A Warning Re Quikclot

[greeneggcat]

Um, the only experience of major bleeding i have is from when a close family member cut thier wrist. It was quite frightening the speed at which they bled, then went sleepy. Because of thiere state of mind they only told me that they had "cut" themselves. Despite getting roun there quick ( note they didnt call an ambulance) she lost a lot of blood. Fortunately a had a ffd in my car 1st aid kit and a good friend with me who was able to phone an ambulance while i elevated and applied pressure. Sometimes there are no guarantees as to what will happen. if i was on my own i would have been buggered. Seems to me that sometimes its all about keeping someones blood in til propper help arrives. I now carry a celox bandage with me (purchased from boundtree medical) not some army surplus site. Medical treatment makes advances. Maybe lightening never strikes twice? But whayever happens time is of the essence.
I am not a medical proffesional martyn, i have had first aid training regularly, and keep it updated as i work in a butchers/abatior.

I just think s**t happens. I believe a lot of our current medical procedure/developments came from millitary medicine, including blood transfusions and not so obviously a lot psychiatric cognetive pherapies.


Ps, the person mentioned above lost 3 pints of blood. When you see that amount of blood it makes you think twice about how dangerous blood loss is.

[greeneggcat]

Hey Martyn, I am waiting for another smart **** reply that presumes we all live in the same perfect world as you?

[Ronnie]

Here's another example of ally military kit. Intra osseous cannulation device...

Not just military, according to the resus council, there are only two acceptable methods of drug delivery during a cardiac arrest now, IV and IO (ET has been binned). That said, I doubt you'll find the IO route used much in the NHS or at least not as a first choice. The military on the other hand, teach IO insertion routinely because it's fast and field expedient and you dont have to fanny around looking for a vein, just stick it in the sternum or shin. One for the FAK?

NHS uses I/O access all the time. Most paediatric CRASH trollies have them on their inventory. Not sure about adult medicine. I have been involved in I/O placement a couple of times, but would have seen it much more often if my speciality was A&E. NHS never use sternal I/O access. That seems unnecessarily macho to me, especially if the casualty has suffered chest trauma.

This is the system my unit currently use - and the site (proximal tibia). It's unusual to establish I/O access in a fully conscious patient. They're usually significantly shocked:

http://www.youtube.com/watch?v=HeRpYu8cxrY

[rik_uk3]

Hey Martyn, I am waiting for another smart **** reply that presumes we all live in the same perfect world as you?

Your a bit out of order there greeneggcat, Martyn has given opinion based on years of solid medical experience; he's not a wannabe paramedic.

[Martyn]

NHS uses I/O access all the time. Most paediatric CRASH trollies have them on their inventory. Not sure about adult medicine. I have been involved in I/O placement a couple of times, but would have seen it much more often if my speciality was A&E. NHS never use sternal I/O access. That seems unnecessarily macho to me, especially if the casualty has suffered chest trauma.

This is the system my unit currently use - and the site (proximal tibia). It's unusual to establish I/O access in a fully conscious patient. They're usually significantly shocked:

http://www.youtube.com/watch?v=HeRpYu8cxrY

They use em in paed's (as a last resort) because of the difficulty in finding access on little people. I dont know about other trusts, but ours dont use them. I've just done my ALS update and I asked if we were going to be having IO kits on the crash trolleys and was told that aside from costing the trust £45,000 to put the kits on all the trolleys, their use is unnecessarily macho as you say. That's my point. Military techniques have their place, but it's usually on the battlefield. Some of it does translate into civvi medicine, but with much of it (quickclot for example), there is a degree of clinical risk taking that is not necessary.

On an aside, but related, on the ALS update I was told that military technicians are now treating trauma before ABCDE? Is that what you are being taught Ronnie? It struck me as another example of the difference between military and civvi medicine.

[Martyn]

Hey Martyn, I am waiting for another smart **** reply that presumes we all live in the same perfect world as you?

