Paramedic protocols - haemorrhage

#1
I'm doing a bit of work around haemorrhage and haemostats, and was trying to find a set of protocols for the treatment of severe bleeds.

I've been into the JRCALC protocols, but all I could find was 'arrest external haemorrhage' as the advice.

Can any of you guys point me in the direction of protocols for the treatment of severe bleeds by EMS, or give me a quick head up on the party line.

Cheers. P-K
 
#2
hello

LAS popped down our station last week, I asked about whether they still do ABC rather than our new C ABC ...the paramedic looked blank , so assume thats a no, moreover they are not encouraged to torniquet and the dressings are standard ambo dressings , thin, rubbish ones in my opinion ..so assume apart from , the normal , pressure , elevate , dress their protocols are the same basic ones ..
 
#3
I've always been taught against the application of a tourniquet as it can cut off circulation and ultimately cause more harm than good. The standard does seem to be, as the previous post said, apply pressure to the wound (being careful of any debris that is still protruding), elevate and dress the wound (again taking care of any protruding debris).
 
#4
That's pretty much what I posted here mate, We do have other dressings for extensive bleeding rather than the usual standard ones, which although they appear thin do work pretty well, but no clotting agents, in fact I dealt with a close range shotgun injury Saturday night using the guidelines I mention and they did the job ok, Don't forget we probably have a shorter time on scene than a lot of the injuries you guys deal with and since everything is money driven by the NHS they won't pay for anything they don't have to, even if we tell them we would want it, which we do on many occasions.

http://www.arrse.co.uk/cpgn2/Forums/viewtopic/t=99462.html
 
#5
Working to the BCDT aide memoire, then its C ABC

The catastrophic amputation haemorrage is dealt with by tourniquet.

A bleed is dressed, if it continues to bleed then a second dressing is added over the first, if it continues to bleed then a tourniquet is used.

Thats assuming you want the battlefield option?
 
#6
Nik_Myshkin said:
I've always been taught against the application of a tourniquet as it can cut off circulation and ultimately cause more harm than good. The standard does seem to be, as the previous post said, apply pressure to the wound (being careful of any debris that is still protruding), elevate and dress the wound (again taking care of any protruding debris).
The cat torniquet is a proven life saver .Unfortunatly the people whose life it would save in civillian life really need it applying before the emergency services arrive .Unfortunatly short of training everyone in the country in first aid slim hope . And do we really want to save drug dealers
who get shot ?
 
#7
woody said:
Nik_Myshkin said:
I've always been taught against the application of a tourniquet as it can cut off circulation and ultimately cause more harm than good. The standard does seem to be, as the previous post said, apply pressure to the wound (being careful of any debris that is still protruding), elevate and dress the wound (again taking care of any protruding debris).
The cat torniquet is a proven life saver .Unfortunatly the people whose life it would save in civillian life really need it applying before the emergency services arrive .Unfortunatly short of training everyone in the country in first aid slim hope . And do we really want to save drug dealers
who get shot ?
It should still only be used as a last resort and closely monitored once applied. In answer to your second point - not really!
 
#9
As I mentioned before I have used a tourniquet in the past but only when dealing with large numbers of casualties some with traumatic amputations etc, but it's not something that's used in normal practice, in fact a lot of Paramedics probably would not use one in any circumstance, it is something I carry in my personal kit and because I work on my own and get to a lot of these calls before the ambulance crews it's my decision as to what I feel is the right treatment depending on what I find.

Having served in the forces (but not in the RAMC) I have different mindset to a lot of my colleagues a lot of who have come straight from civvy jobs and watched ER, Casualty etc etc and have a totally different view on the role and tend to stick to certain guidelines rigidly even when it is obvious that something "outside the box" is required and quickly.
 
#11
"Catastrophic amputation haemorage" Surely you mean any limb catastrophic haemorage. The difficulty is defining it as catastrophic. very subjective and never translates well into words in a forum..

"last resort and monitored carefully" what exactly are you monitoring it for ? bit of a throw away on the advice front don't you think....come on evidence based practice please

Tourinquets have been in use for thousands of years, however there are always nay sayers... which is understandable. Most of the protaganists and fans of the "T" are those that have had to use them in anger.

I will not give advice here or even argue the corner or relate personal experiences (other than to say I am in the USE A BLOODY TOURNIQUET if you need to camp ).

As for the long term effects and the common missaprehensions have a look at this
http://www.wjes.org/content/2/1/28

and ermm this

http://www.ncbi.nlm.nih.gov/pubmed/17414556

and this is very interesting, trial in country of StO2 monitoring (basically checking the oxygen perfusion in extremitys of trauma patients)

http://www.htibiomeasurement.com/news-interviews.asp

However now I mostly work in the civillian sector (mostly) Personal experience is that direct pressure and elevation works well. Sod the 2 dressings get your gloved hand on the first one and squeeze ! (then put a second one on when you stop the flow)

edit, I would also profess that an increasing number of "civvy" Prehospital crews are carrying CATS all be it not part of their official load out. Though those I have talked with have mostly, though not uniquely been ex forces. I know at least 3 of the air ambulances in the southern end of Britain (not wishing to be to specific to avoid desk jockey upset) who's crews carry them.
 
