Page 32 - 2022 Ranger Medic Handbook

Hemorrhage Management
Hemorrhage Control
Extremity trauma hemorrhage is the most frequent cause of preventable combat death, which can generally be pre-
vented by the early use of a tourniquet. The use of compression dressings and/or hemostatic agents to control bleeding
or convert tourniquets is imperative in continued casualty management. For internal or uncontrollable hemorrhage of
the chest or abdomen, the most crucial life-saving intervention is rapid evacuation to a surgical capability. Measures
SECTION 2 that will enhance the possibility of survival of these casualties are early resuscitation with blood products, avoidance of
aggressive crystalloid/colloid fluid resuscitation, prevention of clotting dysfunction caused by hypothermia and acidosis,
and avoidance of platelet-impairing medications.

TCCC Application
Care Under Fire: Stop life-threatening external hemorrhage if tactically feasible. Direct casualty to control hemorrhage
by self-aid/buddy-aid if able. Use a CoTCCC-recommended tourniquet for hemorrhage that is anatomically amenable
to tourniquet application. Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the
casualty to cover. Initial tourniquet placement should be as high as possible on the limb.
Tactical Field Care & Tactical Evacuation: Assess for unrecognized hemorrhage and control all sources of bleeding. If
not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is ana-
tomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2–3 inches above
wound and never over a joint. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tour-
niquet removal (if evacuation time is anticipated to be longer than 2 hours), use a pressure dressing with a hemostatic
agent. Hemostatic gauze should be packed into cavitation of wound with at least 3 minutes of direct pressure. Before
releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to
resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain in-
jury). Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet
from over uniform and apply directly to skin 2–3 inches above wound. If a tourniquet is not needed, use other techniques
to control bleeding. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal
pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and
proximal to the first, to eliminate the distal pulse. Expose and clearly mark all tourniquet sites with the time of tourniquet
application. Use a permanent marker.
a. Reassess patient and verify bleeding is controlled.
b. Verify distal pulses are absent in extremities with tourniquets.
c. Reassess if tourniquet is required or other hemorrhage control means are appropriate.
Advanced Hemorrhage Control: Consider the early use of a junctional tourniquet for high femoral or axillary bleeding
not amendable to tourniquet application. Any improvised junctional technique must be trained and practiced to ensure
proper application. Other advanced hemorrhage control techniques such as REBOA should only be performed by those
with extensive training and experience in the individual tasks required to successfully complete the procedure.

Extended Care
Tourniquet Conversions: If a tourniquet is applied, loosened, or reapplied, ensure the approximate time is recorded on
the tourniquet and the casualty card. Reevaluate all applied tourniquets for efficacy and further need. Perform tourniquet
conversion procedure as applicable, as early as possible, and if hemorrhage control is achieved otherwise.
Wound Management: Change and/or reinforce all hemorrhage control dressings as applicable and dependent on medi-
cal supplies. Irrigate and redress wounds (any potable water can be used for irrigation). Debride only obviously devital-
ized tissue. Change dressings every 24 hours or as needed. Consider converting to silver impregnated dressings to
reduce frequency of dressing changes. Continue antibiotics. Repeat moxifloxacin 400mg PO or ertapenem 1g IV/IO/IM
q24hr.
Abdominal Injuries: Control any visible hemorrhage from bowel. Irrigate gross debris off of exposed bowel. Attempt to
gently reduce bowel back into abdominal cavity. If bowel is reduced, approximate skin (sutures or staples) and cover
abdominal wound with dressing. If bowel is unable to be reduced, cover bowel with moist dressing and keep covered.

18 SECTION 2 PRIMARY TRAUMA PROTOCOLS