1. This document provides training on emergency hemorrhage control, including the recognition and treatment of uncontrolled hemorrhage. 2. It reviews techniques for controlling arterial bleeding including the use of tourniquets, hemostatic gauze, phenylephrine, and tranexamic acid (TXA). 3. Clinical trials have shown that the early administration of TXA can increase trauma patient survival by reducing bleeding and mortality.

1. We’ve Got a
Emergency Hemorrhage Control

2. Joe Sherrell
EMS Officer
Tulsa Fire Department
(918) 596-9808
jsherrell@cityoftulsa.org

3. The student shall be able to effectively
recognize uncontrolled hemorrhage and
immediately provide the indicated
treatment.

4. Upon completion of this course, the student will be able to:
1. Recognize uncontrolled hemorrhage
2. Identify the proper method of treatment
3. Discuss the indication for tourniquet use
4. Demonstrate the proper use of a tourniquet

5. Objectives
5. Discuss the indication for the use of Combat Gauze
6. Demonstrate the proper use of Combat Gauze
7. Discuss the indication for the use of Phenylephrine
8. Demonstrate the proper use of Phenylephrine
9. Discuss the indication and use of TXA

6. Lacerations
Penetrations
Amputations

14. Assessment
Scene Safety & PPE
Primary Survey
Hospital Notification

15. Primary Survey Care
Control Arterial Bleeding
Open and Maintain Airway
Minimize on scene time

16. En Route Care
Reassess
Oxygenation/Ventilation
Vascular Access
Secondary Survey

17. BLS Skills
Identification
Tourniquet
Hemostatic Agent
Hospital Notification
BLS Before ALS

20. Battlefield tested
Endorsed by PHTLS
Associated complications <1.5%

22. Uncontrollable Hemorrhage

25. How long does it take for death to occur due to
complete femoral artery and vein dissection?
As little as
3 minutes

26. Combat Application Tourniquet
(C-A-T)

29. Apply just proximal to the bleeding wound
Route the band around the extremity

30. Pass the band through the outside slit of buckle
The friction adaptor buckle locks the band in place

31. Pull the self-adhering band tight and secure

32. Twist the rod until the bleeding has stopped.

33. Lock the rod in place with the windlass clip

34. Secure the rod with the strap
Indicate the time of tourniquet application
Leave area uncovered
TK 0945
Video

35. Eliminate distal pulse
Do not loosen
Second tourniquet may be required

36. Conscious patients may experience pain
Utilize pain management protocol

38. Combat Gauze

39. Mechanism of Action
Impregnated with Kaolin
Promotes activation of Factor XII
Initiates the clotting cascade

40. Indication
Hemorrhage not controllable with tourniquet or
other means
C-A-T ineffective
Wound location does not allow use of a C-A-T

41. Application
Remove pooled blood
Pack gauze into wound
Hold pressure over bleeding source
3 minutes or hemostasis
Apply pressure bandage

43. The Newest Kid on the Block

44. 274 Hospitals
40 Countries
20,211 adult trauma patients
With, or risk of, significant bleeding
HR > 110, SBP <90, clinical judgement
Treatment within 8 hours of injury
TXA or placebo

45. Death in hospital within 4 weeks
Bleeding
Vascular Occlusion (MI, Stroke, PE)
Multiorgan Failure
Head Injury
Other
Vascular Occlusive Events
Need for blood/surgery

46. All Cause Mortality
9.1% Increase in survival
Bleeding
8.5% Increase in survival

47. Did Not reduce
the need for blood
the need for surgery
Did increase survival

48. TXA is Safe
TXA Makes a Difference
TXA Increases Survival
TXA doesn’t create clots in bad places

49. Retrospective
Combat Casualties in Afghanistan
British Helo Physicians
TXA vs No TXA
1+ unit(s) PRBC
10+ units of PRBC
896 Patients
293 received TXA

50. Characterize TXA use in combat injury care
Effect of TXA on
Blood Product Use
Bad Clots
Mortality (24 hrs., 48hrs., 30 days)

51. ~7 times more likely to survive with TXA

52. Slight increase in DVT & PE formation

53. Higher Injury = Increase Risk of Clots
Military Theater – penetrating/ortho
Survival allows DVT/PE to be diagnosed

54. Increase Survival
Massive Transfusion
TXA independent predictor of survival
Benefit shown after 48 hours
Possible anti-inflammatory component
Earlier is Better

55. If a casualty is anticipated to need
significant blood transfusion:
presents with hemorrhagic shock
one or more major amputations
Penetrating torso trauma
Evidence of severe bleeding
Administer 1 gram of tranexamic acid in 100 cc
Normal Saline or Lactated Ringers as soon as
possible but NOT later than 3 hours after injury.
Begin second infusion of 1 gm TXA after Hextend
or other fluidtreatment.

56. Formulary

57.  Anti-Fibrinolytic

58. Promotes clot formation

59. Hemorrhagic shock
Trauma < 3 hours old
Suspected need for massive blood transfusion

60.  In metropolitan Tulsa:
sustained tachycardia ≥ 110
AND
sustained hypotension systolic BP≤ 90

61. Non-hemorrhagic shock
Non-traumatic hemorrhagic shock
Hemorrhagic shock stabilized with other hemostatic
agents/measures

62. Onset of action within 4 hours after IV administration
Delayed effects up to 48 hours consistent with anti-
inflammatory actions.

63. While a theoretical concern, TXA has not been shown
to cause significant increase in:
deep venous thrombosis
pulmonary embolism
myocardial infarction
stroke

64.  1 gram IVPB over 10 minutes.
Administer in 100 mL or 250 mL NS.

66.  The CRASH-2 Collaborators. Effects of tranexamic acid on death,
vascular occlusive events, and blood transfusion in trauma patients
with signifcant hemorrhage (CRASH-2): a randomised, placebo-
controlled trial. Lancet 2010; 376: 23–32.
 Jonathan J. Morrison; Joseph J. Dubose; Todd E. Rasmussen; Mark J.
Midwinter. Military Application of Tranexamic Acid in Trauma
Emergency Resuscitation (MATTERs) Study. Arch Surg. 2011
 Medical Control Board. EMS Protocols for Metropolitan Oklahoma
City and Tulsa. 2013.
 Tactical Combat Casualty Care Guidelines. Prehospital Trauma Life
Support. 2012.