#12
Nik_Myshkin said:
I've always been taught against the application of a tourniquet as it can cut off circulation and ultimately cause more harm than good.
A tourniquet that DOESN'T cut off circulation is pretty fucking useless, you know.
 
#13
Carcass said:
Nik_Myshkin said:
I've always been taught against the application of a tourniquet as it can cut off circulation and ultimately cause more harm than good.
A tourniquet that DOESN'T cut off circulation is pretty fucking useless, you know.
ROFL !

however the problem is that folk are genuinely concerened, due to miss education, that they will cause a loss of the entire limb below the tourniquet. Truth is there will be some perfusion, though there are obviously going to be exceptions which is demonstrated in most of the studies. Trying to find the canadian one from last year that suggested anything up to 8 hours was fine, though again that would need qualification
 
#14
Carcass said:
Nik_Myshkin said:
I've always been taught against the application of a tourniquet as it can cut off circulation and ultimately cause more harm than good.
A tourniquet that DOESN'T cut off circulation is pretty fucking useless, you know.
Yeah! Fair point. Bad phraseology on my part. :oops: The point I was making was that a tourniquet, because it does cut off circulation, can cause more harm than good, both when the circulation is cut and when reperfusion occurs. Yes it should still be used when neccessary but only as a last resort. Historically it was often used when it wasn't really needed.

I agree with gibson that it really comes down to education, both on how to use one and when to use one.
 
#15
Whats the difference between neccessary and last resort ? and Historically what source of information do you refer to ? Not to be pedantic but IMHO education and the quashing of anecdotal "expertise" is a major priority.
Of course T's have been applied innapropriatly but should this be the driving point of training and use ? Or should it be that if you identify the situation as needing it then get your CAT on. (CAT over and above any of the other bobbins devices that are around, with the begrudging exception of the NATO but never ever the MAT which is pants)
 
#16
It depends on what phase of care you are talking about with regards to neccesity.

During care under fire where there is a significant amount of blood loss then a tourniquet is indicated and indeed taught to most.

When the CLINICIAN moves into tactical field care then it can be re addressed and other methods used (such as good old gauze as packing).

As for training people are being taught to apply the CAT themselves using only one loop, whereas the clinician should most definately thread the thing through both loops. If i needed to apply one to myself id do everything i could to thread it through both loops!

The CAT is good but there have been failures. The SOF Tactical tourniquet has been updated and is a mean bit of kit.
 
#17
Always been in the "use a tourniquet" camp myself as well. The reason I've always thought for the "don't use them" camp, as well as perfusion issues, are to do with 1. build-up of lactic acid in the limb (a la crush syndrome), and more importantly, 2. the risk that an incorrectly applied tourniquet will block the veins but not the arteries (due to thicker muscle walls (take the egg, suck carefully) as the aim is during canulation and venepuncture), and will therefore result in greater blood loss.

Mind you, I'm now a train guard, so what do I know!
 
#18
tony_quet said:
It depends on what phase of care you are talking about with regards to neccesity.

During care under fire where there is a significant amount of blood loss then a tourniquet is indicated and indeed taught to most.

When the CLINICIAN moves into tactical field care then it can be re addressed and other methods used (such as good old gauze as packing).

As for training people are being taught to apply the CAT themselves using only one loop, whereas the clinician should most definately thread the thing through both loops. If i needed to apply one to myself id do everything i could to thread it through both loops!

The CAT is good but there have been failures. The SOF Tactical tourniquet has been updated and is a mean bit of kit.
Sorry to revive a long dead thread, with regard to the bold above, your assuming you still have both arms and that the surviving limb is the dominant one?
 
#19
http://www.ramcjournal.com/2007/mar07/tourniquet_debate.pdf

read the above....

Depending on the stage of casualty care depends on whether a tourniquet/haemostatic’s are used – QT has already mentioned CUF…

Current guidelines are in CGO's and Batls - make sure your reading the up to date versions.

CAT used on the leg/legs. Due to large muscle mass always use the friction buckle. If not the velcro strap will give when tightening the CAT - these tourniquets are put on extremely tightly. This problem was identified out in theatre some time ago and all training establishments will have been informed.

CAT is the standard issue tourniquet. I have seen failures but they have always been a result of incorrect fitting or damage to them due to them being att to the outside of webbing body armour.

The CAT has been designed for military trauma – I know that some Ambulance Trusts are against there use and I can understand their argument “they don’t see that kind of trauma”. However – London Bombings, need I say more.. :roll:
 
#20
I know we use the CAT in London mate (although for some reason they went for the bright orange version lol)
 

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