Developing a Blow Out Kit

by November 5, 2009 11/5/09

TireBlowoutThe term “blow out kit” comes from the Military, and refers to a medical kit to treat life threatening wounds in the field.

Our take on the terminology is that just like a tire has a blowout, so can you if you’re severely injured.

A blow out kit is the human equivalent to a tire’s patch kit, which treats the sustained damage.

Just as a patch kit is a temporary fix for a tire, a blow out kit is a temporary fix until a higher echelon of care can be reached.

A blow out kit is designed to treat the three leading preventable causes of death in the field.

These are Extremity Hemorrhage, 60%; Tension Pneumothorax, 33% and Airway Obstruction, 6%.

While we say a blow out kit is used “in the field,” this doesn’t just refer to a military battlefield, it represents YOUR everyday field.

It can be driving to and from work; serving with local Law Enforcement, Fire or EMS; attending various shooting schools and everyday activities in between.

Be Prepared

The concept of a blow out kit is being prepared. Plain and simple.

Carrying a blow out kit will enable you, or someone coming to your aid, to have the necessary supplies to save a life.

You have to ask yourself if the cost and inconvenience of maintaining, carrying, and having a working knowledge of these supplies is worth saving a life. The answer should hopefully be YES!

We could talk all day about other medical equipment to carry for an emergency situation, but the purpose of a blow out kit is to have the essentials on you to prevent death.

EMS is typically a phone call away, and barring any natural disasters. etc., their response time should be quick. But “quick” depends on many variables, and will they always be quick enough to save a life?

If you’re out in an area away from EMS, then you should adjust your equipment accordingly and have the what’s necessary to sustain for longer periods of time until higher echelon care can reach you.

Law Enforcement

There’s a local Law Enforcement organization in our AO that doesn’t equip their officers with anything more than a boo-boo kit which is just a glorified box of band-aids.

You aren’t going to stop arterial bleeding with band-aids, and their protocol is to call 911 in an emergency. Are the few minutes it takes an ambulance to arrive on scene enough time to bleed out?

Law Enforcement Officers take risks daily dealing with the bad guys, and are more likely to get into a shoot out than any civilian out there with a Concealed Handgun License.

More and more Law Enforcement agencies are starting to adopt some form of a blow out kit today, but as with everything, the Military model takes awhile to be adopted by the LEO model and even longer to reach the civilian world.

We got word not too long ago that the city of San Diego was accepting bids on blow out kits for every single Police Officer. We feel this a huge step in the right direction, and look forward to the day when this becomes the standard across the country, and the world.

If there’s one message to take away from this entire article, it’s how important it is to have the necessary equipment to save a life within your reach at all times.

Keep one in the glove box of each vehicle, keep one next to the fire extinguisher everyone should hopefully have in their homes, It’s just as important.

Military

As mentioned above, the original idea of a blow out kit was developed by the Military to give each soldier the minimum equipment needed to save a life without the need for a medic. In a firefight, a medic could be unable to reach an injured soldier.

Having the individual soldier carrying their own kit also enables a medic to not have to exhaust their own supplies, carry enough for everyone, or worry about running out of essential lifesaving equipment.

We all know that in an emergency situation the only one you can count on is yourself. Local resources will be tied up in a man-made or natural disaster and response times will be out the window.

So how do you treat the three leading preventable causes of death in the field? Let’s break it down by the three causes.

Hemorrhage

BloodCellsHemorrhage is merely blood loss from the circulatory system, and commonly treated with direct pressure. This can be done by placing gauze over the injury and either applying pressure yourself, or having the victim hold the required pressure to stop the bleeding.

Pressure exerted on a wound will prevent the collection of fluids in the underlying tissues, and prevent edema (swelling caused by trapped fluid).

If the victim is unable to maintain pressure themselves, or to make things easier, a pressure dressing/bandage can be used. The most common pressure dressing is the multi-functional IBD (Israeli Battle Dressing) which combines a primary dressing with a pressure applicator and secondary dressing.

What if direct pressure is unable to stop uncontrolled bleeding and traumatic hemorrhage?

Your options are to use a hemostatic agent or as a last resort, a tourniquet. While we say a tourniquet is a last resort, applying a tourniquet can be the first response if the severity of the injury warrants it.

Hemostatic Agents have become increasingly popular because they work to promote hemostasis (stop bleeding) by introducing an agent the allows the blood to clot quicker than traditional direct pressure will.

If a Hemostatic Agent is used, the packaging should try to be saved to show to higher echelon care what was used, or at least be noted somewhere.

When a hemorrhage occurs from major limb trauma or if a hemostatic agent is not enough to achieve hemostasis, a tourniquet is used.

The time that a tourniquet was applied, and that one is applied, is important for higher echelon care to know and should be noted.

If a tourniquet is to be used for over two hours, where higher echelon care is not immediately available, it’s recommended to release pressure for five minutes every half hour to prevent muscle and nerve damage due to compression.

To recap the treatment of simple hemorrhage to traumatic hemorrhage, we’ve described needing these essentials:

  • Hemostatic Agent
  • Pressure Dressing / Bandage
  • Gauze
  • Tourniquet
  • Something to note hemostatic agent used and/or tourniquet use/time applied

Tension Pneumothorax

Sucking_chest_wound_mechanicsDuring a penetrating chest wound (Pneumothorax) air is being taken into the pleural cavity with each breath and if not treated, the build up can cause pressure to build against a lung and prevent it from fully inflating (Tension Pneumothorax).

