Raid on Entebbe by RADM Bill McRaven As previously ordered, the three assault elements disregarded Netanyahu and stormed the building. At this point in the operation, there wasn t time to attend to the wounded. 61
Do seconds really matter? 62
Ma a lot Rescue Attempt by RADM Bill McRaven 15 May 1974 3 PLO terrorists take 105 hostages Schoolchildren and teachers When assault commenced, terrorists began killing hostages 22 children killed, 56 wounded The difference between a dramatic success and a disaster may be measured in seconds. 63
Care Under Fire NO IMMEDIATE MANAGEMENT of the airway should be anticipated at this point because of the need to move the casualty to cover as quickly as possible. 64
Care Under Fire Control of hemorrhage is the top priority. Bleeding to death from extremity wounds is the number one cause of preventable death on the battlefield. Cause of death in more than 2500 casualties in Vietnam who had no other injuries. 65
Bloodborne Pathogens First Aiders may be exposed to infectious diseases when treating ill or injured persons. Blood or body fluid contact with: mouth, eyes, nose, or breaks in skin Needle sticks (or other sharps) Sexual contact 66
Bloodborne Pathogens Bodily fluids can transmit: HIV Hepatitis Tuberculosis 67
Universal Precautions If you don t already share bodily fluids with this person, Now is not the time to start! 68
Universal Precautions Gloves Eye and face protection Airway barrier devices Hand washing Contaminated clothing Potential exposure incidents 69
Universal precautions Bodily fluids can transmit HIV, hepatitis, tuberculosis, Gloves First choice: nitrile Second choice: latex (allergy?) Avoid vinyl Need for eye protection, mask? 70
Is This Life Threatening Hemorrhage? 71
Extremity Trauma Any penetrating extremity wound associated with a fracture is at serious risk for life threatening hemorrhage. 72
5.56mm Rifle Exit Wound 73
Questions/Comments? 74
How Do You Control Hemorrhage? Direct Pressure / Elevation Pressure point Pressure dressing Tourniquet Packing 75
Direct Pressure Can you exert enough pressure? Can you exert enough pressure at the site of bleeding? 76
Direct Pressure Use both hands Gloves Gauze helps clotting Best method in a stable environment Elevate injured limb 77
Direct Pressure Works most of the time for external bleeding Two hands Ground or hard surface underneath Lean into it DON T LET UP TO CHECK WOUND! Hard to maintain on big bleeders during casualty carry 78
Pressure Point Apply where artery can be trapped against bone Use two hands Should be use in conjunction with direct pressure or pressure dressing 79
Pressure Dressing Used to replace direct (manual) pressure If direct pressure didn t work a dressing WILL NOT be successful! A neat bandage (dressing) is a happy bandage 80
Pressure Dressing Probably less effective that direct pressure Direct pressure possible on top of dressing Assess your treatment: bleeding in the dressing is not effective 81
82
Questions? 83
Tourniquets Discouraged by ATLS Most reasonable initial choice to stop extremity bleeding in the Care Under Fire Phase Direct pressure is hard to maintain during casualty transport under fire. 84
Tourniquets from the front line Tourniquets are not being placed correctly Too liberal use on small oozing distal wounds. They are not being tightened enough Venous -vs- Arterial 85
The Death of General Albert Sidney Johnston Leading Confederate General KIA at Shiloh 7 April 1862 Gen Johnston s Surgeon - Dr. David Yandell - directed that tourniquets be issued During the battle, Gen Johnston sustained injury to popliteal artery - bled to death Tourniquet was in his pocket 86
Extremity Hemorrhage Control Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. These casualties had no other injuries. Vietnam. Medical Evacuation. Marines of Company E, 2nd Battalion, 9th Marines, while under heavy firefight with NVAs within the DMZ on Operation Hickory III, are carrying one of their fellow Marines to the H-34. 07/29/1967 87
OIF Fatality Marine shot in leg in Iraq Pulsatile femoral artery bleeding Corpsman arrived 10 minutes later Attempted to use hemostatic material Failed IV attempted failed Tourniquet finally applied Casualty died 88
Hemorrhage Control in COMBAT The recommended means to control bleeding in a tactical environment while under fire is a rapidly applied tourniquet COMBAT APPLICATION TOURNIQUET 89
Journal of Special Operations Medicine, Volume 5, Edition 4 / Fall 05 90
Cravat/Windlass 91
Tourniquets Damage to the arm or leg is rare if the tourniquet is left on less than an hour. Tourniquets often left in place for several hours during surgical procedures. In the face of massive extremity hemorrhage, in any event, it is better to accept the small risk of damage to the limb than to have a casualty bleed to death. 92
The Five Big Tourniquet Mistakes 1. Not using one when you should 2. Using one when you shouldn t 3. Putting it on too high above the wound 4. Not taking it off when you could 5. Not making it tight enough 93
Tourniquets How long does it take to bleed to death from a complete femoral artery and vein disruption? Answer: 2-4 minutes 94