Challenge your thinking: mechanical direct pressure device

Nothing new

The control of compressible catastrophic haemorrhage prior to airway, breathing and circulation (CABCDE) is not a new approach, being advocated for civilian use by Hodgetts et al in 2006, and implemented by most ambulance services (including the South Western Ambulance Service NHS Foundation Trust) in 2008. It includes strategies for tourniquet use, pressure dressings and haemostatic agents, and while all have a place in the control of haemorrhage, they also require accurate teaching and practise.

However, despite these implementations, it seems that we still have some way to go to ensure that all paramedic and ambulance staff are drilled in the use of their haemorrhage control equipment.

Compressibility

In a previous paper outlining changes made to the patient assessment primary survey for ambulance staff at South Western Ambulance Service NHS Foundation Trust, Halliwell et al (2011) wrote about catastrophic haemorrhage, but as many authors have since explained the true description should be ‘compressible catastrophic haemorrhage’. This change in wording may seem very minor, but is in fact a key component of the current concepts in wound management, since compressibility has become a far more important concept and, to control haemorrhage in pre-hospital care, we rely mostly on pressure of some description to occlude the vessel.

Direct pressure, indirect pressure and mechanical direct pressure devices all use physical pressure.

Direct pressure is an easy and effective initial way to control haemorrhage, and one which can often be achieved with a single finger or hand on the bleeding point. Direct pressure should be held for at least 3–5 minutes before checking to see if it is effective. Gloves and other personal protective equipment should be worn, and the patient should be encouraged to ‘push here’ where appropriate.

The application of dressings is one of the first lessons taught to those at the beginning of their ambulance careers; however, dressings are not always good for patients. Paramedics should not rush to apply dressings unless they are being used to pack the wound.

An ambulance bandage/dressing does not equate to a method of direct pressure. In fact, they may ‘wick’ or absorb blood from the wound without actually aiding in clotting. It makes bleeding patients sicker, increasing blood loss, decreasing red cells, creating issues with clotting, hydration etc. Dressings often act to hide any ongoing bleeding, and, while they assist in keeping the rescuer clean, they do very little to control haemorrhage.

There are elasticised bandages, and these do aid in providing some pressure if applied correctly, but many are not taught correct application. Elasticated bandages are in use in military circles and are often combined with other haemorrhage control strategies. They are in use by many UK ambulance services and the UK military, and they have the ability to be adapted to include pressure pads built in to them. An example of one of the latest devices would be the Air Wrap compression bandage.

This type of bandage allows for pressure to be applied into the wound while still allowing distal circulation.

Mechanical direct pressure device (MDPD)

The iTClamp^™ 50 is a great solution for holding pressure into or onto a wound. It is this device that is gaining significant traction worldwide when considering mechanical direct pressure, since this tool maintains direct pressure, hastens clotting and allows the rescuer to see the wound and ensure that it is closed. It is a device but, compared with other tools designed to control haemorrhage, this uses the body's own system to create quick haemostasis.

The iTClamp^™ 50 is a haemorrhage control device that seals the wound closed using eight small, sterile (suture like) needles and pressure bars to pull and keep the wound edges together, and therefore creates a static haematoma underneath the wound. It is easy to use and able to deal with complicated and time-consuming wounds such as scalp or junctional areas (see Figure 1).

How the iTClamp^™ works

Application of the clamp is used to create pressure above/into the wound. It creates a seal and will allow a small haematoma (blood clot) to form within the wound bowl, but as soon as the pressure of the haematoma and the clamp above it are greater than the pressure within the bleeding vessel, the vessel doesn’t bleed any more; it tamponades the vessel.

Dennis Filips, MD, iTraumaCare (former military trauma surgeon), is the designer and brains behind the clamp. He argues that the reason why the voluntary sector are still not using sensible haemorrhage control strategies and why many shy away from tourniquets is due to the fear that a tourniquet by its nature has risks of necrosis, whereas the modern solutions such as the iTClamp^™, when used on similar injuries (except amputation), allows for blood flow distal to the injury. Also, patient pain during correct application of a tourniquet can be substantial (Kragh et al, 2008). Even for voluntary agencies a tourniquet will still be required for a major amputation.

The iTClamp^™ 50 can be effectively applied through several layers of clothing and has been robustly tested, including histology examination after 6 hours of application showing no change in the skin tissues where applied (Filips et al, 2014).

It is quicker to apply than a tourniquet—7-10 seconds (iTClamp^™) versus up to 1 minute (tourniquet) (Filips et al, 2014)— and dramatically reduces risks associated with tourniquet use, such as pain, necrosis, toxin build up etc.

The device itself is suitable for scalps, limbs and junctional areas, such as the neck, groin and axilla, which are usually very difficult to control, and also stays in place while patients are being moved. It is a great solution to many wounds that otherwise would have been problematic.

The use of haemostatic agents to pack junctional wounds

Evidence to show the benefits of haemostatic agents versus standard gauze are still being researched, but whether using standard gauze or haemostatic gauze to pack the wound bowl, the application of pressure above that gauze for at least 5 minutes is essential.

It is possible that haemostatic agents may have a place, but, if used, it should be combined with a mechanical direct pressure device, freeing up hands of the responder and dramatically reducing blood loss.

Final thoughts

Lastly, clinicians should think about using <C>ABCDE in traumatic cardiac arrest.

As paramedics we are starting to see many helicopter clinicians choosing to adopt low flow strategies for non-compressible traumatic cardiac arrest management, using technology to ensure that flow continues, without the application of CPR.

However, in the case of ambulance clinicians and police, we need to ensure that before commencing CPR there is not a compressible catastrophic haemorrhage present, since by doing CPR we would simply speed up the flow of blood onto the floor.

The purpose of doing CPR is to build up pressure, but if there is an obvious hole in the circulatory system the hole should be plugged before starting CPR.

<C>ABCDE as an algorithm is perfectly suitable for cardiac arrest management. It enables clinicians to focus on one algorithm for all disciplines and ensures that we can build up coronary perfusion pressure.

Case Study

Following an attempted suicide where a patient had cut through both of his brachial arteries at the elbow, a paramedic was called. On arrival, compressible catastrophic haemorrhage was present, and was simply controlled with the application of the iTClamp^™to each arm.

The paramedic could see that bleeding had stopped, yet flow continued beyond the injury keeping all other tissues in both arms perfused. If there is no further external bleeding from the wound when the clamp is applied to a compressible area then the bleeding has been controlled.

With the bleeding having stopped and blood loss controlled, the paramedic attending this case could continue their primary survey without the need to worry about pain from arterial tourniquets complicating their management.

IV lines could be established below the point of injury. The patient was transported to an appropriate treatment facility for vessel repair.

Conflict of interest: this article was supported by iTraumaCare, the manufacturer of the ITClamp^™.