Blow-out kit contents recommendation

[Medic4070]

I've used them occasionally for my college drunks when running EMS and like them for those folks who are obtunded and need a little airway help, but not so far out as to take an OP or other airway. Plus, it's pretty hard to screw up a NPA, so the training investment for first responders is pretty minimal. Just curious what the .mil side was seeing or thought too.

[DvlDoc8404]

Originally Posted by Medic4070

If you're still considering adding a hemostatic dressing, you might want to think about the cost and expiration dates of those dressings. You can get a roll of QuikClot Combat Gauze for $30-ish...which will expire in about 18 months, if you're lucky and get a "long" expiration date.

Or you can get a roll of compressed gauze for about $1 (if they gouge you) and it doesn't have an expiration date, yet has similar efficacy (when used properly).

Also remember, that you will have to train people in the use of these kits. To that end, I would emphasize basics, basics, basics. Introduce MARCH because looking for bleeds first isn't a huge logical leap for most people. Then hammer home direct pressure on limbs, and do a fam on the CAT to include MULTIPLE rounds of applying trainers on each other.

And yes, I'd follow up each scenario with packaging the patient in a mylar blanket at a minimum. I read a study a year or two ago that said something like 60% of trauma patients that arrive at US Level I trauma centers are hypothermic to one degree or another. I've really been beating this drum recently at my volunteer agency, and with my EMT's and EMR's at work.

Agree 100% on all points. Regular kerlex is just as good. It's about the technique, not the "magic fairy dust" sprinkled in the gauze. As for hypothermia, wasn't there a study in Iraq several years ago that demonstrated something to the effect that the mortality rate for hypothermic trauma patients approached 100% due to the effect of hypothermia on clotting?

NPAs are fairly benign and easy to train. About the only contraindication I can think of is serious midface trauma. As long as folks remember to go straight back (anterior to posterior) and not up they should go in pretty easy.

I also think chest seals are fairly easy and appropriate in a CONUS setting where EMS is (on average) 7 to 10 minutes away. There's a little training burden with them insofar as you have to teach people to recognize the S/Sx of tension pneumo, (I usually emphasize "guppy breathing and bulging neck veins"), and how to "burp" the wound (if that even works), but again, EMS should be there pretty soon and they can do needle decompression if needed. Training for use of chest seals, recognizing tension pneumo etc depends on the audience but I don't think it is an absolute "no-no" for the lay person audience.

[Old_Starlight]

Originally Posted by DvlDoc8404

<snipped for brevity> As for hypothermia, wasn't there a study in Iraq several years ago that demonstrated something to the effect that the mortality rate for hypothermic trauma patients approached 100% due to the effect of hypothermia on clotting?

I was embedded in A/stan in 2007 when this stuff came down. I don't recall the actual numbers. There was a briefing on studies of both theatres which showed significant complications for the surgical pipeline from hypothermia issues. Everyone was instructed to treat all CAS as hypothermic regardless of symptoms.

So everyone was wrapped in the blankets to include feet and head before they were put in the birds.

I'll see if I have the notebook with the notes from the briefing tucked away where I can find it. Better yet if someone here has links to those studies?

This relates to the OP in that no blow out bag should be considered complete unless several space blankets are included.

Cheers,

[MWL]

One thing to consider when recommending kit specifically for CONUS, or any civilian/domestic situation, is that in an active shooter or similar situation, EMS may not be 5 minutes away.

They could very well be staged for a considerable amount of time, and even LE might not be able to enter the scene immediately. What you have available to hand may be all you have for a lot longer than you might think, or wish.

Regards.

Mark

[firstshirt]

Originally Posted by DvlDoc8404

...I also think chest seals are fairly easy and appropriate in a CONUS setting where EMS is (on average) 7 to 10 minutes away. There's a little training burden with them insofar as you have to teach people to recognize the S/Sx of tension pneumo, (I usually emphasize "guppy breathing and bulging neck veins"), and how to "burp" the wound (if that even works), but again, EMS should be there pretty soon and they can do needle decompression if needed. Training for use of chest seals, recognizing tension pneumo etc depends on the audience but I don't think it is an absolute "no-no" for the lay person audience.

Training burden? Two sentences should do it -

Do you see a hole in the chest?
Put one of these over it.

Done and done.

[Old_Starlight]

Originally Posted by firstshirt

Training burden? Two sentences should do it -

Do you see a hole in the chest?
Put one of these over it.

