Hemorrhage ControlHemorrhage ControlCOMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)
CMAST 2IntroductionIntroduction Review methods of hemorrhage control inReview methods of hemorrhage control ina tactical environment.a tactical environment. Hemorrhage is the leading cause ofHemorrhage is the leading cause ofpreventable death on the battlefield.preventable death on the battlefield. Hemorrhage control save lives.Hemorrhage control save lives. New Hemostatic agents available.New Hemostatic agents available.
CMAST 3Cardiovascular SystemCardiovascular System
CMAST 6BloodBlood Adult body:Adult body:– Contains approximately 5 to 6 liters of bloodContains approximately 5 to 6 liters of blood– Loss of 1 pint of blood without harmful effectsLoss of 1 pint of blood without harmful effects– Loss of 2 pints may cause shockLoss of 2 pints may cause shock Three phases ofThree phases ofhemostasis:hemostasis:– Vascular spasmVascular spasm– Platelet plug formationPlatelet plug formation– Blood clottingBlood clotting(coagulation cascade)(coagulation cascade)
CMAST 7HemorrhageHemorrhage Pulse vs. Blood Pressure.Pulse vs. Blood Pressure. How long until there are changes?How long until there are changes? Young healthy adults compensate for longYoung healthy adults compensate for longperiods, then decompensate rapidly.periods, then decompensate rapidly. At what blood pressure do casualties loseAt what blood pressure do casualties loseconsciousness?consciousness?─ @ 50 mm Hg@ 50 mm Hg
CMAST 8Clinical Signs of Acute HemorrhageClinical Signs of Acute HemorrhageClassClass % Blood% BloodLossLossClinical SignsClinical SignsII Up to 750 mlUp to 750 ml(15%)(15%)Slight increase in HR; no change in BPSlight increase in HR; no change in BPor respirationsor respirationsIIII 750-1500 ml750-1500 ml(15-30%)(15-30%)Increased HR and respirations;Increased HR and respirations;increased diastolic BP; anxiety, fright orincreased diastolic BP; anxiety, fright orhostilityhostilityIIIIII 1500-20001500-2000ml (30-40%)ml (30-40%)Increased HR and respirations; fall inIncreased HR and respirations; fall insystolic BP; significantsystolic BP; significant AMSAMSIVIV >2000>2000(>40%)(>40%)Severe tachycardia; severe lowering ofSevere tachycardia; severe lowering ofBP; cold, pale skin; severe AMSBP; cold, pale skin; severe AMS
CMAST 9Sources of HemorrhageSources of Hemorrhage External:External:– Visible blood is hard to estimateVisible blood is hard to estimate Internal:Internal:– May be hidden within the torso or even inMay be hidden within the torso or even inthe extremities secondary to fracturesthe extremities secondary to fractures
CMAST 10Sources of External BleedingSources of External Bleeding Arterial:Arterial:─Rapid, profuse and pulsatingRapid, profuse and pulsating─Bright red in colorBright red in color Venous:Venous:─Steady flowSteady flow─Dark red or maroon in colorDark red or maroon in color Capillary:Capillary:─Slow and oozingSlow and oozing─Often clots spontaneouslyOften clots spontaneously
CMAST 11Extremity HemorrhageExtremity HemorrhageClick on picture for video
CMAST 12Internal Signs of HemorrhageInternal Signs of Hemorrhage Soft tissue bruising.Soft tissue bruising. Abdominal tenderness.Abdominal tenderness. Hemoptysis.Hemoptysis. Hematemesis.Hematemesis. Melena.Melena.
CMAST 14Hemorrhage ControlHemorrhage Control Assess the tactical situation.Assess the tactical situation. Expose the wound.Expose the wound. Attempt to control theAttempt to control thebleeding with directbleeding with directpressure or a pressurepressure or a pressuredressing.dressing.
CMAST 16Hemorrhage ControlHemorrhage ControlClick in box for video
CMAST 17Hemorrhage ControlHemorrhage Control Life-threatening arterial bleedingLife-threatening arterial bleeding(amputation) may require early use of a(amputation) may require early use of atourniquet.tourniquet. If under enemy fire or in a dangerousIf under enemy fire or in a dangerousposition rapidly apply a tourniquet andposition rapidly apply a tourniquet andmove casualty to cover.move casualty to cover.
CMAST 18TourniquetsTourniquets Several new tourniquets have beenSeveral new tourniquets have beenselected as primary means to controlselected as primary means to controlhemorrhage in combat.hemorrhage in combat.
CMAST 19Combat Application TourniquetCombat Application TourniquetWINDLASSSELF ADHERING BANDWINDLASS STRAP The C-A-T was selected as the primary tourniquetThe C-A-T was selected as the primary tourniquetfor every soldier.for every soldier.
