Granted, this comes with some additional things to consider but it makes sense that we all be prepared. I have yet to meet a fireman that does not carry webbing and or rope in their turnout pant pocket. The hope is that they will never have to use it for a bail out or rescue, but it’s there if it is needed. The unfortunate counter to that is, there are many agencies that have said they will continue to field a “improvised tourniquet” with no plan to replace it with a commercially approved device. There may be justification through call volume or previous uses, but this in itself has proven a sense of complacency that is rampant. There is no community that is immune to acts of violence against individuals or groups, and we should not prepare like we are. With that, I would like to provide a starting list of kit components and rationale behind each piece.
Designing a kit can be made as easy or as difficult as you would like. Making a decision is better than making none. Over thinking or over building kits has often left the user in an odd spot to carry more than what is needed, or be forced to utilize one bag for every possible scenario. My suggestion with a trauma kit is to make it independent or modular. Ease of access to essential trauma care items is imperative. Following along with information the military has gathered, individual’s ability to use clear cognitive reasoning as well perform complex tasks decreases as the stress of the environment increases. This simply means to keep things simple. A simple kit, with a few components, and easy accessibility can have significantly better outcomes should it need to be used. Follow the MARCH model and pick a device to manage each component, and a container that suits the equipment.
The first item to consider is a tourniquet. It has turned into a bit of a reinvention of the wheel scenario on the industry side, when it comes to tourniquets. There are lots of organizations that are manufacturing tourniquets now, and all of them will tell you they are the best. So how do you pick? For starters, in a professional rescuer setting both paid and volunteer, it’s advisable to pick a strap and windlass tourniquet. These devices are labeled by the government as strap and windlass non-pneumatic limb tourniquet. Simply put and scientifically backed, these are the best. These devices have the best track record, the highest success rate and are easily deployable, says most evidence based data. Within that realm reference the Committee on Tactical Combat Casualty Care (CoTCCC) recommendations, as well as some of the studies that have been produced and referenced by the committee.
(Link to resources and approved equipment through CoTCCC) http://cotccc.com/wp-content/uploads/CoTCCC_Recommended_Devices_and_Adjuncts_01_DEC_2016.pdf.)
This is in no way attempting to discredit the other devices offered, but rather to give guidance if starting fresh. The caveat is that this information is produced by the military and is centric to military patients. There are currently studies going on that are centric to the civilian population, and will hopefully have an impact on the professional rescuer and their use of tourniquets. As of right now quite possibly the best tourniquets (data supported) are the Special Operations Forces Tactical Tourniquet- Wide Gen. 2 (SOFTT-W) or the Combat Application Tourniquet Gen. 7 (CAT). This will cover one piece of the massive hemorrhage component in your kit.
When considering the airway, continue to think simple. We often find ourselves performing tasks on patients that may be more than what is absolutely necessary. This simplistic approach to severe trauma patients, specifically in a high threat environment is a fantastic opportunity to hone the basics of your patient care. Airway management can start incredibly simply and escalate until there is a definitive airway established. This situation could warrant as little intervention as a chin lift, jaw thrust or change in patient position to re-establish a patient airway. Don’t forget about that before jumping to grab a laryngoscope and ET tube. For this simplistic approach some Nasopharyngeal Airways are a great starting point. They are reasonably priced; they are easy to use and able to be used by BLS providers. NPAs also can be placed in conscious or semi-conscious patients with little discomfort and do a huge service by maintaining movement of air even if our number one airway obstruction (the tongue) falls back. Carrying a few 28 Fr. NPAs in a trauma kit is a huge added value to be able to manage an airway incredibly simply. This is not intended as a long term solution to a patient with a compromised airway, but it does serve to buy time if there are more patients than providers, or to allow you to manage other life threats.
