Self Defense Medicine Session 10: Hemostatic Agents

Let's talk about hemostatic agents. Hemostatic agents are a great tool for us to use when dealing with moderate to severe bleeding. Especially in places that we can't always get a tourniquet. So locations of the body like up high around the hips or the abdominal region. Okay, or even maybe up in the armpits where we're just even high enough.

Now, places we don't wanna use a hemostatic agent, we're gonna talk about that in here in a moment. But let's first talk about what exactly is a hemostatic agent and what does that do? Well, we've got with us, we've got the quick clot combat gauze. Now we've got a couple of different variants of it and makes and models of it, of the combat gauze. And we'll talk about those but specifically talking about quick clot combat gauze.

What an hemostatic agent does, is it actually assists and helps the clotting factor of the blood and the hemoglobin and just helps it along more or less. Okay? Now, there's been some myths about, or some here's some hearsay about, oh, well if you use those things they create heat and they're going to burn the patient. Well, that's not exactly true. They used to, but nowadays the combat gauze and the other manufacturers out there, they've gotten rid of that formula that creates those second degree burns.

Another thing is that, well, they started using the powdered form. Well, to debunk that myth, we aren't using powder anymore because the powder forms were actually causing pulmonary embolisms and moving throughout the body and some of the clots were actually traveling through the body and places we don't need clots to be like the lungs and the heart and other places like that. So here, into modern times, now we've got it down and we've got these products that have been vetted and we've been using them with a great success rate. However, these are not your just cure all. Okay?

A lot of my students come up and say, "Hey, I bought this package of combat gauze from a local retail store or a local online store, and I threw it in my glove compartment or threw in my IFAK, and that's all I need in an IFAK, or my Individual First Aid Kit, or your med kit." That's not entirely true. They're a great tool, but it does take some, you actually have to know not just how to use it but when to appropriately use it. So speaking about probably when do we use this stuff? Well, like I said, we can use this in certain parts of the body. Places we do not want to use a hemostatic agent or actually pack the wound.

And that's how we're going to use this, is we're actually going to pack the wound, and we'll talk about the pros and cons of packing and some of the cautions with that. So to help us along with that we've got our simulator here and this is simulating the skin with a penetrating injury here. Let's just call it a gunshot wound for right now. But we first need to talk about, "Hey, well, what's going on with this?" Well, from ballistic studies of ballistic anatomy and anatomy itself with the human anatomy, we know that when that temporary and permanent wound cavity happens there's that hole inside that tissue. And there's that permanent wound cavity.

And the idea is with the blood vessels and arteries leaking into that cavity, the idea is to actually add direct pressure with the hemostatic agent to that site. So first thing we have to do is actually get that pool of blood that's inside that cavity out of there. Now we can do this a couple different ways. If you can, we actually roll it, the patient if need be and help it out. If you've got an extra packet of gauze you can actually real quickly use it to help you assist and removing some of that gauze, but probably, if it's that bad it's going to be filling up quick.

So what we need to do is be quick about it but also we gotta locate the exact spot of where that source of bleeding is coming from. So before we start looking for that and sticking our fingers in there blindly into the chest, or, excuse me, into that wound cavity, we need to be cautious about a few things. If we've had penetrating trauma from either a gunshot wound or the bullet itself or a knife, well, there may be fragmentations or fragments of either the bullet, the knife, or bone fragments. So if we start, we gotta use caution. We start poking our fingers down inside that skin, inside that tissue, that we may come across some of that and it may end up causing further injury as well.

So, but let's talk about before we start actually packing this wound, what are some locations that we can use and not use the hemostatic agent or packing a wound? The first thing is the head. We don't pack up into the head, anywhere around basically the jaw line up. We're not going to pack or use a hemostatic agent. We'll just use regular cotton gauze for that.

In the neck we can use it. Okay? A hemostatic agent and we can pack it, but you've got to use caution. You've got some serious arteries and veins running along there. The windpipe, the trachea, okay?

You've also got your esophagus and we don't want to start packing those things. Moving down to the thoracic region and anywhere we have ribs, we don't want to pack that wound there, it's a hollow organ, a hollow space. We can end up putting hundreds of yards of gauze inside that space, not to mention we're going to start collapsing the lungs, the heart, causing a lot of other problems. So we're not going to pack in there. The abdominal region, anywhere it's soft where there's no ribs, the front and the sides and the back, we can pack a wound, but again, you've got hollow and solid organs in there, not to mention the skin's very elastic and some of those organs are as well.

So you may end up packing the wound, but we'll talk about specifically on the abdominal region here in a minute. If we're packing the legs we can pack the full length of the legs. That's fine. Also the arms. Now, one place we specifically do not pack a wound or apply the hemostatic agent is anywhere in or near the penis, the testicles, the vagina, or the rectum itself.

Those areas we don't pack with any regular gauze, and we sure don't pack it with the hemostatic agent. So looking at our entry here we've got a simple gunshot wound and we've got a couple different versions of the combat gauze that we can use. One version is the military version and it comes packaged two different ways. One is rolled, this is the rolled version. And it actually comes in a flat one like the law enforcement or the civilian version here, where it's kind of fan folded and it has a little bit smaller cubic footprint for when you're packing into your IFAK.