C-A-T Step 1C-A-T Step 1Place thewoundedextremitythrough the loopof the Self-adhering Band
C-A-T Step 2C-A-T Step 2Place tourniquetabove the injurysite
C-A-T Step 3C-A-T Step 3Pull the free-running end ofthe Self-adheringBand tight andsecurely fasten itback on itself.
C-A-T Step 4C-A-T Step 4Adhere Self-adhering Bandcompletelyaround the limbuntil the clip isreached.
CMAST 35SOFTT ApplicationSOFTT Application Similar to the CAT:Similar to the CAT:─ Slide loop over extremitySlide loop over extremity─ Pull strap tightPull strap tight─ Twist windlass untilTwist windlass untilbleeding stopsbleeding stops─ Latch the windlassLatch the windlasswith one of thewith one of thetri-ringstri-rings─ Tighten the safetyTighten the safetyscrewscrew
CMAST 37Improvised TourniquetImprovised Tourniquet Place cravat between heart and wound.Place cravat between heart and wound. Tie a half-knot on upper surface.Tie a half-knot on upper surface. Place a short stick on half-knot.Place a short stick on half-knot. Tie a square knot on top ofTie a square knot on top ofstick.stick. Twist stick (windlass) toTwist stick (windlass) totighten.tighten. UNTIL BLEEDING STOPS.UNTIL BLEEDING STOPS. Secure windlass to prevent unwinding.Secure windlass to prevent unwinding.
CMAST 39Tourniquet PrinciplesTourniquet Principles Never cover a tourniquet.Never cover a tourniquet. Mark a “T” on the casualtys forehead orMark a “T” on the casualtys forehead orsomewhere obvious (sharpie pen).somewhere obvious (sharpie pen). In combat when the tactical situationIn combat when the tactical situationallows, loosening a tourniquet isallows, loosening a tourniquet isappropriate.appropriate.
CMAST 40Tourniquet RemovalTourniquet Removal Once the tactical situation allows,Once the tactical situation allows,tourniquets should be loosened and othertourniquets should be loosened and othermethods to stop bleeding applied.methods to stop bleeding applied.─Direct pressure - pressure dressingDirect pressure - pressure dressing─HemCon Chitosan BandageHemCon Chitosan Bandage─QuikClot powderQuikClot powder
CMAST 41Tourniquet RemovalTourniquet Removal When loosening a tourniquet, do notWhen loosening a tourniquet, do notremove it from the limb.remove it from the limb. If the tourniquet has been in place forIf the tourniquet has been in place for> 6 hours, do not remove.> 6 hours, do not remove. If fluid resuscitation is required, it shouldIf fluid resuscitation is required, it shouldbe accomplished before the tourniquetbe accomplished before the tourniquetis removed.is removed. Tourniquets are very painful, provideTourniquets are very painful, providepain medications as needed.pain medications as needed.
CMAST 42Tourniquet RemovalTourniquet Removal If tourniquet has been in place for onlyIf tourniquet has been in place for only1-2 hours, loosening and using other1-2 hours, loosening and using othermethods to control hemorrhage canmethods to control hemorrhage cansalvage limbs.salvage limbs. Remember: if unable to controlRemember: if unable to controlhemorrhage by other means, re-tightenhemorrhage by other means, re-tightenthe tourniquet.the tourniquet. It is better to sacrifice the limb than toIt is better to sacrifice the limb than tolose a life to hemorrhage.lose a life to hemorrhage.
CMAST 43AmputationAmputation Apply a pressure dressing to cover theApply a pressure dressing to cover theend of the stump.end of the stump. Kerlix and 6” Ace wrap for effectiveKerlix and 6” Ace wrap for effectivepressure dressing.pressure dressing. Rinse amputated part free of debris.Rinse amputated part free of debris. Wrap loosely in saline-moistened sterileWrap loosely in saline-moistened sterilegauze.gauze.
CMAST 44Preservation of Amputation PartsPreservation of Amputation Parts Seal amputated part in a plastic bag orSeal amputated part in a plastic bag orcravat.cravat. Place in a cool container; do not allow toPlace in a cool container; do not allow tofreeze.freeze. Never place an amputated part in water.Never place an amputated part in water. Never place amputated part directly on ice.Never place amputated part directly on ice. Never use dry ice to cool an amputatedNever use dry ice to cool an amputatedpart.part.
CMAST 46Chitosan Hemostatic DressingChitosan Hemostatic Dressing Hold the foil over-pouch so that instructions canHold the foil over-pouch so that instructions canbe read. Identify unsealed edges at the top of thebe read. Identify unsealed edges at the top of theover-pouch.over-pouch.
CMAST 47Chitosan Hemostatic DressingChitosan Hemostatic Dressing Peel open over-pouch by pulling the unsealedPeel open over-pouch by pulling the unsealededges apart.edges apart.