A BLS provider can manage respiratory management in the severe trauma patient fairly well, with early recognition. The tension pneumothorax is a deadly condition when left untreated. Assessment, confirmation, and then management can minimize the chances of mortality significantly. The ability to stop the process from worsening is the primary goal of BLS respiratory and breathing management. Covering the hole with an occlusive dressing early is one of the best ways to mitigate this issue. As a rule of thumb if there is a penetrating injury on the trunk from neck to navel it warrants a chest seal. This is another area we have gotten away with utilizing improper tools for far too long. Petroleum gauze or expired defibrillator pads have long been the go to. While these are much better than the alternative of nothing, they are not as good as a device purpose built to seal an open chest wound. One of the issues with non-vented chest seals and improvised chest seals (petroleum gauze and defib pads) is that in a traumatic injury, a tension pneumothorax can still develop after we have sealed the hold. Unless we have keen reassessment skills, this deterioration after treatment can and has been missed. The commercial chest seals that exist, are now primarily all vented. This means that they have a one-way valve that utilizes changes in pressure gradients with the respiratory cycle to let air in the wrong place out, yet allow for negative pressure to build then pulling the injured lung back open. When choosing a chest seal for your kit, ensure that it is vented and that it is hydrogel based. This material allows for the seal to stick over hair, blood and dirt better than most of the alternatives. Some of the best seals available are the Hyfin Vent, the Russell Chest Seal and Halo Vent.
Now that we have covered the three biggest pieces to go in a kit for high threat or severe trauma patient management, we’ll continue with the last two pieces. Circulation is most commonly associated with vascular access by IV or IO and then fluid administration. While this is most certainly correct to be covered in this category, it is also a chance to manage any non- life threatening bleeding. The tools covered here are also fantastic for mitigating severe bleeding that cannot be managed by a tourniquet, such as high inguinal (the groin) high axillary (the armpit) and the base of the neck. Hemostatic agents should not be used in the abdomen, chest or head. This does not include surface lacerations such as to the scalp or a non-penetrating injury to the chest or abdomen. Hemostatic agents have gained a bit of a mystical understanding of how they work. Many have felt that just opening the wrapper to an agent like QuikClot would stop the bleeding. OK, maybe that’s a stretch, but there are some misunderstandings that follow the use of hemostatics. First and foremost, hemostatics work through a mechanical process (you packing the wound) augmented by a chemical process (the agent in the gauze works with the body to help build stronger clots). The inverse of this is not true, yet it has been taught that way often. For a hemostatic to work, it must absolutely reach the base of the wound bowl or the interrupted vessel. If that does not happen then, it is in essence useless to use hemostatics. These agents are absolutely fantastic if utilized correctly. So prior to making a decision to purchase hemostatic agents for your kit, ensure that those that would be using them are able to adequately pack a wound prior to spending significant money on a device that may or may not be utilized effectively. This is an opportunity to look hard at your training practices and assess if they meet the need. Some of the best hemostatic agents, again come from the CoTCCC recommendations, with the exception of one mentioned. QuikClot Combat Gauze is possibly the most well-known followed by Celox and then NuStat Tactical. All of these have a similar price point of $35 to $45 each. In your kit, if you decide that a hemostatic isn’t necessary, it is not a bad idea to put in a roll of kerlex or compressed gauze that could be used to pack wounds instead of a hemostatic. While it does not have the agent impregnated into the gauze, it is still effective at controlling bleeding when properly used.
Lastly, a pressure dressing goes hand in hand with the hemostatic or compressed gauze. The Olaes bandage actually comes with 12 feet of compressed gauze built into the bandage, that you could then use to pack a wound if needed as well as an occlusive sheet to use as a temporary occlusive dressing. The NARescue Emergency Trauma Dressing is an excellent other option.
The last major component of the MARCH algorithm is the H or head injury and hypothermia. While there is little you can do in the prehospital setting for head injuries outside of recognition and supportive care, there is something you can do for hypothermia. Head injury management becomes pretty consistent with what is currently accepted practice. On the other side, when it comes to hypothermia, we have some room for improvement. Trauma patients specifically are more susceptible to hypothermia. This being said, mitigation of hypothermia has a great impact on outcomes on patients long after you drop them off to the emergency department. Adding a foil blanket or a few to your kit could greatly benefit the patients you encounter.
Hopefully this is a beneficial starting point to some for kit building. This is not at all a substitute for formal training, but it gives some of the rationale behind what components to pick. There are lots of other pieces to consider and here are just a few of the ones that don’t fit specifically into the MARCH components, but have multiple uses.
- Triangular Bandage
- Trauma Shears
- Triage Tags
- QuickLitter or evacuation strap for moving patients.
- Decompression Needle (Scope Dependant)