We're using the blue trainer gauze today, okay? And that's what we're going to use today to pack this wound. Now, it says on here we've got about four yards of this combat gauze, okay? And it may take that much, it may not to the pack that wound. However, it's always a good idea that if we've got a package of this, well, in our med kit or IFAK we've either got the bandage, and as we remember earlier, it's got the guts inside.

So we can actually use the gauze inside here to pack inside there, to back it up if we need to. We've also got the Z-Pak Dressing which is just regular cotton gauze, fan folded in there, and it leaves a really small cubic footprint as well in your IFAK. It's always good to have just another extra piece of gauze in there, should you need it. One thing to be aware of about hemostatic agents is that some of them are actually made from using parts of shellfish. But if you're allergic to shellfish, no need to worry.

The proteins are a little bit different, so there's really no indications for using a hemostatic agent. So we've identified the injury. We realize, "Hey, it isn't a location that we can actually apply, that we can wound pack and pack the wound." We can also apply the hemostatic agent. So, let's go ahead and do that. We've identified it.

We see that the bleeding, but let's say it's too small for us to go fishing around in there. So, I'm not going to stick my fingers in there blindly and start trying to find the artery. I'm just gonna go ahead and start packing it. So, I'm going to open up the package here, and I'm going to leave the actual gauze inside the package. I'm not going to pull it all out because this stuff reacts with liquid and fluids.

Well, I don't want to pack this stuff inside there and have it already started to react, all right? So, I want to keep as much as I can inside the package itself. So, I'll find the end of it. I'll find it here, kind of wrapping around your finger if you want, and then I'm simply going to start packing it in there. Now, packing the wound, we're going to pack up, down, left, and right, in that order.

So we're going to pack up towards this direction a little bit, then down a little bit, and then to the left, and then to the right. We're going to keep packing this until a couple of things happen. One, we either get this solid rock hard. And when I say rock hard, it means when you push onto this gauze, it's rock hard. It's very, very solid.

It's not squishy or soft. Okay? And second it's flushed with the skin. Now that may take one yard of this material. It may take, you know, all four yards.

It depends on the wound itself. So, as you can see, I'm still packing this pretty well. And this may take you a while, so think about this. This is not the quick fix either. Now, once I actually get this rock solid, and I've got it packed hard enough, and it's flush with the skin, which I'm kind of getting there already, then what I'm going to do, I can either cut this and store the rest in case of additional injuries on the same patient.

And remember, this is for the same, one patient use, so you shouldn't be using this with different patients. If it's all you've got and you've got your family members, eh, okay. It may not be such a bad idea that if you need to work on family members specifically and they've got multiple wounds, than you can use this if you need to. Okay? But it's for the most part, keep it with you.

And let's say, "Hey, I've cut this and I don't need to use the rest of it." Well, then the rest of this package stays with that patient and goes with them when they transport them with the ambulance crew and tell them, "Hey I used this much", or, "Hey, here's, what's left. I did use a hemostatic agent product." And that way, when they get to the OR or in the ER, and they start to bring them and start pulling this stuff out of them, they can measure and say, "Okay, well. they told us they use three yards. So we should have one yard left in the package. We've got the one yard here.

Let's see if we've got three more yards inside the patient", in which we do. If they don't, they know that they need to keep digging and find the rest of that. So now that that's on there, we cut this off, cut this here with our scissors, set it to the side, and now we're gonna apply direct pressure as hard as we can 'cause it's flush with the skin and it's rock hard now, right there. It's spongy around the side and the skin, but this wound site itself is pretty solid right there. Now I'm gonna apply direct pressure for three to five minutes.

Three to five minutes doesn't sound long. And that should be your clue, like, "Hey, this is not the cure all". Especially during our environment where we just had a violent altercation, we need to be sure and keep on reassessing our scene, reassessing the environment we're in, in case there's other threats that show up during this, okay? The extra gauze is there if you need it. And if they get this on there, if you've applied the hemostatic agent, well, don't just let it lay there so that it pops back out.

Go and take your pressure dressing and wrap it up as best you can, or simply just hold it directly on there after your direct pressure for three to five minutes. Now, if you look, even that small little hole, I didn't even really get a full yard out of there. Just maybe a foot or two of gauze in that small hole, but don't let that fool you, okay? Just because gunshot wounds, they're all a little bit different. Stab wounds are all a little bit different.

If you've got an entrance and exit wound then you need to think about that and make sure you're not pushing that all the way through, and through the exit wound, and it's just falling out the backside of the patient. Okay? If you need to, wrap it up or have someone else, or a bystander or someone else hold that other inch with the pressure dressing and hold that while you start packing the wound if you need to. Also, it's going to be really painful and the patient may not be so cooperative just letting you sit there, packing this into them. All right?

So that's where you've got to talk to your patient let them know what you're doing. Let them know you're there to help. Try to calm them the best you can, okay? And try to work as quickly as you can as well. Remember, this stuff starts reacting as soon as it touches the blood.

So we don't want to sit there and take too much time doing so. In summary, when dealing with the hemostatic agents, the first thing we've got to do is make sure that the wound is actually located in a place that we can use wound packing techniques and that we can use a hemostatic agent. Second, we need to pack the wound correctly and thoroughly and apply that direct pressure for three to five minutes. Once we've done that, then we can finish up by applying that pressure dressing nice and tight.