Done and done.

You sound like me. My intro to first aid with civvies goes along the lines of: "Two important things. Blood goes around and around and doesn't come out. Air goes in and out and only by one route. If either of these two things is screwed up, fix it. The rest will be gravy"

Cheers,

[Just Another Guy]

Keep in mind, metro Denver is a "no carry zone". The church incident here (COS) was "mitigated" by an armed response on site. GG can probably shine more light on that aspect (local laws) as well. In addition to finding out what the EMT response times are, LE times would also come in handy. Lastly, I would think a church that size could afford some pretty good stuff and training (Oh, I realize getting money out of those organizations can be difficult)

[Bellerophon]

I'd add some saran wrap, 10 or 20 good size safety pins and 100 mph tape. Low cost, low space, good payout.

[8654maine]

Originally Posted by Bellerophon

I'd add some saran wrap, 10 or 20 good size safety pins and 100 mph tape. Low cost, low space, good payout.

Yup, someone should have some loose plastic sheets, i.e. sandwich bag, freezer bags, plastic shopping bags, bread bag, etc... to convert a sucking chest wound to a controlled pneumothorax valve.

I like MARCH.

I would run scenarios, with and without gear/tools.

One can have all the training/certs in the world, but the first encounter with screaming/panicked bodies, squirting blood, body fluid turning floor-into-skating-rinks, things WILL going amok.

You need directors and people with simple jobs.

People need to practice their roles.

[Bellerophon]

Originally Posted by 8654maine

squirting blood, body fluid turning floor-into-skating-rinks,

Speaking of that, since this is prepositioned gear in a fixed location, you may want to consider a pile of cotton towels in the hidey holes with the kits. Nothing fancy, just old bath towels from the congregation.

[Devildoc]

Originally Posted by DvlDoc8404

.......As for hypothermia, wasn't there a study in Iraq several years ago that demonstrated something to the effect that the mortality rate for hypothermic trauma patients approached 100% due to the effect of hypothermia on clotting?

There's a reason hypothermia is a leg in the Trauma Triad of Death, and of the legs, it's really the only one we can impact pre-hospital (the other two legs being acidosis and coagulopathy).

[sarmed1]

The concern I have with using TCCC data to guide treatment concerns for civilian casualties is that due to the level of ballistic protection employed down range the data line may be skewed away from chest injuries toward extremity trauma bleeding as far as causes of preventable death. Though I have yet to find a concrete data study. I found one looking at injuries in Chicago, that seemed to show a higher frequency death from torso than extremity injury. (there still seemed to be a lot of lower extremity injuries, but far less that resulted in death proportionally) It did not explain what exactly was the cause of death, as far as resp related complications vs massive bleeding from organ/vascular damage.
So with that in mind, when thinking civilian training, there may need to be at least equal covering of management of chest related injury (cover, position and TPx recognition) vs extremity bleeding (TQ and packing)

With that thought, I wouldnt worry as much about a hemostatic gauze vs kerlex; especially when looking at a cost saving. Spending that saved money on a couple of extra chest seals might be more appropriate. (in recognition of pneumo vs tension pneumo, a vented seal may be the way to go)

MK

[firstshirt]

Originally Posted by sarmed1

The concern I have with using TCCC data to guide treatment concerns for civilian casualties is that due to the level of ballistic protection employed down range the data line may be skewed away from chest injuries toward extremity trauma bleeding as far as causes of preventable death. Though I have yet to find a concrete data study. I found one looking at injuries in Chicago, that seemed to show a higher frequency death from torso than extremity injury. (there still seemed to be a lot of lower extremity injuries, but far less that resulted in death proportionally) It did not explain what exactly was the cause of death, as far as resp related complications vs massive bleeding from organ/vascular damage.
So with that in mind, when thinking civilian training, there may need to be at least equal covering of management of chest related injury (cover, position and TPx recognition) vs extremity bleeding (TQ and packing)

With that thought, I wouldnt worry as much about a hemostatic gauze vs kerlex; especially when looking at a cost saving. Spending that saved money on a couple of extra chest seals might be more appropriate. (in recognition of pneumo vs tension pneumo, a vented seal may be the way to go)

MK

If you're not comfortable with TCCC you might give TECC (Tactical Emergency Casualty Care) a go. It's essentially TCCC adapted and modified as appropriate for the civilian world.

