Escape of blood from the vessel either into the tissue, inside the cavity or on a free surface due to the break in the wall of the vessel from trauma.

1. Control Of Hemorrhage
In Combat
Col. Dr
Homoud A Alenezi
North Miltary medical complex (Kuwait Army)
2 / 5 / 2019
Email : ahomoud@hotmail.com

2. Hemorrhage
Escape of blood from
the vessel either into the tissue,
inside the cavity or on a free surface
due to the break in the wall of the
vessel from trauma.

3. Hemorrhage
Approximately 40% of trauma-related deaths
are due to bleeding or its consequences
- 1st Leading cause of death in combat trauma
- 2nd leading cause of death in civilian trauma
Hemorrhage is a leading cause of potentially
preventable death in trauma

4. Types of Hemorrhage
• Spurting blood
• Pulsating flow
• Bright red color
• Steady slow flow
• Dark red color
• Slow, even flow

5. Types of Hemorrhage
External Hemorrhage
Loss of blood from wounds that damage the large vessels of the
extremities.
• common source of massive external hemorrhage in combat
• gunshots, stabbings, shrapnel, and blasts
Internal Hemorrhage
• Blood loss into the chest or abdomen
• Blunt trauma, injuries from blasts, vehicle accidents, falling from
heights, and collapsing buildings.

6. ESTIMATING BLOOD LOSS (EBL)
Gather a quick estimation of blood loss based on the following factors:
- Look for blood surrounding the patient.
- Inspect clothing for blood saturation.
- Inspect bandage saturation for associated blood loss.
- Determine level of shock

7. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hemorrhage Airway Obstruction Tension pneumothorax
Extremity ] 119/888 [ = 13.5%
Junctional ] 171/888 [ = 19.2%
Truncal ] 598/888 [ = 67.3%
91%
(n=888)
1.1%
(n=11)
7.9%
(n=77)
Death From Hemorrhage
(Prehospital Trauma Life Support, current Military Edition TCCC Guidelines, 28 OCT 2013 )

8. Massive hemorrhage may
be fatal within 60 –120 seconds.
Treatment should not be delayed
and controlling major
hemorrhage should be the
first priority over securing
the airway.

9. Control bleeding
• Pressure dressing
• Tourniquets
• Wound Packing / Hemostatic Agents
• Tranexamic Acid (TXA)
• Fluid Resuscitation

10. Control bleeding
Dress the wound while applying
direct pressure
Elevation
Pressure dressing directly
over bandage
Digital pressure points
( Temporal, Carotid, Brachial, Radial, Femoral )

11. TOURNIQUET
TOURNIQUET APPLICATION
Tourniquets are most effective in saving lives if
applied before the casualty has gone into shock.
Do not place it directly over a joint or wound.
Place 5 cm above the injury.
Used when there is no time to control bleeding.
Do not cover the tourniquet.
Never remove a tourniquet.
Write the time of tourniquet
application on the patient.

12. Tourniquets

14. Combat Application Tourniquet
(CAT)
A Self-Adhesing
Band
Windlass clip
Windlass Strap
Windlass Rod
Special Operations Forces Tactical
Tourniquet (SOFT-T)

16. One-Handed Application to Arm
Insert the wounded extremity through the loop of the Self-
Adhering Band
Pull the Self-Adhering Band tight and securely fasten it back
on itself
Adhere the Band tightly around the arm. Do not adhere the
band past the clip.
Twist the Windlass Rod until bleeding has stopped
Lock the Windlass Rod in place with the Windlass Clip Hemorrhage is now controlled
1
3
5
2
4
6

17. One-Handed Application to Arm
Adhere the Self-Adhering Band over the Windlass Rod – for
small extremities, continue adhering the band around the
extremity
Secure the Windlass Rod and Self-Adhering Band with the Windlass
Strap – grasp the Windlass Strap and pull it tight, adhering it to the
opposite hook on the Windlass Clip
7 8

18. Two handed Application

19. Other Tourniquets
• SOF Tactical Tourniquet
• Emergency Military Tourniquet

20. • Injured US soldier with two CAT tourniquets
on left leg, Iraq.

21. Hemostatic Agents

22. HemCom
• The Hemcon bandage is made from chitosan, a substance
contained in shellfish shells.
• It works by reacting with blood and provoking a clotting
reaction, which helps stop bleeding.
• It helps stop arterial bleeding in places where tourniquets
aren’t totally effective.
• HemCon dressings also offer an antibacterial barrier against a
wide range of microorganisms.

23. WoundStat
• The granules could cause injury
to the blood vessels
• The granules were also shown
to enter the circulatory system
and cause thrombosis in distal
organs
• Stopped using it since April 2009 in US Army.

24. Combat Gauze
• First line treatment for life-threatening hemorrhage
in wounds not amenable to tourniquet placement.
*Recommendation of the Committee on Tactical Combat Casualty Care

25. Combat Gauze
• It is impregnated with kaolin
• Rapid, localized, caogulation
• It does not absorb into the body
• Does not produce any heat.

27. Combat
Gauze
WoundStatHemCom
+++++++++Hemostatic efficacy
None---NoneSide effect
√√√Ready to use
++++++Training requirement
++++++++Lightweight and durable
√√√2 yrs shelf life
√√√Stable in extreme condition
√√√FDA approved
25~30-35120~Cost ($)
Comparison between Hemostatic Agents

28. XSTAT
Hemostatic device for the control of severe ,
life-threatening bleeding from junctional
wounds from gunshot and shrapnel wounds.
XSTAT works by injecting a group of small,
rapidly-expanding sponges into a wound
cavity using a syringe-like applicator.