A Pneumothorax can be caused by any penetrating injury to the chest wall, such as a gunshot or stabbing, but can also be caused by a fractured rib.

To treat a Pneumothorax before it becomes a Tension Pneumothorax, a seal of some kind needs to be applied to the source of penetration.

There are two schools of thought for sealing a chest wound, one who recommends a vented chest seal to prevent the further buildup of pressure, and some recommend completely sealing the chest wound.

The argument is that completely sealing the chest wound can lead to the development of a Tension Pneumothorax, but a tension takes some time to develop and can be relieved quickly and easily with a decompression needle should that problem arise.

That leads us to treating a Tension Pneumothorax, which as described above is the prevention of a lung fully inflating due to pressure build up inside the pleural cavity. if left untreated the pressure has the potential to produce pressure on the mediastinum and compress the heart decreasing blood flow, or even cause the trachea to move away from midline.

To treat a Tension Pneumothorax, this pressure build up must be released some how. This is done with the insertion of a 14 gauge 3.25″ needle into the 2nd intercostal space in the midclavicular line (Needle Thoracentesis). A 3.25″ needle is used to ensure it reaches the pleural space.

The 2nd intercostal space is the area between the 2nd and 3rd rib on the affected side. Always double check to ensure the needle is being inserted into the side with pressure built up.

Further treatment of a Tension Pneumothorax may require intubation and higher echelon care should be sought out immediately.

To recap the treatment of a Pneumothorax and/or a Tension Pneumothorax, we’ve described needing these essentials:

  • Chest Seal
  • Decompression Needle

Airway Obstruction

AirwayAn airway obstruction or blockage can often be as simple as a relaxed tongue in an unconscious or semiconscious victim. This can be cleared up with the head-tilt / chin-lift method and looking for chest rise.

In a traumatic situation there may be blood or bone that might be able to be removed with a finger sweep of the airway, but to maintain the airway of a unconscious or semiconscious an NPA should be used.

An NPA or Nasopharyngeal Airway is a soft rubber tube that is inserted into the nasal cavity to bridge the airway between the tongue and the back of the throat or between any other damage that the victim may have sustained.

There’s a flared end at the end of an NPA which prevents it from getting carried down the throat, and always remember to insert an NPA with the beveled side towards the septum (divider between nostrils).

In major facial trauma, ensure the NPA is used on the unaffected side, not the injured side.

An NPA can also be used for an emergency Cricothyrotomy, which is an incision through the skin and Cricothyroid Membrane to secure a patients airway during an obstructed airway or major facial trauma.

Gauze can be used to secure the NPA by placing a gentle overhand knot over the NPA and securing the gauze around the back of the neck.

To recap the treatment of a Pneumothorax and/or a Tension Pneumothorax, we’ve described needing these essentials:

  • NPA (Nasopharyngeal Airway)
  • Gauze (for emergency Cricothyrotomy)

In addition to all of the above named life saving items, it’s a good idea to carry gloves with you in order to provide a barrier between you and body fluids.

Our Contribution

We felt so strongly about everyone needing some kind of blow out kit with the best materials on the market today, that we began to research what was commercially available and whether it filled that need.

While there are many commercially available kits, none that we found matched our requirements or compared to the price point we could offer them to the community at.

So we designed our own, and waited until we had a product we felt confident recommending to our readers in this article before we published it.

Check out the ITS Tactical ETA Kit!


Are you getting more than 14¢ of value per day from ITS Tactical?

Please consider joining our Crew Leader Membership and our growing community of supporters.

At ITS Tactical we’re working hard every day to provide different methods, ideas and knowledge that could one day save your life. Instead of simply asking for your support with donations, we’ve developed a membership to allow our readers to support what we do and allow us to give you back something in return.

For less than 14¢ a day you can help contribute directly to our content, and join our growing community of supporters who have directly influenced what we’ve been able to accomplish and where we’re headed.

Click here to learn about all the benefits and Join!


TacMed
TacMed

You guys rock

I will say however inserting a deco needle in the 2nd intercostal space on mid clavicular is a bad idea for someone who isn't trained on how to do it. I would say 4th intercostal space on the mid axillary line.That way you have less of a chance of hitting the lung.

I ordered your eta fatboy and I am definitely impressed.

Winston Smith
Winston Smith

Kevin Larkin November 6, 2009 "Is it possible to set up a “Print” version of your articles. I’d love to print some of them and read them while on the road."

I cut web pages and paste them in Word. (Your choice of word processors). I start each paste with the link to the material. That way if I print it and give it away, they can find it and I can go back for updates. I put all the grabs on one subject in one document but you can make them each separate. Whatever suits your filing style. There are free word processor to .pdf converters on the web. Keep the .doc file so you can edit and update it in the future.

Robert Navarro
Robert Navarro

Great article, a couple of things I would mention. First, I would be sure to mention that a tourney should be applied as close to the wound as possible. I.e. Don't place a tourny on the bicep for a wrist injury. The general rulw of thumb is approx three to four inches above the injury site. Second, I would be very very carful about doing a chest decompression or should I say, describing how to do so to the average "joe". A chest seal is the way to go. Using just a clear semi soldish piece of plastic is a cheap and fast way to achieve this, simply tape three sides of the plastic down leaving the "down" side open for drainage. I'm just saying this because of the fact that everyone seems to "sue crazy" now-a-days. One last thing, you guys have a great site here, and thankfully I am able to make the days go by a lot faster at work by reading the articles. I work full time in EMS and want to thank you for the distraction. I have already employed a lot of your ideas, and have even come up with a few of my own.

