How long should you apply direct pressure after packing a wound with combat gauze?

Hemorrhage control guidelines direct paramedics to use hemostatic gauze but medics are often not formally trained in wound packing

DALLAS — Proper use and application of hemostatic gauze was presented to EMS providers and medical directors at the 2016 Gathering of Eagles XVIII EMS State of the Science program by Peter Taillac, MD, Utah medical director.

The 2014 Evidence-Based Prehospital Guidelines for External Hemorrhage Control directs application of hemostatic gauze in wounds that can't be controlled with direct pressure or tourniquet. But the guideline doesn't include specific details on the training provided to paramedics to pack a wound with gauze.

Taillac described a five-step wound packing process that can be used with plain gauze or gauze treated with a hemostatic agent.

Uncontrolled hemorrhage is the largest cause of preventable mortality in trauma. When extremity bleeding is uncontrolled many, if not most EMS agencies, have now recognized the benefit of using tourniquets.

Today, because of national Stop the Bleed educational campaigns emphasizing bystander response to active shooter situations, many laypersons are now becoming familiar with simple but effective hemorrhage control techniques.1

Using direct pressure and tourniquets on extremity bleeding is relatively straightforward for EMS providers. The most challenging wounds however, are those in the junctional areas-the groin and the axilla-where tourniquets can’t be used. The bleeding in these locations is often deeper and maintaining adequate external pressure can be difficult or impossible.2

The U.S. military has been teaching wound packing with standard gauze and hemostatic dressings to its medics for years.3 Like the transition of tourniquets from military to civilian EMS, these skills are now becoming adopted by tactical EMS teams as well as field EMTs and paramedics. Wound packing can be utilized in concert with tourniquet use or as a solo hemorrhage management technique.

National Guidelines

Shortly after the tragedy at Sandy Hook Elementary in December 2012, a joint committee was convened by the American College of Surgeons (ACS) and attended by many other agencies to develop a national policy to improve survivability from mass casualty incidents (MCI) and active shooter events.

To date, the committee has published four documents that include recommendations for EMS, public safety and the community’s response to MCIs and active shooters.

One of these documents, The Hartford Consensus III: Implementation of bleeding control, recommends that direct pressure be used primarily for hemorrhage control, whenever possible.3 When direct pressure is ineffective or impractical, the application of a hemostatic agent to junctional wounds is suggested. The evidence-based guideline specifically suggests that the hemostatic agent be “delivered in a gauze format that supports wound packing.”2

Although physicians and military medics have long been trained in wound packing techniques, traditional EMS training programs haven’t typically included this skill, because it’s not currently included in the national scope of practice published by the National Highway Traffic Safety Administration/Office of EMS (NHTSA/OEMS).

However, given that wound packing has been recommended by the Hartford Consensus and the recent evidence supports this procedure, many training programs have begun including the procedure in their curricula.

In fact, NHTSA/OEMS has convened an expert panel to review and update the national scope of practice and wound packing is on the agenda to be considered. If approved, this skill will then be integrated uniformly into standard EMS training curricula.

Supporting Evidence

When the ACS hemorrhage control guideline was published, there was little human evidence to support the recommendation for hemostatic gauze. The recommendation was primarily based on animal experiments in a laboratory. However, physicians have been using wound packing as a hemostatic technique for centuries, so the empirical evidence for the technique is strong.

In 2015, the largest case series of prehospital hemostatic dressing use was published; it included 122 patients treated by the Israel Defense Forces Medical Corps. Study authors concluded that “hemostatic dressings seem to be an effective tool for junctional hemorrhage control.”4

Incidentally, only about a quarter of the wounds packed were junctional injuries, the remainder were wounds of the extremities, back and head. Nonetheless, the authors found that there was a high rate of successful hemorrhage control (approximately 90%) in all locations where hemostatic gauze
was used.4

When to Pack

Simply stated, if there’s no (or only minimal) bleeding, the wound doesn’t need packing. Wounds of the extremities and junctional areas are amenable to packing. If a tourniquet is initially placed on an extremity wound, it may later be replaced with a pressure dressing or with packing, which may be more comfortable for the patient and provide for a moderate amount of distal circulation.

Direct pressure will usually suffice for bleeding neck wounds. Wounds of the neck aren’t generally packed because of the risk for airway compromise.

Although the bleeding from a back wound will typically not be profuse and may be controlled with a simple pressure dressing, in the Israeli experience, wounds of the back were packed successfully.

Wounds of the chest, abdomen or pelvis shouldn’t be packed because bleeding from these wounds is generally from a very deep source that can’t be reached from the outside. These patients must be rapidly transported to a surgeon for operative bleeding control. Packing of wounds in these areas should therefore be performed at the discretion of local EMS Medical Directors or the appropriate state agencies where applicable.

Wound Packing Material

There are many choices for packing material designed to control hemorrhage. The commercial hemostatic gauze products are impregnated with a variety of substances designed to enhance clot formation, including kaolin, chitosan and others.