CMAST 48Chitosan Hemostatic DressingChitosan Hemostatic Dressing Trap dressing between bottom foil and non-Trap dressing between bottom foil and non-absorbable green/black polyester backing withabsorbable green/black polyester backing withyour hand and thumb.your hand and thumb.
CMAST 49Chitosan Hemostatic DressingChitosan Hemostatic Dressing Hold dressing by the non-absorbable polyester backingHold dressing by the non-absorbable polyester backingand discard the foil over-pouch. Hands must be dry toand discard the foil over-pouch. Hands must be dry toprevent dressing from sticking to them.prevent dressing from sticking to them.
CMAST 51Chitosan Hemostatic DressingChitosan Hemostatic Dressing Place the light colored sponge portion of thePlace the light colored sponge portion of thedressing directly to the wound area with thedressing directly to the wound area with themost severe bleeding. Apply pressure for 2most severe bleeding. Apply pressure for 2minutes or until the dressing adheres andminutes or until the dressing adheres andbleeding stops. Once applied and in contactbleeding stops. Once applied and in contactwith the blood and other fluids, the dressingwith the blood and other fluids, the dressingcannot be repositioned.cannot be repositioned. A new dressing should be applied to otherA new dressing should be applied to otherexposed bleeding sites; each new dressingexposed bleeding sites; each new dressingmust be in contact with tissue where bleedingmust be in contact with tissue where bleedingis heaviest. Care must be taken to avoidis heaviest. Care must be taken to avoidcontact with the casualty’s eyes.contact with the casualty’s eyes.
CMAST 52Chitosan Hemostatic DressingChitosan Hemostatic Dressing If dressing is not effective in stoppingIf dressing is not effective in stoppingbleeding after 4 minutes, remove the originalbleeding after 4 minutes, remove the originaland apply a new dressing. Additionaland apply a new dressing. Additionaldressings cannot be applied over ineffectivedressings cannot be applied over ineffectivedressings.dressings. Apply a battle dressing/bandage to secure aApply a battle dressing/bandage to secure ahemostatic dressing in place.hemostatic dressing in place. Hemostatic dressings should only beHemostatic dressings should only beremoved by responsible persons afterremoved by responsible persons afterevacuation to the next level of care.evacuation to the next level of care.
CMAST 56QuikClotQuikClot Warning: Avoid contact with wet skin;Warning: Avoid contact with wet skin;product reacts with small amounts ofproduct reacts with small amounts ofwater and can cause burning.water and can cause burning. Stop burning by brushing away granulesStop burning by brushing away granulesand flooding area with large volume ofand flooding area with large volume ofwater.water. If ingested, immediately drink two or moreIf ingested, immediately drink two or moreglasses of water.glasses of water.
CMAST 57QuikClotQuikClot Directions:Directions:1-Apply direct firm pressure to wound using sterile1-Apply direct firm pressure to wound using steriledressing or best available substitutedressing or best available substitute2-If bleeding is stopped or nearly stopped after2-If bleeding is stopped or nearly stopped afterapproximately 1 minute of pressure, wrap and tieapproximately 1 minute of pressure, wrap and tiebandage to maintain pressure on woundbandage to maintain pressure on wound3-If moderate to severe bleeding continues, hold3-If moderate to severe bleeding continues, holdpack away from face and tear open at tabspack away from face and tear open at tabs
CMAST 58QuikClotQuikClot4-Use wiping motion to remove gauze and4-Use wiping motion to remove gauze andexcess blood – immediately start a slowexcess blood – immediately start a slowpouring of one QuikClot packet directly ontopouring of one QuikClot packet directly ontothe wound. Stop pouring as soon as drythe wound. Stop pouring as soon as drygranules cover the wound areagranules cover the wound area5-Use only enough QuikClot to stop bleeding. If5-Use only enough QuikClot to stop bleeding. Ifbleeding continues open a second packet ofbleeding continues open a second packet ofQuikClot and continue to use as directedQuikClot and continue to use as directed
CMAST 59QuikClotQuikClot6-Reapply firm pressure to QuikClot covered6-Reapply firm pressure to QuikClot coveredwound using sterile gauze. Wrap and tiewound using sterile gauze. Wrap and tiebandage to maintain pressurebandage to maintain pressure
CMAST 60QuikClotQuikClotClick in box for video
CMAST 61Treatment GoalsTreatment Goals Hemorrhage control continues to be theHemorrhage control continues to be thepriority in battlefield care.priority in battlefield care. Hemorrhage is the leading cause ofHemorrhage is the leading cause ofpreventable death on the battlefield.preventable death on the battlefield. Our focus must be on stopping soldiersOur focus must be on stopping soldiersfrom bleeding to death on the battlefield.from bleeding to death on the battlefield.