WSAR
WSAR

While lenghty, the notes on the tourniquet above are important. In Wilderness SAR, when dealing with such long term situations, the rule of life over limb comes into play. However, in addition to the points above about arterial bleeding, its important to note that there is another hidden danger in releasing a tourniquet that has been on for an extended period: tourniquet shock. Primarily believed to be caused by the sudden release of pent-up toxins from the wounded extremity to the bloodstream, this form of shock is almost impossible to counteract in the field. As such it is important that the TQ be removed very slowly with proper supervision and monitoring (i.e. hospital + doctor w/proper equipment and support).

I agree with Warthog about the flap - there is no need to create a situation where it is necessary to create another injury in the patient in a wilderness/tactical environment by having to use a cric needle (if its avoidable). The risk of infection and life-threatening mistakes are too high. If you do carry one - make sure you get proper training and know how to do it in your sleep.

Another minor point I'd like to make is about the NPA. It is very important to size this thing properly - otherwise you'll shove the thing too far down and cause damage/gagging/vomiting (which really defeats the purpose). I noticed that the ETA kit ITS tactical provides is the largest size possible. This is good for obvious reasons. However - make sure you measure and trim that thing down before putting it in anyone (pre-cut yours if you wanna be fancy). Measurement of the NPA is from the nostril of insertion to the same side's earlobe. When you trim it, make sure you remake the bevel.

Great article ITS - would love to seem more articles on wilderness/tactical medicine!

WSAR
WSAR

While lenghty, the notes on the tourniquet above are important. In Wilderness SAR, when dealing with such long term situations, the rule of life over limb comes into play. However, in addition to the points above about arterial bleeding, its important to note that there is another hidden danger in releasing a tourniquet that has been on for an extended period: tourniquet shock. Primarily believed to be caused by the sudden release of pent-up toxins from the wounded extremity to the bloodstream, this form of shock is almost impossible to counteract in the field. As such it is important that the TQ be removed very slowly with proper supervision and monitoring (i.e. hospital + doctor w/proper equipment and support). I agree with Warthog about the flap - there is no need to create a situation where it is necessary to create another injury in the patient in a wilderness/tactical environment by having to use a cric needle (if its avoidable). The risk of infection and life-threatening mistakes are too high. If you do carry one - make sure you get proper training and know how to do it in your sleep. Another minor point I'd like to make is about the NPA. It is very important to size this thing properly - otherwise you'll shove the thing too far down and cause damage/gagging/vomiting (which really defeats the purpose). I noticed that the ETA kit ITS tactical provides is the largest size possible. This is good for obvious reasons. However - make sure you measure and trim that thing down before putting it in anyone (pre-cut yours if you wanna be fancy). Measurement of the NPA is from the nostril of insertion to the same side's earlobe. When you trim it, make sure you remake the bevel. Great article ITS - would love to seem more articles on wilderness/tactical medicine!

Warthog
Warthog

I think some of you are overcomplicating the issue. What we're talking about is a "need it right now" kit to be used until more help arrives. Super advanced dressings are nice, but tend to be expensive. Triangular bandages can be used in any number of ways, you can get them super cheap. Also, skip the fancy dan blood stoppers and go down to the drug store and buy Kotex. Yep, world's best blood stoppers and a box of a whole bunch of pads is cheap enough to have one everywhere.

Direct pressure and elevation is the key. For the pneumo? Leave a flap.

For the record, I am a former Paramedic who worked most of his career in and around Detroit.

Warthog
Warthog

I think some of you are overcomplicating the issue. What we're talking about is a "need it right now" kit to be used until more help arrives. Super advanced dressings are nice, but tend to be expensive. Triangular bandages can be used in any number of ways, you can get them super cheap. Also, skip the fancy dan blood stoppers and go down to the drug store and buy Kotex. Yep, world's best blood stoppers and a box of a whole bunch of pads is cheap enough to have one everywhere. Direct pressure and elevation is the key. For the pneumo? Leave a flap. For the record, I am a former Paramedic who worked most of his career in and around Detroit.

SM
SM

Great article, very informative. I applaud ITS for their dedication in putting out solid relevant information to their subscribers. Good point made by TacZen. I also teach TCCC and Assault Rescue to various DoD and civilian tactical units, the one other point to bring up is the following;

"If a tourniquet is to be used for over two hours, where higher echelon care is not immediately available, it’s recommended to release pressure for five minutes every half hour to prevent muscle and nerve damage due to compression."

This had previously resonated from wilderness medicine, and older first aid courses. With the enormous use of pre hospital TQ's during the GWOT, many of the anecdotal guidelines have been dispelled. The Committee on TCCC has also included this topic within their curriculum.

The CoTCCC does not recommend this or teach "reperfusion intervals"even if TQ time is lengthy. Although when examining the This is from their current presentation,

"Tourniquets Points to Remember

•All unit members should have a tourniquet at a standard location on their battle gear.

