surgery. Cross clamps and REBOA are only for arrests/when our MTP cannot keep up with their blood loss.
 
Akulahawk said:
Key thing: don't wait around, load and go. This is one instance where doing EMT thinking on scene and any "advanced" stuff en-route is a life-saver.
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This is one thing we do well. We will usually be at a hospital <30 minutes and often closer to 20 assuming everything goes as it should. The last guy I took was 21 minutes dispatch to hospital with a 6 mile drive and 10 of those minutes were spent driving. We do good at not wasting time, but I've been looking at material based off of the military to see if we can do better. I certainly have the time on the way to the hospital to do more than I currently can. I don't want to propose anything that would overcomplicate things and add unnecessary time, but we have had multiple calls I think the ability for more aggressive treatments sooner may have been of some benefit.
 
Akulahawk said:
This is one instance where doing EMT thinking on scene and any "advanced" stuff en-route is a life-saver.
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I so love this approach when it comes to legitimate trauma's. As far as the knee into the groin and put weight on it I've heard of this technique... think I read about it on some military trauma writeup or something like that. Does it work as good as the limited reading I've done on it say's? I doubt I'll ever run into a scenario like this, but the more you know...
 
Also, like most major trauma I would have a low threshold for needle compression. Bullets have crazy trajectories.
 
CALEMT said:
I so love this approach when it comes to legitimate trauma's. As far as the knee into the groin and put weight on it I've heard of this technique... think I read about it on some military trauma writeup or something like that. Does it work as good as the limited reading I've done on it say's? I doubt I'll ever run into a scenario like this, but the more you know...
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It works pretty well as most of these injuries are going to take alot of pressure to compress and tamponade anything in that region, certainly depending on body habitus. It came out of military and TEMS operations because it allows you to do initial base hemorrhage control for an arterial bleed and still have both hands free to return fire or perform other interventions/ready equipment for example.
 
I had a femoral GSW which we were able to control with a strong knee in the groin. We rode like that to the ER a few miles away. After that we purchased the JETT, but now we have the Sam sling which can also be used as a pelvic binder. The knee in groin trick was taught to us in TCCC.

In my agency i stock all my rigs jump bags with the blow out kit supplies, as well as an IFAK pouch under each seat for each provider. At this point, hemostatic dressings, tqs, and chest seals are basic supplies every apparatus should have. The pelvic binders are a little pricey, but how often are we really using them? I bought them a year ago and havent used them yet.

All that ALS stuff is great if you have time, but i wont wait for an ALS intercept and id be pissed of a BLS squad waited for me to get there.
 
CALEMT said:
I so love this approach when it comes to legitimate trauma's. As far as the knee into the groin and put weight on it I've heard of this technique... think I read about it on some military trauma writeup or something like that. Does it work as good as the limited reading I've done on it say's? I doubt I'll ever run into a scenario like this, but the more you know...
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I can put more weight/pressure onto a groin using my knee than I can comfortably do with my hands. Doing this also keeps my hands free for doing things like wound packing and TQ placement. I was taught this by a good friend of mine who is a corpsman. He's a TCCC instructor. Yes, putting that much pressure onto someone's groin to stop/slow bleeding down is going to be VERY uncomfortable for the person you're doing this to... but it very well may help you save their life.
 
Ever had a patient who was mentating normally enough to complain about pain from ischemia caused by a TQ? How'd you manage that?
 
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