Wound Packing

[STXmedic]

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?

 

[JPINFV]

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.

 

[STXmedic]

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.

 

[JPINFV]

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

 

[Veneficus]

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.

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.

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.

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.

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.

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.

 

[mycrofft]

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.

 

[JPINFV]

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.

 

[RocketMedic]

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.

 

[RocketMedic]

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.

 

[jwk]

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?

 

[JPINFV]

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.

 

[mycrofft]

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).

 

[mycrofft]

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:

 

[mycrofft]

Moisten the compress

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:

 

[JPINFV]

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?

 

[Veneficus]

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.

 

[RocketMedic]

So basically, go forth to the Fort.

 

[JPINFV]

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.

 

[Ace 227]

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.

 

[Veneficus]

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)