•When a tourniquet has been applied, DO NOT periodically loosen it to allow circulation to return to the limb.

• Causes unacceptable additional blood loss.

• This practice caused at least one near-fatality in 2005."

Dr. Kragh, in his 2007 paper "Extended (16-hour) Tourniquet Application After Combat Wounds: A Case Report and Review of Current Literature" which discusses the extended TQ application on a pilot during Operation Anaconda, states the following concerning periodic reperfusion,

"The practice of intermittent reperfusion is common in surgical practice and can significantly extend the duration of safe tourniquet application. However, in battlefield applica- tions there is generally no ability to limit hemorrhage during intermittent reperfusion, and no ability to administer blood products to replace lost volume. History has shown the practice to be ill advised, resulting in many deaths due to incremental exsanguination and current use guidelines expressly forbid the practice.

Conversion is always a possibility during transition periods (CUF - TFC- TACEVAC). One other point to bring up is the documented efficacy of placing two TQs side by side, which increases surface area and decreases pressure needed to cease bleeding and distal pulse. This is currently recommended when tactically feasible while no longer in Care Under Fire (CUF), although some are doing it first line when injury is amendable to technique and tactically reasonable.

We have an opportunity to work with a few members of the Committee on TCCC (CoTCCC) on a regular basis, and through many years of research and phenomenal work from ISR, specifically Dr. John Kragh there has been a huge shift on the opinions of TQ use, especially in the civilian sector. Many solid caveats are contained in his papers, "Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma"(2008), "BATTLE CASUALTY SURVIVAL WITH EMERGENCY TOURNIQUET USE TO STOP LIMB BLEEDING" (2009), and "Use of Tourniquets and Their Effects on Limb Function in the Modern Combat Environment" (2010).

Also (sorry for being long winded), one of the "hot topics" out there in both the DoD and civilian tactical arenas, is the new (about 2 months old) investigation that the USMC performed on C-A-T tourniquet failures. For years we have heard of broken windlass issues and velcro failures, but this is the first paper to publish an "official" investigation. At the surface it doesn't appear too damning, although when you sit back and look at what it actually says and suggests, it is very problematic for the C-A-T and places doubt into those who carry it. If anyone needs a copy of the study feel free to e-mail me.

We wrote the following reaction to this study for ITRAMS (International Tactical Rescue and Medicine Society).

Reaction to MARCORSYSCOM C-A-T Message

This document has obviously been a “hot” topic since it was released. At first look two things hit the reader immediately concerning the MARCORSYSCOM investigative conclusion of the reported effectiveness and failures of the Combat Application Tourniquet. If the operational effectiveness and failures of the C-A-T is due to “improper use” (user error) and improper storage then 1) Is the C-A-T too complex to be utilized in combat while under survival stress? There doesn’t appear to be any complaints or claims similar to this concerning the SOFT-T (the only other CoTCCC recommended tourniquet), or the TK-4 the other TQ used by the USMC, so why utilize a TQ that has documented failures in combat chalked up to user error, when we know the amount of stress the user will be under while applying a life-saving piece of kit. 2) Improper storage is expounded on in section 7 and 8 of the document. It is here that they state the following;

7. ALL TOURNIQUETS SHOULD BE STORED IN A DRY ENVIRONMENT AND MAXIMUM TEMPERATURE NOT TO EXCEED 180 DEGREES F.

A. STORAGE OR PRE-STAGING THE C-A-T ON AN INDIVIDUAL'S BODY ARMOR, EXPOSED TO THE ELEMENTS, LIKELY DEGRADES THE MATERIAL AND EFFECTIVENESS OF THE TOURNIQUET.

B. IT IS RECOMMENDED THAT PERSONNEL KEEP THE TOURNIQUET IN ITS ORIGINAL PROTECTIVE PACKAGING.

8. IF THE TOURNIQUET HAS BEEN OPEN FOR AN UNDETERMINED AMOUNT OF TIME, IT IS RECOMMENDED TO HAVE THE TOURNIQUET REPLACED.

This seems to be the most controversial and catastrophic blow to the C-A-T. This now brings up a multitude of issues. The C-A-T must be kept in a dry environment, in its original wrapper, and not on an individual’s body armor or exposed to elements. Is this TQ now even compatible with the tactical or combat environment? As stated before, there does not appear to be any complaints or claims against the SOFT-T about improper storage leading to failure, apparently you can carry and store the alternate TQ anyway you want including being exposed to the elements, without degrading the piece of kit. The TQ is a first –line piece of gear. We don’t keep our primary weapon in its case while going through a door or our ammo in the box until the second we need to pull the trigger, then quickly open the box, load a magazine and charge our weapon and pull the trigger in a split second to save our lives from a threat.

The majority of TCCC trainers, if not all preach to always remove the TQ from its wrapper, and attach to the outside of your kit (not in an IFAK) in an area that you can access rapidly with either hand. There have been cases where users have had tremendous difficulty getting the TQ out of an IFAK and wrapper while under severe survival stress, with bloody hands, when seconds make the difference. I will let Cris Cook expound on this in his response.

