Case by Paul Roszko, MD
It is a typical Friday night at the station. The shift supervisor is back in his office listening to pop-country music and some of your colleagues are lounging on the couch watching reruns of It’s Always Sunny (the one where the gang starts selling gas door-to-door).
Dispatch calls in an excited voice telling you that you are being sent out to respond to a report of a shooting about 2-3 miles away. You and your partner spring into action and get wheels rolling toward the scene. While en route you start to think about all the different interventions you might need to employ to treat any victims – needle decompressions, chest seals, tourniquets… or maybe you’re just going to scoop and run and book it to the nearest trauma center.
As you approach the scene you notice that Fire and Police have arrived and have set a perimeter for you and report that the scene is safe. You come up to a single male victim, in his mid-20’s, who is lying on the ground with one of the first responders holding pressure near his groin. He is awake, anxious, and shaking. There is a significant amount of blood that has pooled around his body and there is active bleeding in spite of direct pressure being held by the first responder. A quick glance at the wound reveals a penetrating wound about 2 to 3 inches in diameter around the inguinal crease. You immediately think to grab a tourniquet to control the hemorrhage but realize that as you try to place the tourniquet the wound is too proximal for it to be effective. Your partner goes to look for a junctional tourniquet but reports back that he cannot find the bulb to inflate the bladder of the tourniquet.
You remember that as part of your recent active shooter response training your company has stocked all units with packages of QuikClot® Combat Gauze (Z-Medica, Wallingford, CT), a kaolin impregnanted gauze that is the current hemostatic dressing of choice by the Committee on Tactical Combat Casualty care (CoTCCC). You decide your best course of action is to pack the wound with the Combat Gauze and hold pressure while transporting to the trauma center. While transporting you notice that the gauze has become saturated with blood but the rate of bleeding has seemed to decrease.
You begin to wonder if you could have had the same effect with standard cotton roll gauze, or if there is any other hemostatic dressing that may have been easier to place into the narrow gunshot wound? You have also heard that other hemostatic agents use different types of active agents to achieve hemostasis and wonder if any of those have been shown to be more effective than another?
Discussion question(s) – for compressible hemorrhage not amenable to control via tourniquet placement, what is your agency’s current hemostatic dressing of choice? Are you still using standard cotton roll gauze for cost reasons? How do you instruct your providers to apply these hemostatic dressings?
Please share your comments below. An evidence-based discussion including your comments will be posted in the third week of January.