29. XSTAT
Junctional wounds in the groin or axilla and
bleeding from narrow entrance extremity wounds
in the arms or legs not amenable to tourniquet
application
XSTAT 12, XSTAT 30

30. XSTAT

31. XSTAT

33. Tranexamic Acid (TXA)
Tranexamic acid (TXA) is a synthetic amino
acid (lysine)
TXA reduce mortality from hemorrhage
due to trauma associated bleeding
by up to 32%. (within 3-hours)

34. TXA
TXA is an anti-fibrinolytic that inhibits both
plasminogen activation and plasmin activity, thus
preventing clot break-down rather than
promoting new clot formation.
TXA - 1 gm in 100ml NS infusion
over 10 minutes, followed by
infusion of 1 gm over 8 hrs.

35. TXA

37. Fluid Resuscitation
IV access: Intravenous (IV) or intraosseous (IO)
1. Whole blood
2. 1:1:1 plasma:RBCs:platelets
3. 1:1 plasma:RBCs
4. Either plasma or RBCs alone
5. Hextend
6. Either Lactated Ringer’s or Plasma-Lyte A

38. Fluid Resuscitation
*The Tactical Combat Casualty Care Guidelines on Fluid Resuscitation (2011)
(A) If not in shock:
(i) No IV fluids necessary
(ii) PO fluids permissible if conscious and can
swallow.

39. Fluid Resuscitation
(b) - If in shock and no blood products:
(i) Hextend 500 mL IV bolus
(ii) Repeat after 30 minutes if still in shock
(iii) Reassess the casualty after each 500 mL IV bolus
(iv)Continue resuscitation with Hextend or crystalloid
solution as needed to maintain target BP 80-90mm Hg
or clinical improvement.

40. Fluid Resuscitation
(C) If in shock and blood products are available:
(i) Whole blood if not available,
(ii) Plasma, RBCs and platelets in a 1:1:1 ratio; or if not available,
(iii) Plasma and RBCs in 1:1 ratio.
(iv) Reassess the casualty after each unit.
(v) Continue resuscitation until a palpable
radial pulse, improved mental status or
systolic BP of 80−90 mm Hg.

41. Conclusion
Hemorrhage is a leading cause of potentially
preventable death in trauma.
Massive hemorrhage maybe fatal within 60 –
120 seconds.
Treatment should not be delayed and
controlling major hemorrhage should be the
first priority over securing the airway.

42. Conclusion
Tourniquets and hemostatic agents reduce
hemorrhage and improve survival.
TXA should be used as an integrated part of a
massive hemorrhage protocol.
Fluid Resuscitation:
- Crystalloid and colloid limited to one litter during
initial resuscitation.
“ latest edition of the Advanced Trauma Life Support(ATLS) manual 9th ed.”

43. Conclusion
Hemorrhagic shock resuscitation:
Decreased crystalloid and
colloid use, and increasing
use of blood for resuscitation
*Whole blood
* Blood components at a 1:1:1
* RBC plus plasma= 1:1 ratio
* Plasma with or without RBC
* RBC alone

44. TCCC Tactical Combat Casualty Care Guidelines
2011
• Assess hemorrhage site & control all sources
of bleeding.
• Tourniquet to control life-threatening external
hemorrhage ( 2-3 inches above the wound)
• Combat Gauze
Should applied with at least
3 minutes of direct pressure
• Direct Pressure by Combat
Ready Clamp

45. Combat Ready Clamp is the first COTCCC-
recommended device for junctional hemorrhage

46. TCCC Tactical Combat Casualty Care Guidelines
2011
• Intravenous (IV) or Intraosseous (IS) - 18 gauge
• Tranexamic Acid (TXA)
- 1gm in 100 NS as soon as possible (3 hrs)
- 1 gm over 8 hrs.
• Fluid resuscitation:
A) If not in shock
- No IV fluid
- PO fluid if casualty conscious and can swallow.

47. TCCC Tactical Combat Casualty Care Guidelines
2011
B) If in shock and no blood products:
- Hextend 500 mL IV bolus
- Repeat after 30 minutes if still in shock
- Reassess the casualty after each 500 mL IV bolus.

48. TCCC Tactical Combat Casualty Care Guidelines
2011
(C) If in shock and blood products are available:
- Whole blood if not available,
- Plasma, RBCs and platelets in a 1:1:1 ratio; or if not
available,
- Plasma and RBCs in 1:1 ratio.

50. References
• Damage Control Resuscitation (CPG ID: 18)
• TranexamicAcid (TXA) in Tactical Combat Casualty Care.
Guideline Revision Recommendation Committee on Tactical
Combat Casualty Care 11 August 2011
• DOT HS 811 999b. Washington, DC: National Highway Traffic
Safety Administration. May 2014. Available at: www.ems.gov.
• US Army Institute of Surgical Research, Fort Sam Houston, TX,
USA, January 2009)

51. Check On
Learning

52. Q: What is the different
between Bleeding &
Hemorrhage ?
A: bleeding is the flow or loss of blood from a
damaged blood vessel.
haemorrhage is (pathology) a heavy release of
blood within or from a body.

53. Check On Learing
Q: What is the leading preventable cause of
death on the battlefield?
A: Major bleeding from extremities

54. Q: Do you use tourniquet, which one ?
A:Use a tourniquet ONLY
for severe a bleeding.

55. A soldier has just had his forearm amputated slightly above the
wrist. The bleeding from the amputation site is not severe.
Q: What should you do first?
A: Apply a Tourniquet two inches above the
amputation site.

56. • Bleeding wound in the Junctional areas
( Neck , Axilla, Groin)
Q: What you will do?
A:The use of a hemostatic agent (e.g., Combat
Gauze) with direct pressure for 3 minutes

57. KEEP
CLAM
AII BLEEDING STOPS
EVENTUALLY