If this is how the manufacturer suggests that the C-A-T be stored, does it still meet its claim of being one-handed? It is if I fold it in its one handed configuration, and then store it outside of its “original protective packaging” on the outside of my kit and exposed to the elements. It will take me two hands to remove from my medical kit (as stated in section 6 C), and then it also takes two hands to remove the C-A-T from the “original protective packaging”. This no longer allows the C-A-T to claim to be a “one-handed” tourniquet, which interferes with its stated compliance to the DoD / Biomedical engineers seven absolute requirements and five desirable features of a combat TQ. These requirements and features are as follows;

Seven Absolute Requirements

• Occlusion of arterial blood flow in a thigh 26.7” in diameter.

• Easy application to both upper and lower extremities.

• Will not slip during or after tightening.

• Easy release and subsequent reapplication.

• Weigh less than 230 grams.

• No power or electricity to operate.

• Shelf life of greater than 10 years.

Five Desirable Features

• 2” width

• One handed application to upper extremity

• Ability to be applied to entrapped limbs

• Protection from over-tightening

• Large scale production cost of $25

The portion that strikes many odd is section 8. It states that if the C-A-T has been open for an undetermined amount of time, it is recommended to have the tourniquet replaced. This seems a bit crazy for a TQ that was to be designed for utilization in the harshest conditions, which by the tone of this document it may not have been. Also since most of us that have this TQ do not utilize these storage techniques, and we decide to stay with this TQ, then someone will be making frequent visits to the bank with the amount of re-ordering about to occur.

As a side note, due to where the C-A-T originated from, by no means am I implying that the original design and concept was not specifically designed for the harshest combat conditions, although the end product seems to have some substantial limitations if these investigative conclusions are valid.

The last portion of this document that is unique occurs in section 6, which explains how to fold the C-A-T for one-handed storage. This seems odd since I obviously do not need to know this technique since we are instructed to keep it in its original protective packaging so it doesn’t degrade.

There have been numerous lives saved with the C-A-T, and I doubt the users of this kit adhered to the specified storage instructions listed in this document. The issue becomes that there were reported failures in the tactical environment, an investigation was completed, and the conclusions bring up some very concerning issues. The simple statement in 7 A, “Storage or pre-staging the C-A-T on an individual’s body armor, exposed to the elements, Likely degrades the material and effectiveness of the tourniquet” is troubling to say the least considering the intended AO of its use. Considering there is an alternative TQ that is recommended by the CoTCCC that doesn’t have the same concerns forces a decision to be made.

Many have made statements or blogged about the “great tourniquet debate”. The C-A-T is always mentioned and many either love or hate it. Failures mentioned are anything from the windlass snapping to the Velcro not adhering. Others have saved lives or their own with it. Some argue the C-A-T is a little wider (1.5”) and more effective compared to the SOFT-T (1”). This claim is not true and has a built in fallacy. The C-A-T uses a constricting band (attached to windlass), which travels inside a tubular piece of nylon. The constricting band is only 1”, which is the portion applying all the pressure. The added width of the tubular carrier does not add width to the compression. When applying tension you will actually see the outside tubular portion slant upward, obviously not applying pressure. If you threaded a 1/4” piece of bungee through a 3” section of tubular webbing and pulled the bungee circumferentially around an object tight, you would still only get the ¼” of pressure to occlude.

Finally, whichever tourniquet you decide to utilize train on it incessantly, under a full-spectrum of operational conditions because when you need it you will only have one chance to get it right.