[MF]

About two years ago I spoke with my county Medical Examiner about this issue. She told me a vast majority of those that died from gunshot wounds had been either shot in the head or the chest; bleeding out from an extremity wound was a rarity. The county is located in a fairly large metropolitan area with plenty of hospitals.

Mark

Originally Posted by sarmed1

The concern I have with using TCCC data to guide treatment concerns for civilian casualties is that due to the level of ballistic protection employed down range the data line may be skewed away from chest injuries toward extremity trauma bleeding as far as causes of preventable death. Though I have yet to find a concrete data study. I found one looking at injuries in Chicago, that seemed to show a higher frequency death from torso than extremity injury. (there still seemed to be a lot of lower extremity injuries, but far less that resulted in death proportionally) It did not explain what exactly was the cause of death, as far as resp related complications vs massive bleeding from organ/vascular damage.
So with that in mind, when thinking civilian training, there may need to be at least equal covering of management of chest related injury (cover, position and TPx recognition) vs extremity bleeding (TQ and packing)

With that thought, I wouldnt worry as much about a hemostatic gauze vs kerlex; especially when looking at a cost saving. Spending that saved money on a couple of extra chest seals might be more appropriate. (in recognition of pneumo vs tension pneumo, a vented seal may be the way to go)

MK

[sarmed1]

I mostly tech TECC anymore, as most of my classes are 100% civilian oriented. Sadly the NAEMT did a horrible job trying to take TC3 and make a civilian-ized version. In essence, they changed the colors to blue, change to pictures of cops instead of soldiers and a few nomenclatures ie enemy combatant to suspect, care under fire to direct threat etc etc. The didnt change any wound data, its still all combat statistics; their evac section still even talks about using a 9 line. The scenarios are hardly different (dignitary convoy attacked vs supply convoy attacked) I think I was even more disappointed by TECC than I was when they took over TCCC.

mk

[Devildoc]

Originally Posted by sarmed1

The concern I have with using TCCC data to guide treatment concerns for civilian casualties is that due to the level of ballistic protection employed down range the data line may be skewed away from chest injuries toward extremity trauma bleeding as far as causes of preventable death. Though I have yet to find a concrete data study. I found one looking at injuries in Chicago, that seemed to show a higher frequency death from torso than extremity injury. (there still seemed to be a lot of lower extremity injuries, but far less that resulted in death proportionally) It did not explain what exactly was the cause of death, as far as resp related complications vs massive bleeding from organ/vascular damage.
So with that in mind, when thinking civilian training, there may need to be at least equal covering of management of chest related injury (cover, position and TPx recognition) vs extremity bleeding (TQ and packing)

With that thought, I wouldnt worry as much about a hemostatic gauze vs kerlex; especially when looking at a cost saving. Spending that saved money on a couple of extra chest seals might be more appropriate. (in recognition of pneumo vs tension pneumo, a vented seal may be the way to go)

MK

Exsanguination over resp compromise by probably a 10:1 ratio. Can't respire when you have no heart, lungs, or great vessels.

[sarmed1]

Originally Posted by Devildoc

Exsanguination over resp compromise by probably a 10:1 ratio. Can't respire when you have no heart, lungs, or great vessels.

True, the TCCC slides say 25% in overall cause by non correctable trauma, 10% by correctable trauma and 5% for tension pneumo. (the data I have doesnt differentiate between closed vs open TP)
I assume that the correctable surgical would be things like hemothorax, cardiac tamponade and other non TP lung/airway injury.
What I would be curious to find out in the civilian (non ballistic protection) stats would be how much those percentages increase to the overall correctable and non correctable causes.
If there is a disproportionate increase in correctable causes, is it enough to alter the skill/equipment focus or is the existing coverage adequate irregardless of any change in the percentage.

mk

[57Medic]

Nasal trumpets (Nasopharyngeal airways) are only useful if the patient is unconscious or drowning in blood or secretions. No conscious person would tolerate it.

I would suggest caution in telling non-medical people to randomly slap a chest seal over a chest wound, thus possibly making a pneumothorax into a life threatening tension pneumothorax.

Some though might be to include injuries in non-compressible sites, like the neck. Although if you are shot in the neck, you are gonna need a lot of things to go right to survive. This is where Celox, or other pro-coagulants come in.

The others were correct in warning against hypothermia, which begets acidotic blood, which begets coagulopathy (the platelets go by each other, flip the bird and say "fuck you I am not sticking with you")
Bravo for taking the initiative!