Page 166 - Journal of Special Operations Medicine - Spring 2017

of the lower extremities that is commonly seen in pa- b. For compressible hemorrhage not amenable to limb
tients with displaced pelvic fractures and reduce the tourniquet use or as an adjunct to tourniquet removal,
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forces acting through the hip joint that contribute to use Combat Gauze as the CoTCCC hemostatic dress-
pelvic deformity. If there is an amputation, the thighs ing of choice.
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should be bound together. 3
Alternative hemostatic adjuncts:
– Celox Gauze or
Pelvic compression may be effectively accomplished – ChitoGauze or
with a commercial device, a sheet or other cloth material – XStat (Best for deep, narrow-tract junctional wounds)
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such as the trouser legs secured with zip ties, or possibly Hemostatic dressings should be applied with at least
other combinations of improvised devices (ex. Wilder- 3 minutes of direct pressure (optional for XStat ). Each
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ness Medicine guide to pelvic splints). 63 dressing works differently, so if one fails to control
bleeding, it may be removed and a fresh dressing of the
Application techniques are different for each of the three same type or a different type applied.
currently available commercial devices; therefore, medi- If the bleeding site is amenable to use of a junc-
cal personnel must be trained on the specific device to be tional tourniquet, immediately apply a CoTCCC-rec-
used. If an improvised device is used, it must be incorpo- ommended junctional tourniquet. Do not delay in the
application of the junctional tourniquet once it is ready
rated into training. Improvised compression with sheet/ for use. Apply hemostatic dressings with direct pressure
clothing is best applied by two personnel—one to pull if a junctional tourniquet is not available or while the
the cloth tightly and another to secure it. junctional tourniquet is being readied for use.
c. Reassess prior tourniquet application. Expose the wound
In addition, currently available circumferential junc- and determine if a tourniquet is needed. If it is, replace
tional tourniquets (SAM Junctional Tourniquet or Junc- any limb tourniquet placed over the uniform with one
tional Emergency Treatment Tool) are also effective applied directly to the skin 2–3 inches above wound.
pelvic compression devices. Routine use of junctional Ensure that bleeding is stopped. When possible, a distal
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tourniquets for any suspected pelvic fracture, however, pulse should be checked. If bleeding persists or a distal
will significantly increase cost. pulse is still present, consider additional tightening of the
tourniquet or the use of a second tourniquet side-by-side
with the first to eliminate both bleeding and the distal
Pneumatic Antishock Garment (PASG) pulse.
d. Limb tourniquets and junctional tourniquets should be
The use of PASG has previously been included in the converted to hemostatic or pressure dressings as soon
TACEVAC phase of the TCCC guidelines for stabiliz- as possible if three criteria are met: the casualty is not
ing pelvic fractures and controlling pelvic and abdomi- in shock; it is possible to monitor the wound closely for
nal bleeding. In recent guideline changes, the addition bleeding; and the tourniquet is not being used to con-
of junctional tourniquets as well as pelvic binders has trol bleeding from an amputated extremity. Every effort
replaced the use of PASG for this purpose. Concern for should be made to convert tourniquets in less than 2
potential harm with lack of proven benefit related to hours if bleeding can be controlled with other means.
the use of PASG, as well as the contraindications of Do not remove a tourniquet that has been in place more
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thoracic and brain injuries, have led us to recommend than 6 hours unless close monitoring and lab capability
are available.
removal of the PASG from the TCCC guidelines.
e. Expose and clearly mark all tourniquet sites with the
time of tourniquet application. Use an indelible marker.
PROPOSED CHANGE TO THE TCCC GUIDELINES
Current wording TACEVAC Care
Care Under Fire
N/A 3. Bleeding
a. Assess for unrecognized hemorrhage and control all
Tactical Field Care sources of bleeding. If not already done, use a CoTCCC-
recommended limb tourniquet to control life-threaten-
4. Bleeding ing external hemorrhage that is anatomically amenable
a. Assess for unrecognized hemorrhage and control all to tourniquet use or for any traumatic amputation. Ap-
sources of bleeding. If not already done, use a CoTCCC- ply directly to the skin 2–3 inches above the wound. If
recommended limb tourniquet to control life-threaten- bleeding is not controlled with the first tourniquet, ap-
ing external hemorrhage that is anatomically amenable ply a second tourniquet side-by-side with the first.
to tourniquet use or for any traumatic amputation. Ap- b. For compressible hemorrhage not amenable to limb
ply directly to the skin 2–3 inches above the wound. tourniquet use or as an adjunct to tourniquet removal,
If bleeding is not controlled with the first tourniquet, use Combat Gauze as the CoTCCC hemostatic dress-
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apply a second tourniquet side-by-side with the first. ing of choice.

142 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017