SM
SM

Great article, very informative. I applaud ITS for their dedication in putting out solid relevant information to their subscribers. Good point made by TacZen. I also teach TCCC and Assault Rescue to various DoD and civilian tactical units, the one other point to bring up is the following; "If a tourniquet is to be used for over two hours, where higher echelon care is not immediately available, it’s recommended to release pressure for five minutes every half hour to prevent muscle and nerve damage due to compression." This had previously resonated from wilderness medicine, and older first aid courses. With the enormous use of pre hospital TQ's during the GWOT, many of the anecdotal guidelines have been dispelled. The Committee on TCCC has also included this topic within their curriculum. The CoTCCC does not recommend this or teach "reperfusion intervals"even if TQ time is lengthy. Although when examining the This is from their current presentation, "Tourniquets Points to Remember •All unit members should have a tourniquet at a standard location on their battle gear. •When a tourniquet has been applied, DO NOT periodically loosen it to allow circulation to return to the limb. • Causes unacceptable additional blood loss. • This practice caused at least one near-fatality in 2005." Dr. Kragh, in his 2007 paper "Extended (16-hour) Tourniquet Application After Combat Wounds: A Case Report and Review of Current Literature" which discusses the extended TQ application on a pilot during Operation Anaconda, states the following concerning periodic reperfusion, "The practice of intermittent reperfusion is common in surgical practice and can significantly extend the duration of safe tourniquet application. However, in battlefield applica- tions there is generally no ability to limit hemorrhage during intermittent reperfusion, and no ability to administer blood products to replace lost volume. History has shown the practice to be ill advised, resulting in many deaths due to incremental exsanguination and current use guidelines expressly forbid the practice. Conversion is always a possibility during transition periods (CUF - TFC- TACEVAC). One other point to bring up is the documented efficacy of placing two TQs side by side, which increases surface area and decreases pressure needed to cease bleeding and distal pulse. This is currently recommended when tactically feasible while no longer in Care Under Fire (CUF), although some are doing it first line when injury is amendable to technique and tactically reasonable. We have an opportunity to work with a few members of the Committee on TCCC (CoTCCC) on a regular basis, and through many years of research and phenomenal work from ISR, specifically Dr. John Kragh there has been a huge shift on the opinions of TQ use, especially in the civilian sector. Many solid caveats are contained in his papers, "Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma"(2008), "BATTLE CASUALTY SURVIVAL WITH EMERGENCY TOURNIQUET USE TO STOP LIMB BLEEDING" (2009), and "Use of Tourniquets and Their Effects on Limb Function in the Modern Combat Environment" (2010). Also (sorry for being long winded), one of the "hot topics" out there in both the DoD and civilian tactical arenas, is the new (about 2 months old) investigation that the USMC performed on C-A-T tourniquet failures. For years we have heard of broken windlass issues and velcro failures, but this is the first paper to publish an "official" investigation. At the surface it doesn't appear too damning, although when you sit back and look at what it actually says and suggests, it is very problematic for the C-A-T and places doubt into those who carry it. If anyone needs a copy of the study feel free to e-mail me. We wrote the following reaction to this study for ITRAMS (International Tactical Rescue and Medicine Society). Reaction to MARCORSYSCOM C-A-T Message This document has obviously been a “hot” topic since it was released. At first look two things hit the reader immediately concerning the MARCORSYSCOM investigative conclusion of the reported effectiveness and failures of the Combat Application Tourniquet. If the operational effectiveness and failures of the C-A-T is due to “improper use” (user error) and improper storage then 1) Is the C-A-T too complex to be utilized in combat while under survival stress? There doesn’t appear to be any complaints or claims similar to this concerning the SOFT-T (the only other CoTCCC recommended tourniquet), or the TK-4 the other TQ used by the USMC, so why utilize a TQ that has documented failures in combat chalked up to user error, when we know the amount of stress the user will be under while applying a life-saving piece of kit. 2) Improper storage is expounded on in section 7 and 8 of the document. It is here that they state the following; 7. ALL TOURNIQUETS SHOULD BE STORED IN A DRY ENVIRONMENT AND MAXIMUM TEMPERATURE NOT TO EXCEED 180 DEGREES F. A. STORAGE OR PRE-STAGING THE C-A-T ON AN INDIVIDUAL'S BODY ARMOR, EXPOSED TO THE ELEMENTS, LIKELY DEGRADES THE MATERIAL AND EFFECTIVENESS OF THE TOURNIQUET. B. IT IS RECOMMENDED THAT PERSONNEL KEEP THE TOURNIQUET IN ITS ORIGINAL PROTECTIVE PACKAGING. 8. IF THE TOURNIQUET HAS BEEN OPEN FOR AN UNDETERMINED AMOUNT OF TIME, IT IS RECOMMENDED TO HAVE THE TOURNIQUET REPLACED. This seems to be the most controversial and catastrophic blow to the C-A-T. This now brings up a multitude of issues. The C-A-T must be kept in a dry environment, in its original wrapper, and not on an individual’s body armor or exposed to elements. Is this TQ now even compatible with the tactical or combat environment? As stated before, there does not appear to be any complaints or claims against the SOFT-T about improper storage leading to failure, apparently you can carry and store the alternate TQ anyway you want including being exposed to the elements, without degrading the piece of kit. The TQ is a first –line piece of gear. We don’t keep our primary weapon in its case while going through a door or our ammo in the box until the second we need to pull the trigger, then quickly open the box, load a magazine and charge our weapon and pull the trigger in a split second to save our lives from a threat. The majority of TCCC trainers, if not all preach to always remove the TQ from its wrapper, and attach to the outside of your kit (not in an IFAK) in an area that you can access rapidly with either hand. There have been cases where users have had tremendous difficulty getting the TQ out of an IFAK and wrapper while under severe survival stress, with bloody hands, when seconds make the difference. I will let Cris Cook expound on this in his response. If this is how the manufacturer suggests that the C-A-T be stored, does it still meet its claim of being one-handed? It is if I fold it in its one handed configuration, and then store it outside of its “original protective packaging” on the outside of my kit and exposed to the elements. It will take me two hands to remove from my medical kit (as stated in section 6 C), and then it also takes two hands to remove the C-A-T from the “original protective packaging”. This no longer allows the C-A-T to claim to be a “one-handed” tourniquet, which interferes with its stated compliance to the DoD / Biomedical engineers seven absolute requirements and five desirable features of a combat TQ. These requirements and features are as follows; Seven Absolute Requirements • Occlusion of arterial blood flow in a thigh 26.7” in diameter. • Easy application to both upper and lower extremities. • Will not slip during or after tightening. • Easy release and subsequent reapplication. • Weigh less than 230 grams. • No power or electricity to operate. • Shelf life of greater than 10 years. Five Desirable Features • 2” width • One handed application to upper extremity • Ability to be applied to entrapped limbs • Protection from over-tightening • Large scale production cost of $25 The portion that strikes many odd is section 8. It states that if the C-A-T has been open for an undetermined amount of time, it is recommended to have the tourniquet replaced. This seems a bit crazy for a TQ that was to be designed for utilization in the harshest conditions, which by the tone of this document it may not have been. Also since most of us that have this TQ do not utilize these storage techniques, and we decide to stay with this TQ, then someone will be making frequent visits to the bank with the amount of re-ordering about to occur. As a side note, due to where the C-A-T originated from, by no means am I implying that the original design and concept was not specifically designed for the harshest combat conditions, although the end product seems to have some substantial limitations if these investigative conclusions are valid. The last portion of this document that is unique occurs in section 6, which explains how to fold the C-A-T for one-handed storage. This seems odd since I obviously do not need to know this technique since we are instructed to keep it in its original protective packaging so it doesn’t degrade. There have been numerous lives saved with the C-A-T, and I doubt the users of this kit adhered to the specified storage instructions listed in this document. The issue becomes that there were reported failures in the tactical environment, an investigation was completed, and the conclusions bring up some very concerning issues. The simple statement in 7 A, “Storage or pre-staging the C-A-T on an individual’s body armor, exposed to the elements, Likely degrades the material and effectiveness of the tourniquet” is troubling to say the least considering the intended AO of its use. Considering there is an alternative TQ that is recommended by the CoTCCC that doesn’t have the same concerns forces a decision to be made. Many have made statements or blogged about the “great tourniquet debate”. The C-A-T is always mentioned and many either love or hate it. Failures mentioned are anything from the windlass snapping to the Velcro not adhering. Others have saved lives or their own with it. Some argue the C-A-T is a little wider (1.5”) and more effective compared to the SOFT-T (1”). This claim is not true and has a built in fallacy. The C-A-T uses a constricting band (attached to windlass), which travels inside a tubular piece of nylon. The constricting band is only 1”, which is the portion applying all the pressure. The added width of the tubular carrier does not add width to the compression. When applying tension you will actually see the outside tubular portion slant upward, obviously not applying pressure. If you threaded a 1/4” piece of bungee through a 3” section of tubular webbing and pulled the bungee circumferentially around an object tight, you would still only get the ¼” of pressure to occlude. Finally, whichever tourniquet you decide to utilize train on it incessantly, under a full-spectrum of operational conditions because when you need it you will only have one chance to get it right.

