Wound Packing

What do I do if the tourniquet doesn’t reach up high enough on the limb and there is still heavy bleeding from the arm pit or groin?

Once someone learns about tourniquet use and becomes proficient, the above question is the most obvious and common to be asked.  Anyone who has seen the film, “Blackhawk Down” vividly remembers seeing that ranger laying on the makeshift treatment table, shooting blood across the room, a tourniquet powerless to save his life.  You don’t have to be a surgeon or a Ranger medic to stop bleeding for this injury.  This is where proper and aggressive wound packing comes into the picture.  Packing the wound is not meant to soak up the blood.  It is meant to put firm pressure directly against the injured artery or vein, against the bone if possible, which is causing the bleeding.  The other reason to pack a wound is when a properly trained medical provider is attempting to convert a tourniquet down to a pressure dressing.  We will save that discussion for another day.

Hemostatic Gauze is recommended as packing due to the chemicals added to the gauze.  Quick Clot Combat Gauze DOES NOT PRODUCE HEAT.  It works with the body’s natural clotting abilities and is recommended for use by the Committee on Tactical Combat Casualty Care.  Other hemostatic gauzes such as HemCon Chitogauze, ChitoSam 100 and Celox Gauze have chemicals that work independently of the body’s ability to clot which becomes important if you have a patient taking blood thinners or who has other clotting disorders.  Talk to your medical director to find out what is best for you and the patients you are likely to encounter.

Before you begin, remember that if your casualty is conscious this will be an extremely painful procedure.  Do not hesitate.  Blood is life and your temporary mercy, which is really just you being squeamish, will get your patient killed. Harden your heart and do not stop until the bleeding has.

The video and step by step instructions below are meant to give you an idea on the basics of properly packing wounds. Reading a blog post and watching a video will not make you an expert in tactical medicine.  You have to seek out reputable training and continuously practice and incorporate any skill into realistic training scenarios.

  • Once massive bleeding is observed direct pressure in the form of a knee or fist should be placed directly into the wound. I prefer the knee, as it keeps my hands free to prepare my packing material or hemostatic gauze.
  • Tightly wad the end of the material into what we call a power ball. This is what you will use to apply direct pressure to the vessel inside the wound.
  • Quickly remove your knee, identify the source of the gushing blood and jam the power ball directly into the source.
  • Don’t worry about the pooled blood in the wound, as you won’t ever get enough out and it doesn’t make a difference with this strategy anyway.
  • Now that you have effectively controlled the source of bleeding, you can relax a little so that you do the next critical steps properly. Remember the key to this is to maintain continuous, firm pressure so you can’t let that power ball move off of the artery while you pack the rest of the gauze or other material on top and around the power ball.
  • Inch the gauze into the wound replacing one finger with another until the wound is entirely packed and you can’t fit any more. This may require multiple roles of gauze or other material depending on the wound. Don’t be surprised and have a plan for more material.
  • If your packing was not effective you will begin to notice blood soaking through the dressing as you hold pressure. Ready another power ball, remove all of the other packing and start over.
  • If you don’t have 5 minutes due to the developing situation or other patients, be sure to wrap the pressure dressing on top of the packing and secure it before moving on.
  • If it was effective and no blood is noticed during the 5 minutes you are holding pressure you can apply a tightly wrapped and secured pressure dressing.

Improvising medical equipment such as tourniquets and packing material should not be your plan A.  Carry a minimal med kit on and off duty and be aware of where bleeding control kits are available in public places.  I routinely carry a tourniquet and flat folded hemostatic gauze everywhere I go, especially if I am carrying a weapon.  Both tourniquets and hemostatic dressings are TSA friendly and can be carried on to an airplane.  If however, you find yourself in a mass casualty situation or another unexpected situation where you need to pack a wound pick the right material with which to improvise.  A ripped up t-shirt makes great wound packing material because you can wad it up tightly into the proper powerball configuration explained above and demonstrated in the video.  What you don’t want is anything fluffy that just soaks up blood without having the ability to apply point pressure.  Tampons make for terrible wound packing when packing a massively bleeding arterial wound.  Do not use a tampon.  Even if you are barricaded in a bathroom with a bleeding casualty pick toilet paper over the basket of tampons.  At least the toilet paper can be waded up and pressed tightly into the wound against the artery.  If your packing has failed and a tourniquet won’t reach your next option will be a junctional tourniquet or even just holding junctional pressure until help arrives.  This will be covered in a future post.

Check out the video below…

https://youtu.be/RwaaGXOrWW8

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