Just trying to help people spot the walts, wannabes and armchair paramedics. You've stopped one arterial bleed, I do it nearly every day and have done for many years. It's what I'm trained to do and what I'm paid to do. Take it or leave it, but I have no interest in debating the issue further with someone incapable of having a civil disagreement without being abusive.

[EdS]

You've stopped one arterial bleed, I do it nearly every day and have done for many years.

To honest Martyn it really is about time you learnt to handle that knife collection of yours safely.

[Martyn]

To honest Martyn it really is about time you learnt to handle that knife collection of yours safely.

it's always the little ones.

[Ross Bowyer]

Hi Martin,

I have just completed my MIRA (Medicine In Remote Areas). On that we were taught DCABCDE
Danger
Catastrophic hemorrhage
Airway
Breathing (inc Flap Twelve)
Circulation
Disability
Environment

Apparently the main cause of death in Afghanistan now is blood loss from IED's, hence the change in priorities, I guess. But again as you said, in Civvy street, major bleeds are very rare and most of the time can be stopped with Direct/Indirect pressure (both) and elevation.

Ross

[Martyn]

Hi Martin,

I have just completed my MIRA (Medicine In Remote Areas). On that we were taught DCABCDE
Danger
Catastrophic hemorrhage
Airway
Breathing (inc Flap Twelve)
Circulation
Disability
Environment

Apparently the main cause of death in Afghanistan now is blood loss from IED's, hence the change in priorities, I guess. But again as you said, in Civvy street, major bleeds are very rare and most of the time can be stopped with Direct/Indirect pressure (both) and elevation.

Ross

Sounds like a good course, some pretty advanced airway management there. One thing new for us is we're starting to use the i-gel LMA's ...big improvement over the old masks IMO. I've only used em on a doll to date, but they look superb.

Yeah, that military protocol change is what I was talking about - makes sense they'd teach it on your MIRA course too. Still ABCDE for us civvies though and unless we have a civil war or something, probably always will be.

I remember a few years back when quickclot started to gain popularity with the military, we had one of our "whats new in trauma management" training things. We are kept pretty up to date with this stuff, mainly I think because we have military doctors on attachment to us when they are not on a tour, so they can get continued training and exposure to trauma in a modern university hospital. We were always bumping into them over protocols, they were so cavalier - it was like "whoaaaa ..slow down Tex, this aint MASH, you have time and options".

Anyway, We were shown a series of videos produced by the makers of QC. They basically featured a series of anaesthetised pigs who had their femoral arteries surgically cut. The pigs were allowed to bleed out for a moment and then a packet of QC granules dumped into the wound. The haemorrhaging stopped almost immediately, it was very impressive. It was supposed to be though, as it was basically a QC advert. One thing they didnt show, was what happened to the pigs afterwards. I suspect they were all euthanased. Most of our docs were pretty sceptical about these vids. It was obvious that QC stopped bleeding, but at what cost? How did it affect the tissues? How did it affect the surgical repair of the site? What was the long term prognosis after use etc? None of these issues were addressed. They were selling it to the military on the basis of if they have a "black hawk down" scenario, what is there to loose. The cas will die anyway. That's well and good in theory and the military bought into it. I guess they saw the film too. Problem is, the stuff does cause pretty horrible tissue damage, so your medic needs to be making the decision that the bleeding is too severe to stop with conventional methods and the cas will die without it. In practice, it started to get used too frequently. The hospitals started to see some pretty horrible tissue damage from it being used on wounds that could have been managed without it. Now they seem to have dumped QC, stopped using granules and switched to cellox impregnated sponges and bandages. Cellox certainly doesnt cause the same tissue damage and by using it on a sponge or bandage, it should be possible to remove the bulk of it later. So is cellox safe? The makers say it is - but the makers of QC said that was safe too. Cellox certainly should be safer, I think we can be sure of that, but there is still precious little long term data relating to things like DVT's, PE's strokes and wotnot. Does it cause the formation of micro emboli? We need more data and ideally a control group. At the moment, we are relying on anecdote and civvy medicine needs to be better than that. I'd agree that if someone is well trained, has the right skills and knows what they are doing, it's another tool in the bag. But as happened with QC, even then it can start being used inappropriately. My main worry is that civvies are buying it because it's cool ally kit that the soldiers use, without any training or medical knowledge watsoever. Personally, I think until we have some better data and have more certainty over it's efficacy and safety, it should not be sold to the public.