Anthony Steele
Anthony Steele

Hi Guys,

great kit, ive been working as an operator/Emt in Iraq for the past six years and can vouch for the need to have a blow out kit on hand.

Check out the Olaes modular bandage from TACMED. it combines the trauma dressing,gauze and ACE wrap in one and could make the kit even smaller without any impact on performance.

Keep up the good work

Anthony Steele
Anthony Steele

Hi Guys, great kit, ive been working as an operator/Emt in Iraq for the past six years and can vouch for the need to have a blow out kit on hand. Check out the Olaes modular bandage from TACMED. it combines the trauma dressing,gauze and ACE wrap in one and could make the kit even smaller without any impact on performance. Keep up the good work

TacZen
TacZen

Great Article. I teach TCCC and this covers the basics. My only comment is about the "Tourniquet as a last resort"... you did in fact esentially correct this as you went on, but I still wouldn't make that statement. Now I know "Touriquet as a last resort" is STILL taught in civi EMS, but it just leaves too many thinking they do to need something else before using it, and even seconds of blood loss can mean the difference. It's a lot like saying "CPR as a last resort"... would I do CPR if it wasn't indicated, no... but if it is indicated it is the FIRST thing you do. You know that, just need to get rid of the "last resort" concept. Thanks again for a great article.

ITS Admin
ITS Admin

Kenpojitsu,

Thanks for the kind words and the comment! Not cool that someone had a Pneumothorax, but must have been awesome to see!

Our kit definitely has QuikClot, and it's the Combat Gauze too!

~ Bryan

ITS Admin
ITS Admin

Morgan,

Glad you like it! Let us know what you think of the kit!

~ Bryan

ITS Admin
ITS Admin

Kevin,

Thanks for the comment. We'll definitely look into a way to add a "print" feature to our articles, and we all appreciate the suggestion!

~ Bryan

ITS Admin
ITS Admin

Gillies,

I think readers showing off their BOKs would fall under the ITS Reader Photos Flickr Group :) Who knows we could outgrow it one day!

ITS Admin
ITS Admin

Thompson,

I'm guessing you're married to one? LOL

~ Bryan

ITS Admin
ITS Admin

Thanks Ryan... Pssst, it's here!

ITS Admin
ITS Admin

Thanks for the comment Band-Aid! Hope you enjoy what we've selected.

kenpojitsu
kenpojitsu

Great article!!(as usual) I've been needing to get some quick Clot added to my gear. Its on My priority list. I have Kerlix & 8x10's in just about every bag I own that I can fit some in, but I need to get a few "Blow Out Kits" going other than My med kit in the car trunk.

& Speaking of Tension Pneumothorax we just transported a spontaneous Pneumothorax the other day. For those who have never seen someone getting stuck with a huge ass needle into the lung its a trip!! instant relief for the Patient though.

kenpojitsu
kenpojitsu

Great article!!(as usual) I've been needing to get some quick Clot added to my gear. Its on My priority list. I have Kerlix & 8x10's in just about every bag I own that I can fit some in, but I need to get a few "Blow Out Kits" going other than My med kit in the car trunk. & Speaking of Tension Pneumothorax we just transported a spontaneous Pneumothorax the other day. For those who have never seen someone getting stuck with a huge ass needle into the lung its a trip!! instant relief for the Patient though.

M. Atwood
M. Atwood

Excellent!

This is a nice run down of the concept, and why its necessary.

I'm looking forward to seeing what you guys have put together!

