Page 127 - JSOM Winter 2018

ranges from 0 (negative findings in all sites) to 4 (posi- to allow initial thrombus formation. It may take ≥20 minutes
tive findings in all four sites). for a full, stable thrombus to form in trauma patients that are
4. Thoracic FAST: evaluates for the presence of a pneumo- hypothermic and/or suffering some degree trauma-associated
thorax, pericardial effusion, and/or pleural effusion. The coagulation impairment. It is imperative to always reassess fre-
techniques consists of scanning the following five sites: quently for evidence of continued bleeding or rebleeding; any
a. Bilateral right and left chest tube sites: time the canine is moved, re-evaluate previous hemorrhage
i. Assesses for pneumothorax control interventions to ensure they are still effective.
ii. Probe placement: directly dorsal to the xiphoid pro-
cess between the eighth and ninth intercostal spaces Arterial pressure points
b. Bilateral right and left pericardial sites: A pressure point is located where a major artery passes over a
i. Assesses for pericardial effusion and/or pleural bone near the surface of the skin. Exerting external pressure,
effusion either digital (i.e., fingers, thumb, heel of hand) or with a knee,
ii. Probe placement: region of the third, fourth, and to an arterial pressure point proximal to the bleeding site shuts
fifth intercostal spaces at the costochondral junction off distal blood flow to the bleeding wound (thus acting as a
or over the location of an auscultated or palpable pseudotourniquet). In canines, the typical sites for compres-
heartbeat sion include the femoral artery against the femur high in the
c. AFAST diaphragmatic-hepatic site: inguinal crease and the brachial artery against the underlying
i. Assesses for pleural effusion and pericardial effusion medial humerus as high as possible. Brief use of proximal ar-
ii. Probe placement: immediately caudal to the xiphoid terial pressure points may serve as a stopgap to buy time until
process more effective methods of hemorrhage control can be used;
proximal arterial pressure points are not effective or feasible
Even if the initial findings of a FAST examination are negative, as a long-term hemostatic intervention. It is logistically dif-
22
it is important to do the following: ficult and physically challenging to attain and continuously
maintain pressure that is sufficient and consistent enough to
• Conduct serial thoracic FAST and AFAST examinations provide adequate long-term hemorrhage control, particularly
to try to identify the potential development of fluid ac- during casualty movement.
cumulation at a later time.
• Keep ongoing retroperitoneal hemorrhages on the dif- Pressure dressing and bandage
ferential diagnosis list for any canine suffering blunt ab- A pressure bandage is used to provide additional, continuous
dominal trauma with hemorrhagic shock unresponsive pressure to a wound in attempts to staunch arterial bleed-
to appropriate treatment interventions. ing. Although the pressure bandage provides pressure over
the entire wound, applying more focal pressure directly over
External Hemorrhage the main source of bleeding may increase its effectiveness.
External bleeding is more readily detected than internal bleed- Where anatomically feasible, a circumferential pressure ban-
ing; however, as noted, the canine’s hair coat may effectively dage achieves the greatest applied pressure for stopping arte-
hide wounds and external hemorrhages. To facilitate find- rial flow. Noncircumferential bandages often do not generate
ing external wounds and hemorrhages on an injured OpK9 pressure that is continuous and sufficient to successfully abate
quickly, considering the following: arterial hemorrhage. Placing the wrap with focal pressure
directly over top of the source of bleeding helps reduce the
1. Perform a rapid head-to-tail visual assessment for any ob- amount of manual pressure required to occlude the damaged
vious evidence or sources of bleeding such as open wounds, vessels. Some commercial trauma bandages (e.g., OLAES ;
®
spurting blood, blood-stained or wetted hair coat, and Tactical Medical Solutions, https://www.tacmedsolutions.com/
bleeding orifices. OLAES-Modular-Bandage) are designed with a “pressure
2. Immediately follow the visual assessment with a hands-on, cup” (Figure 2) that applies focused pressure directly on top of
systematic, head-to-tail “hemorrhage sweep” of the body. the wound site. After application of a pressure bandage on an
Consider sweeping each body part with fingers bent at extremity, assess the circulation (pulses) and neurologic status
an angle and closed together like an ice scraper. Sweep or (e.g., motor, sensation) distal to the bandage. Open wounds to
scrape in a rake-like fashion against the normal lay of the the neck may present a risk for a vascular air embolus due to
canine’s hair coat. This technique facilitates detecting any large vessel injury (e.g., external jugular vein); therefore, for
blood or wounds that are often missed when sweeping each these wounds, consider applying an occlusive dressing over the
body part with hands flattened (i.e., fingers straightened) wound as a primary layer.
and/or going with the normal lay of the hair coat.
3. Only sweep and assess one area at a time and evaluate Always assess the applied pressure bandage for evidence of
hands or gloves for blood or wetness. ongoing bleeding. Some bandages may wick blood from the
wound without actually stopping the hemorrhage. Depending
Methods of Pressure Control on the thickness and type of the bandage material applied,
Direct pressure its wicking effect may lead to unrecognized ongoing hemor-
Direct pressure applied to the source of bleeding is a highly rhage. In general, if blood continues to soak through the ini-
effective intervention for controlling most external hem- tial dressing and pressure bandage, do not remove the first
orrhages, including major arterial hemorrhages. Principles pressure dressing or bandage. Instead, apply an additional
relative to direct pressure application in humans also apply layer of dressing atop the first and then reapply pressure and
to canines. Apply focal pressure directly over the source of pressure bandage. An exception to this recommendation ap-
bleeding at a force significant enough to staunch arterial flow. plies when following manufacturing guidelines for select he-
Maintain continuous pressure for a minimum of 5–10 minutes mostatic agents (e.g., Combat Gauze ); for these agents, the
®
Prehospital Traumatic Hemorrhage Control in Operational K9s | 125