[Spikey DaPikey]

Martyn, your last post makes a lot of sense. Cheers.

[3bears]

By the way i tried the superglue trick once on my finger it got infected and two days later i had to burst it open to let the **** out The 5 minuets looking at it first was by far the worst bit .

guess I've been lucky with that one so far then, but it might have been sealing some infection in the wound as well as keeping it shut maybe? then again try not to make a make a habit of cutting myself- I've used all sorts over the years, bog roll and duct tape- never anything serious touch wood!

[Martyn]

Martyn, your last post makes a lot of sense. Cheers.

It's hard to make it clear sometimes. As I thought, the anaesthetised pig video has made it onto youtube, I wont embed it, but if you want to watch it, here's the link...
http://www.youtube.com/watch?v=TnqxNQmgcqg

It's impressive, but unfortunately, no videos of how the pigs were doing 6 weeks later. But as I said, in the battlefield where traumatic haemorrhage is the leading cause of death, when the cas is gonna die anyway, then why not?

But to put it into perspective, I looked up the gov stats on causes of death for a random year (2005) here....
http://www.statistics.gov.uk/downloa..._No32_2005.pdf

I did a search on "exsanguination" which returned 0 results from all 334 pages. I couldn't find anything which suggested there were any deaths in England and Wales from simply "bleeding" or related to traumatic bleeding. Obviously there were things like subarachnoid haemorrhage and so on, but they are not pertinent and certainly not treatable with quikclot. I'm sure there must have been people crushed in car crashes and so on, where massive haemorrhage must have contributed to the cause of death, but that is not listed as the primary cause. I know there are numerous deaths each year from bleeding oesophageal varacies, but again, the blood loss is secondary to the primary condition and so not listed as the cause of death. I did find "Injury of unspecified blood vessel of upper limb" = 3 deaths. Also "Traumatic amputation of upper limb" = 1 death. Of note there is no detail surrounding these and it's impossible to say whether or not the deaths were preventable.

Just included that really, to reinforce the point that death from a (treatable) vascular injury is exceptionally rare in the UK, unlike the battlefield where it's extremely common.

Anyway, that's me done on the subject.

[Hangman]

"I will use my own judgement when applying first aid to myself, my family, and indeed anyone else"

An interesting comment, as an ex RAF SAR Medic things we were taught about is the concept of 'invasive procedures' and medical assualt' whilst medical practitioners have a degree of lattitude due to thier training, sometimes reading the threads here I do worry that some posters if they do genuinely do what they say they would in an emergency are flying very close to the wind.

Having had to deal with the aftermath of 'have a go heroes' including a fatality caused by aspirin overdose, I do worry at the idea of 'because we are going outbounds we need heavy duty kit and we are going to use it even if we are not quite sure'.

As a now safety officer and accident invetsigator who works for a bushcraft school as an instructor in my spare time I do worry the emphasis that some people put on the 'after the event' details. Something we hammer home to every student even those who have done courses elsewhere is that good knife technique will negate and prevent serious injury yes things go wrong, and we always recommend a personal FA kit but if you feel as an individual that you are that likely to require seriously heavy duty kit then maybe it might be prudent to review / revise the techniques you use when handling knives, axes, etc.

A pinch of prevention is worth a pound of cure.