In its January 2017 update, the military’s Committee on Tactical Combat Casualty Care (CoTCCC) recommended QuikClot Combat Gauze as the “hemostatic dressing of choice.”5

Alternatives approved by the CoTCCC include Celox Gauze, ChitoGauze and XStat. Military medics have the most experience with Combat Gauze, as it has been widely deployed for years.

All the hemostatic products are highly effective when used properly. Interestingly, even plain gauze (without an impregnated hemostatic agent) has been found to be highly effective.6 It’s nice to know you can use plain gauze if hemostatic agents are not available to you.

Wound Packing Technique

It’s less important to the field provider which product is used; what’s more important is how the product is used.

Step 1: Stop the bleeding. Now! Immediately apply direct pressure to the wound, using gauze, clean cloth, elbow, knee-whatever it takes to slow or stop the hemorrhage-until you have time to get out your wound packing supplies.

Place your gloved fingers-with or without a dressing-into the wound to apply initial pressure to the target area (with your target being the vein, artery or both) and compress the source of bleeding. Keep in mind that the body’s anatomy presents with major vessels running close to bones. So, whenever possible, utilize a bone to assist with vessel (i.e., bleeding) control. This will also give you an idea of which direction the wound travels and you can insert the gauze accordingly.

Step 2: Pack the wound with gauze. Tightly! Your goal is to completely and tightly pack the wound cavity to stop hemorrhage. Begin packing the gauze into the wound with your finger, while simultaneously maintaining pressure on the wound.

It’s critical that the gauze be packed as deeply into the wound as possible to put the gauze into direct contact with the bleeding vessel. By doing so, you’re simultaneously putting direct pressure onto the bleeding vessel and allowing the hemostatic agent to do work its magic.

Step 3: Keep packing! The key to successful wound packing is that the wound be very tightly packed, applying as much pressure as possible to the bleeding vessel. This pressure against the vessel is the most important component of hemorrhage control. This explains why plain gauze (without an impregnated hemostatic agent), when tightly packed, is also quite effective.

Step 4: Apply very firm pressure to the packed wound for 3 minutes. This step pushes the packing firmly against the bleeding vessel and aids in clotting.

Step 5: Secure a snug pressure dressing and transport. After applying pressure for 3 minutes, place a snug pressure dressing over the wound. You may consider splinting or immobilizing the area, if possible because movement during transport can dislodge the packing and allow hemorrhage to restart.

Continued Hemorrhage

Should the bleeding continue, hemostatic gauze manufacturers recommend removal of the original packing and repacking with fresh gauze. The rationale for this is that they assume it wasn’t packed properly the first time, or perhaps the packing didn’t quite get to the bleeding vessel.

Prior to repacking, another option is to pack more gauze into the wound, if possible. If no further packing is possible, you must decide whether to remove the gauze and start over or simply apply as much direct pressure to the wound as possible and get the patient to a trauma center quickly. This decision should be made during transport; transport shouldn’t be delayed for extensive packing and repacking of the wound.

Don’t Be Shy!

EMS providers aren’t typically trained to put their finger deeply into wounds, so a natural hesitancy by EMS personnel is understandable. However, please keep in mind that you won’t harm the patient by deeply packing a wound, you’ll help them.

The biggest mistake in wound packing is being timid. Don’t be shy! Be bold! Pack that wound tightly! And, remember to also perform a complete assessment of your patient so as not overlook other life-threatening injuries.

References

1. American College of Surgeons. (2016.) Stop the Bleed. BleedingControl.org. Retrieved March 7, 2017, from www.bleedingcontrol.org.

2. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163-173.

3. Joint Committee to Create a National Policy to Enhance Survivability from Mass-Casualty Shooting Events. (July 1, 2015.) The Hartford Consensus III: Implementation of bleeding control. American College of Surgeons. Retrieved March 7, 2017, from http://bulletin.facs.org/2015/07/the-hartford-consensus-iii-implementation-of-bleeding-control/

4. Shina A, Lipsky AM, Nadler R, et al. Prehospital use of hemostatic dressings by the Israel Defense Forces Medical Corps: A case series of 122 patients. J Trauma Acute Care Surg. 2015;79
(4 Suppl 2):S204-S209.

5. TCCC Guidelines for Medical Personnel. (Jan. 31, 2017.) Tactical Combat Casualty Care. Retrieved March 7, 2017, from www.cotccc.com/wp-content/uploads/TCCC-Guidelines-for-Medical-
Personnel-170131.pdf.

6. Watters JM, Van PY, Hamilton GJ, et al. Advanced hemostatic dressings are not superior to gauze for care under fire scenarios. J Trauma. 2011;70(6):1413-1419.

Make Your own Wound Packing Trainer

For a fun, inexpensive and educational way to teach wound packing, try making your own wound packing trainer. All you need is a few items you can pick up at the grocery store!

For step-by-step instructions, go to A.J. Heightman’s blog at: www.jemseditorblog.com/2017/03/11/a-j-macgyver-heightmans-homemade-wound-packing-simulator/.

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