Page 168 - Journal of Special Operations Medicine - Spring 2017

b. For compressible (external) hemorrhage not amenable abdominal bleeding. Application and extended use must
to limb tourniquet use or as an adjunct to tourniquet re- be carefully monitored. The PASG is contraindicated for
moval, use Combat Gauze as the CoTCCC hemostatic casualties with thoracic or brain injuries.
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dressing of choice.
Level of evidence: (Tricoci)
Alternative hemostatic adjuncts: The levels of evidence used by the American College of
– Celox Gauze or Cardiology and the American Heart Association were
– ChitoGauze or outlined by Tricoci in 2009:
– XStat (Best for deep, narrow-tract junctional wounds)
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Hemostatic dressings should be applied with at least – Level A: Evidence from multiple randomized trials
3 minutes of direct pressure (optional for XStat ). Each or meta-analyses.
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dressing works differently, so if one fails to control – Level B: Evidence from a single randomized trial or
bleeding, it may be removed and a fresh dressing of the nonrandomized studies.
same type or a different type applied. – Level C: Expert opinion, case studies, or standards
If the bleeding site is amenable to use of a junc- of care.
tional tourniquet, immediately apply a CoTCCC-rec-
ommended junctional tourniquet. Do not delay in the Using the taxonomy above, the level of evidence for each
application of the junctional tourniquet once it is ready statement below is shown:
for use. Apply hemostatic dressings with direct pressure – Circumferential pelvic compression devices stabilize
if a junctional tourniquet is not available or while the pelvic fractures: Level B
junctional tourniquet is being readied for use. – Circumferential pelvic compression devices help to
c. A pelvic binder should be applied for cases of suspected control bleeding from a fractured pelvis: Level B
pelvic fracture: – Circumferential pelvic compression devices im-
– Severe blunt force or blast injury with one or more of prove survival in individuals with pelvic fractures:
the following indications: Level C
• Pelvic pain – Circumferential pelvic compression devices are un-
• Any major lower limb amputation or near likely to cause further injury when applied to indi-
amputation viduals with suspected pelvic fractures: Level C
• Physical exam findings suggestive of a pelvic – Circumferential pelvic compression devices should
fracture be applied for individuals with suspected pelvic frac-
• Unconsciousness ture as a result of blast injury with lower extrem-
• Shock ity amputation or with blunt trauma and any of the
d. Reassess prior tourniquet application. Expose the following:
wound and determine if a tourniquet is needed. If it is,
replace any limb tourniquet placed over the uniform – Shock
with one applied directly to the skin 2–3 inches above – Pelvic pain
wound. Ensure that bleeding is stopped. When possible, – Compromised exam (GCS ≤ 13 or distracting injury)
a distal pulse should be checked. If bleeding persists or Level C
a distal pulse is still present, consider additional tighten- – There is no clearly superior device among the three
ing of the tourniquet or the use of a second tourniquet currently available circumferential pelvic compres-
side-by-side with the first to eliminate both bleeding sion devices: Level B
and the distal pulse.
e. Limb tourniquets and junctional tourniquets should be Recommendations for
converted to hemostatic or pressure dressings as soon Further Research and Development
as possible if three criteria are met: the casualty is not in
shock; it is possible to monitor the wound closely for bleed- 1. The Joint Trauma System performance improvement pro-
ing; and the tourniquet is not being used to control bleed- cess should be used to identify all future casualties on
ing from an amputated extremity. Every effort should be whom circumferential pelvic compression devices are used
made to convert tourniquets in less than 2 hours if bleed- and how they performed.
ing can be controlled with other means. Do not remove a 2. Clinical study to evaluate outcomes of prehospital pelvic
tourniquet that has been in place more than 6 hours unless binder use, both military and civilian.
close monitoring and lab capability are available. 3. Retrospective review of casualties who would have been
f. Expose and clearly mark all tourniquet sites with the good candidates for circumferential pelvic compression de-
time of tourniquet application. Use an indelible marker vices but for whom these devices were not used.
4. Evaluation of improvised pelvic binders in comparison to
Remove from guidelines: commercial devices with particular interest in binders con-
structed using materials commonly available in combat aid
TACEVAC Care bags.
5. Develop a relevant animal model for pelvic fracture hemor-
17. The Pneumatic Antishock Garment (PASG) may be useful rhage and assess the effect of pelvic binder placement on
for stabilizing pelvic fractures and controlling pelvic and survival.

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