[WanderLust]

Good luck over there brother.... I was a medic and did several tours of duty in both places. While I'm glad they finally got rid of Quikclot, they had already started to phase it out in 2005 with Hemcon dressings. Approx 5x5" pad that you could cut to fit specific injuries and was also made of shellfish. Hemcon was the bees knees, and it sounds like this Celox is an improved version. The other thing about Quikclot that I have not noticed being mention (esp for granulated) is the fact that it is designed to immediate coagulate when in contact with blood. Problems began happening when people poured it onto the wound instead of into, as it sealed the opening but not the inside, which meant you either had to reopen, or now place a TQ on it as well. To avoid this issue we started instructing incoming medics to take their index fingers, place them into the wound, and widen it's opening, push the muscles around and create a little bowl inside the affected area. With the wound larger, it was now more accepting to the granules, but was quickly disdained by the hospital staff for previously mentioned reasons. So while Quikclot can be effective, it is not optimal.... if you can't afford Celox or Hemcom ( Hemcon was $500.00 for 5 bandages last I saw, with an expiration date of about 6 months) you may want to consult with your doctor on an affordable and viable replacement.

[Spikey DaPikey]

I think i'll stick to the large field dressings and a mobile phone !

[Seabeggar]

Very useful discussion. I have a fairly broad experience of A&E trauma in UK and abroad & do some pre hospital training. The key pre hospital message is as stated before PRESSURE AND ELEVATION and very occasionally a tourniquet. I would be very very very worried if someone who was not very experienced had Cellox. My greatest worry would be that the application of Cellox would distract from good pressure and elevation + the obligatory ABC. I have never seen a wound in civi trauma where I could not have controlled bleeding with pressure and perhaps tourniquet. I know it could happen, but I think that kind of trauma would need a lot of Cellox, not just a few dressings. PRESSURE, ELEVATION, occasionally a tourniquet, and RAPID EVACUATION.

[firebear]

I just use Yarrow...

[tenderfoot]

Hi Martin,

I have just completed my MIRA (Medicine In Remote Areas). On that we were taught DCABCDE
Danger
Catastrophic hemorrhage
Airway
Breathing (inc Flap Twelve)
Circulation
Disability
Environment

Apparently the main cause of death in Afghanistan now is blood loss from IED's, hence the change in priorities, I guess. But again as you said, in Civvy street, major bleeds are very rare and most of the time can be stopped with Direct/Indirect pressure (both) and elevation.

Ross

Ross youve piqued my interest... what is flap twelve?

[Martyn]

Ross youve piqued my interest... what is flap twelve?

It's a mnemonic, an acronym that helps you do a thorough and systematic exam of the airway, neck and chest.

FLAP is Feel Look/Listen Auscultate Percuss.
TWELV-E is Trachea, Wounds, Emphysema, Larangeal crepitis, Veins and EVERYTHING (have you checked TWELV?).

It's basically a chest exam - like when you go to the doc and he feels round your neck, listens to your chest with a stethoscope and taps the back of his fingers, he's basically doing a mini flap twelv. The acronym is in common use with paramedics and ER staff as it kind of hold their hand through airway and chest assessments.

[jonajuna]

as we are talking (generally with the nature of the forum) bushcraft rather than combat or teotwawki, wouldn't 99.999% of major haemorrhage be due to a sharp blade cut or internally due to a fall?

would a haemostat be any real use in this? surely with a clean cut arterial bleed, the pressure would be too great for a haemostat to pug the gap (vs a blast type trauma which tends to be a ragged wound which bleeds at far less speed as far as i know (retraction of artery, constriction of muscle tissue etc), internal bleeds are well, beyond all bar a surgeon

maybe see the benefit of a haemostat bandage as best of both worlds, but is there real benefit vs the added risk for the situations us civvies are in?

would've thought, short of tying off the limb, if you dont get blood in and and a clamp on the artery within an hour (and subsequent surgery) it'll be ni nights anyway, so these scenarios of being in the backabeyond, are perhaps all a bit beyond limits

personally, i've nursed 2 arterial bleeds, both from clean cut wounds (but then, years in acute psychiatry gives you that opportunity) direct pressure and elevation stemmed the flow (although still painted me red) for the 30 minutes it took for the paramedics to come and take over

[tenderfoot]

Thought it might be something like that but couldnt track it down online.
Quite useful ( for me anyway ) ill probably use that.
ta martyn

It's a mnemonic, an acronym that helps you do a thorough and systematic exam of the airway, neck and chest.