M. Atwood
M. Atwood

Excellent! This is a nice run down of the concept, and why its necessary. I'm looking forward to seeing what you guys have put together!

Kevin Larkin
Kevin Larkin

Great, very informative post. Is it possible to set up a "Print" version of your articles. I'd love to print some of them and read them while on the road. Cheers, KevLar

CdtGillies
CdtGillies

Hmm, do I see another flickr group coming?

Thompson
Thompson

great idea. I'm lucky enough to have a medic nearby almost always ;)

Ryan Owen
Ryan Owen

Can't wait to see what you've got!

BAND-AID
BAND-AID

I have a blow out kit that I keep in my jump bag in my car. Blow out kits are a very good idea. As an experienced EMT, I have only needed it in a few situations. "Better be safe than sorry!" I will be looking forward to tomorrows article to see what products you have chosen, maybe I can update my kit. Thanks again ITS!!

18D
18D

I have to disagree with you. I have been a Special Forces medical sergeant for over 5 years now, and I have taught how to and applied quite a few tourniquets in both theaters of operation. Because of our anatomy I always teach and apply TQs proximal to the joint. I would never teach or apply an occlusive dressing with a "flap". It is best to cover it up completely and be prepared for needle decompression. The fact is that if the thoracic cavity is compromised (by a bullet or explosive fragment) even if you cover the wound with an occlusive dressing there will still be the problem of air escaping into the plural space from the punctured lung. Therefore you will find it necessary to take further measures. Simply leaving a "flap" will not be enough.

As to my personal "blow out" kit I have 2 x TQs, roll of 3" curlex (rolled gauze), a 3" ace wrap (the two are used for hemorrhage proximal to appropriate TQ sites I.E. axillary or groin) combat gauze, 2 x chest seals (for entrance and exits), an OPA, an NPA, and 2 x 14ga x 3.25" needle catheters. I also carry a red chem light banded to my kit.

18D
18D

I have to disagree with you. I have been a Special Forces medical sergeant for over 5 years now, and I have taught how to and applied quite a few tourniquets in both theaters of operation. Because of our anatomy I always teach and apply TQs proximal to the joint. I would never teach or apply an occlusive dressing with a "flap". It is best to cover it up completely and be prepared for needle decompression. The fact is that if the thoracic cavity is compromised (by a bullet or explosive fragment) even if you cover the wound with an occlusive dressing there will still be the problem of air escaping into the plural space from the punctured lung. Therefore you will find it necessary to take further measures. Simply leaving a "flap" will not be enough. As to my personal "blow out" kit I have 2 x TQs, roll of 3" curlex (rolled gauze), a 3" ace wrap (the two are used for hemorrhage proximal to appropriate TQ sites I.E. axillary or groin) combat gauze, 2 x chest seals (for entrance and exits), an OPA, an NPA, and 2 x 14ga x 3.25" needle catheters. I also carry a red chem light banded to my kit.

ITS Admin
ITS Admin

TacZen,

We completely agree, and referenced tourniquets being used as a "last resort" to get in our correction for that misnomer. For so long people have heard the "last resort" line, and we wanted to try and clear that up by saying "applying a tourniquet can be the first response if the severity of the injury warrants it."

Thank you for the kind words about the article, and your excellent comment! It's great to have your perspective here as someone who teaches TCCC.

ITS Admin
ITS Admin

TacZen, We completely agree, and referenced tourniquets being used as a "last resort" to get in our correction for that misnomer. For so long people have heard the "last resort" line, and we wanted to try and clear that up by saying "applying a tourniquet can be the first response if the severity of the injury warrants it." Thank you for the kind words about the article, and your excellent comment! It's great to have your perspective here as someone who teaches TCCC.

ITS Admin
ITS Admin

Kenpojitsu, Thanks for the kind words and the comment! Not cool that someone had a Pneumothorax, but must have been awesome to see! Our kit definitely has QuikClot, and it's the Combat Gauze too! ~ Bryan

ITS Admin
ITS Admin

Morgan, Glad you like it! Let us know what you think of the kit! ~ Bryan

Winston Smith
Winston Smith

Kevin Larkin November 6, 2009 "Is it possible to set up a “Print” version of your articles. I’d love to print some of them and read them while on the road." I cut web pages and paste them in Word. (Your choice of word processors). I start each paste with the link to the material. That way if I print it and give it away, they can find it and I can go back for updates. I put all the grabs on one subject in one document but you can make them each separate. Whatever suits your filing style. There are free word processor to .pdf converters on the web. Keep the .doc file so you can edit and update it in the future.

ITS Admin
ITS Admin

Kevin, Thanks for the comment. We'll definitely look into a way to add a "print" feature to our articles, and we all appreciate the suggestion! ~ Bryan

ITS Admin
ITS Admin

Gillies, I think readers showing off their BOKs would fall under the ITS Reader Photos Flickr Group :) Who knows we could outgrow it one day!

ITS Admin
ITS Admin

Thompson, I'm guessing you're married to one? LOL ~ Bryan

Trackbacks

  1. [...] friends at Imminent Threat Solutions didn’t just show you how to create a blow out kit they went the extra mile and are offering one for [...]

  2. [...] ITS Tactical Article on Blow Out Kits [...]

  3. [...] you do carry a FAK in your range bag right? And, that FAK has a BOK in it right? Pressure bandage, clotting agent, field [...]

The Latest
Squawk Box