FLAP is Feel Look/Listen Auscultate Percuss.
TWELV-E is Trachea, Wounds, Emphysema, Larangeal crepitis, Veins and EVERYTHING (have you checked TWELV?).

It's basically a chest exam - like when you go to the doc and he feels round your neck, listens to your chest with a stethoscope and taps the back of his fingers, he's basically doing a mini flap twelv. The acronym is in common use with paramedics and ER staff as it kind of hold their hand through airway and chest assessments.

[Adi.]

A very interesting thread, a good read.

When I am asked about Haemostatic products I tell people that it was designed to help the medic and not the casualty!

Let me expand on that a little.
You are doing your primary DRAB assessment. You are at the very first stage, D for Danger. Are you in a hostile environment were you can be shot at if you stay in one location for any length of time? If the answer is Yes then by all means use a Haemostatic product such as Celox.
If you are not in a location that is likely to mean you are a target for someone armed with an AK47 then there is little need for products like this because you have time on your side to elevate and apply direct pressure.

As a side note. Celox is available to the NHS and paramedics and is being used quite effectively in the UK.

NHS Supply Chain
News article
News article

But, that does not mean the rest of us need to carry it in our kits when elevation and direct pressure has the same results.

[EdS]

Celox gauze / bandages are used by a number of organisations in the UK. The problems mainly relate to the powders and granular. The Celox bandages work like an extra absorbent normal bandage. Also the mechanism of CElox and Qikclot is different (or at least way).

[AIRBORNE MEDIC]

Folks,

An interesting read and a further interesting mix of opinions some based on fact and some based on hear say I think.

I’ll give you a bit of an insight into my medical background before I start trying to put anything into perspective.

I joined the army in 1979 as a boy soldier where I became a Parachute Regiment Soldier serving all over the world and in various conflicts. In 1990 I became a military medic and then in 1994 I left the Parachute Regiment and joined 23 Parachute Field Ambulance as an RAMC medic again serving in various conflicts and peace keeping mission throughout the word.

I completed my Paramedic training whilst with 23 PFA and then went on to do a 3 year civilian course (Courtesy of the Army) to become an Operating Dept Practitioner at Southampton General Hospital. I left the Army in 2002 after a good career with plenty of medical qualifications and quickly become involved in the work of the Private Security industry working as a security operator/medic. First in Nigeria and later on in places such as Iraq, Jordan, Kuwait and Afghanistan. I currently work between working on board ships in the Gulf of Aden as protection against Somali Pirates and the UK teaching for security organisations that provide body guard courses etc.

Whilst in Iraq I was the senior medical advisor/instructor for a private security company of some 2,000 men and women who worked for the US Dept of Defence. It was my job to insure the correct medical training was given to all members of the company, the correct implementation of current medical protocols and update the use of current medical equipment and tactics, such as QUICK CLOT/HEMCON/CELOX/CAT.

With regards to any massive haemorrhage or arterial blood control, the simple things work first time every time and that should never be forgotten!

When we first went out to Iraq we were still using First Field Dressings (FFD) and SAMWAY tourniquets which had been in service well before I had joined the army in 1979 and it wasn’t until around 2004/5 that we started to get issued the new Israeli dressing (Favoured by the US Armed forces) which is a far better dressing for the job.

We were further issued a new tourniquet system in the form of the Combat Army Tourniquet (CAT) which again was a major leap forward in medical intervention in the field and indeed as of about 12 months ago the UK NHS ambulance service have adopted these devices for themselves.

You have to remember that Haemostatic agents such as QUICK CLOT where introduced as a result of major battlefield trauma which involved massive limb and lower torso trauma. It was not introduce as some may think, to replace the tourniquet! It was in fact introduce for use in areas where a tournquet could not be used, such as high up in the groin or the arm pit, places where you just couldn’t hope to apply a patent tourniquet to your casualty!

As has been mentioned, there are indeed risks or post use complications to using QUICK CLOT and if people where only to read the product information it would save major dramas on the ground!

QUICK CLOT once introduce to fluid of any kind will generate a heat approximate to that of a boiling kettle of water for approximately 15 seconds. It is made of sand, magnesium and iron. The chemical mix is what generates the heat and the sand aids coagulation of the blood. Once applied correctly the excess granules must be washed clean from the wound to avoid any potential for embolisms.

QUICK CLOT comes in two forms!

• QUICK CLOT granules
• QUICK CLOT T Bags (4 bags attached in a line)

As has been mentioned the granules cause great heat and potential tissue destruction as well as the possibility for an introduction of an embolism into the circulating system which could lead to a Stroke, Heart attack, etc.

The T Bag version on the other hand was introduced a couple of years after the granule version because the manufacturer realised based on post op medical reports, that the product was perhaps not the best.

SAFETY CONSIDRATIONS:

QUCIK CLOT MUST NOT BE USED IN THE FOLLOWING ANATOMICAL AREAS:

• Eyes
• Nose
• Mouth
• Cranial cavity
• Thoracic cavity
• Or any are of the body where there is unintentional exposure to a mucus substance

Its main function is to stem the flow of blood from a massive arterial bleed when a tourniquet cannot be used!

As you can see QUICK CLOT is perhaps not the best haemostatic agent that has ever been introduced and indeed it has mixed reviews in the medical circle. I myself withdrew it from service from our medical trauma bags because it introduced too many negatives rather than positives for saving lives!

The biggest problem with introducing too many new “SHINEY” medical products on both the battlefield and the civilian side of trauma care is that the user is drawn away from the basic medical protocols of treatment. Treatment which works well and works FIRST TIME! EVERY TIME!

So in closing I would urge you all to forget about these nice new shiny items which look like they do the work for you, and instead urge you to KISS (Keep It Simple Stupid).

After all you cannot guarantee that in any given emergency situation that you will have any medical equipment with you let alone haemostatic agents such as QUICK CLOT! So learn the basic medical intervention protocols and stick to them because your knowledge and use of the simple things around you are all you can guarantee to have on the day it may happen to you. Isn’t this what BUSHCRAFT is all about?

I hope this was informative without being lecturing guys, but going off half cocked can get someone killed regardless of environment, and from the Medical Legal side of things can land you in prison for medical mall practice and negligence at best. It takes approximately 30 seconds for someone to bleed to death in your arms! It can take longer than that to mess around opening the packet and application of the product!!!!!

Cheers all

Kenny


P.S. I have not replied on the subject of other Haemostatic agents because this thread is about QUICK CLOT and i didn't want to end up writting WAR & PEACE and boring th pants of you all.

[Robbi]

fantastic post AM, thank you for the first hand information

[Ronnie]

I have not replied on the subject of other Haemostatic agents because this thread is about QUICK CLOT and i didn't want to end up writting WAR & PEACE and boring th pants of you all.

Excellent post, Kenny. Now tell us about the other haemostat products please!

[Mikey P]

Standard field dressing (or more than one) is sufficient for nearly every injury where something like Quickclot would be used. Substances like Quickclot were developed for situations such as deep penetrative gunshot wounds and traumatic limb amputation where combative had to be immediately stabilised as much as possible and then removed under fire. There is, therefore, a risk associated with the use of these kinds of 'quick-fix' solution. You must assess the the risk and act accordingly - if you screw it up, you have to live with the consequences. Know the risks of getting granules in your eyes and mouth. Make your own call.

PS - Great post Kenny and great to see someone with such experience continuing to push home KISS. FFD and knowledge - the way forward!!!

[rik_uk3]

Very very good post Kenny, much of what you said has been posted by an A&E manager and fell of deaf ears and sad to say most won't listen to you either (although your post is 100% spot on), the lure of new kit overcomes common sense so often

[Mikey P]

Very very good post Kenny, much of what you said has been posted by an A&E manager and fell of deaf ears and sad to say most won't listen to you either (although your post is 100% spot on), the lure of new kit overcomes common sense so often

Heh heh! And Quickclot's not even shiney!