Wmk22.files.wordpress.com



HemoSchool Nurses and Combat Zone Preparedness.William TremblayNursing 611December 15, 2015PICO: School Nurses and Combat Zone Preparedness.In victims of active shooter scenarios at schools, does Quikclot Combat Gauze use for hemorrhage occlusion improve survival rates?P: Victims of mass shootings at schools I: Use of Quikclot Combat GauzeC: Hemorrhage occlusionO: Improve rate of survival Issue (Background)In a study of 160 active shooter scenarios in the United States between 2000-2013, the Federal Bureau of Identification (2013) identified that 27 of these were educational institutions. Shooting occurred at locations ranging from Pre-Kindergarten though grade 12. There were 117 killed and 120 wounded. Smith, Laird, Porter, and Bloch (2013) stated that hemorrhage is responsible for 30 to 40 percent of trauma mortality. In preparing for this paper, Hampton Fire Department Emergency Response Officer Nathan Denio was interviewed to determine current protocol for active shooter response. Hampton Fire Department (HFD) protocol currently requires that prior to entering, the scene must be secure. HFD states that they can respond anywhere in Hampton in two to eight minutes. During an active shooter scenario, they must wait for the Seacoast Emergency Response Team (SERT). The SERT team is led by the Portsmouth Police Department must first secure the scene. This wait for SERT slows the actual medical response time, and increases potential time for bleeding of victims. School nurses, and staff will need to begin treatment prior to the scene being secured with whatever equipment they have available. Hampton Fire Department does carry combat gauze with their equipment. The State of New Hampshire Division of Safety (2014) published requirements that “Hemostatic bandages must be of a nonexothermic type that can be washed off with 0.9% NaCl”. While emergency response in Hampton does have the ability to use hemostatic dressings, the initial wait for life saving treatment could mean death in as little as five minutes of bleeding (Wood, 2014). First responders such as school nurses are at minimum are bachelor prepared registered nurses (, 2015). They are fully trained in first aid, CPR, and managing bleeding with usesing of direct pressure, standard gauze, tape, and tegaderm. Then why are there delays in accessing the wounded to provide hemorrhage control? I expect that traditional school nurses find themselves at significant disadvantage for lack of experience with massive hemorrhages caused by multiple gunshots, to multiple victims. These conditions are similar to those faced by military soldiers and medics in combat. If QCG hemostatic dressing improve survival rate in battlefield shootings…, they can be useful in civilian situationshootings as well. These dressings are can be applied with relatively little training. Additionally, that nurses instruct teachers and staff on its use, and that they maintain a readily available supply.Search and StudiesMultiple searches for articles were done using CINAHL, and Medline databases. The search terms “hemorrhage,” “shooting,” and “attack,” yielded one result. A second search using “quikclot,” and “efficacy,” yielded 29 results. In a third search of both databases using the terms “side effects,” “hemostatic,” and “dressing” resulted in seven articles. Results were pared down with requiring full text, English language, and relevancy to the topic. The articles used were selected based on relevance and reviewed. Three articles were selected based on the relevance to the topics, strength of evidence, and included: A level I systematic literature review, a level III controlled trial with randomization, and a level VI qualitative study. Additional searches were performed using CINAHL, and Medline using the terms “pig,” “similarity,” and “human” restricted to full text results, published from 2005 to 2015. The resulting 94 studies were pared down to one with the addition of the term “bleeding.” Information was also searched for using , using terms “Active Shooter,” “Incidents,” “statistics.” Evidence A level II blinded experimental regarding the efficacy of four types of hemostatic dressings on uncontrolled hemorrhage on swine was analyzed. This study used femoral artery puncture induced bleeding to compare time of application, and efficacy in stopping the hemorrhage. The study concluded that QCG required the second lowest packing time of 32 seconds on average, and had the third ranked survivability. The study resulted in a survival rate of 60 percent for QCG, which was third ranked of the four. The shortest packing time gauze had a survival rate of only 50 percent. This study is concluded that the most effective hemorrhage stopping gauzes brands also had the highest times to pack the wounds. It concluded that while it was important to have fast clotting times, the time to pack the wound could mean the difference in survivability on the battle field (Rall, et al., 2013). The study has very precise measurements of controls and vital statistics on each porcine patient. However, a clear drawback is that it is not human testing. The study clearly demonstrates the ability for each of the dressings to be used, but further human testing must be done to identify and quantify suitability. In a level I literature review focused on commercially available hemostatic dressings for use in prehospital care. This review was conducted to summarize literature on current available products and excluded those that had safety concerns, namely exothermic burns. Quikclot Gauze was reviewed and showed a success rate of 79 percent on 13 human gunshot and blast victims. It had longer times to hemostasis with other hemostatic gauzes, but the difference was not statistically significant. Similar to the Rall study, better performing gauze products required more time to pack, and theorized that the additional gauze packed, may have let to increased effectiveness. The QCG is a kaolin-impregnated material that has no reported side affects. QCG was reported to be safely used, unlike the original Quikclot formula, which contained zeolite granules. Significantly, this report noted the lack of large-scale hemostatic dressing studies on humans where outcomes are not statistically significant. The study addressed the difficulties in obtaining rational informed consent during emergency situations, which prevents significant studies on human patients (Smith, Laird, Porter, & Bloch, 2013). In 2015 an level III controlled trial study was published to establish how effective 24 minimally trained Navy Corpsmen could treat pigs with three different hemostatic products, one being QCG. This study contained both data regarding the comfort levels on using the product, and the wound’s rebleed occurrence, and survival rates. This study is significant to both hemostatic literature, and its intended use. The study sought to identify actual use on live tissue by corpsmen that had received a 15 minute power point presentation on the use of the dressings, and were provided no study material. Rebleeding under QCG was 25 percent, the same as the second product, and better than a third product, which came in at 50 percent rebleed. The blood loss was similar across all three products. Survival rates were higher than the Rand study and reported as 96 percent across all products. It was noted that the single death in the study was with a corpsman who had experience with both live tissue and hemostatic gauze, but it was noted he was not as aggressive at applying pressure as the newly instructed corpsmen. Surveys of pre and post use of hemostatic dressings were positive across all products. The high scores of satisfaction of ease use highlights that even with short intervals of training, the dressings were effective. The study highlights the significant effect that hemostatic dressings have even when applied by minimally trained individuals (Conley, et al., 2015).Clinical Bottom Line According to the FBI, in 160 active shooter scenarios there were 486 killed, and another 557 wounded (FBI, 2013). While not all of these occurred in schools, the number of active shooter incidents have climbed over the last few years, including the significant mass casualty shooting at Sandy Hook Elementary in 2012 where the gunman killed 26 people. Along with incidents of terrorism like the Boston Marathon bombing, the Paris attack, and most recently the San Bernardino shootings, these attacks have served to highlight the need for combat-like wound care. Our ability as nurses to provide evidenced based care extends now to military standards in triage and care of multiple bullet and projectile wounds. The research regarding hemostatic dressings is clear that while the differing products each have strengths and weaknesses, a hemostatic bandage improves the chances of survival. Quikclot Combat Gauze uses kaolin, which has no reported side effects, unlike its predecessor that was composed of zeolite granules that produced exothermic burns. QCG meets the New Hampshire mandate of by use of a non-exothermic product (Smith, Laird, Porter, & Bloch, 2012). As one of the least expensive hemostatic products, it is a more feasible option for schools to acquire and place in multiple locations throughout the school (Smith, Laird, Porter, and Bloch, 2012). Hemostatic bandages can be used effectively by minimally trained personnel (Conley, et al., 2015). This ease of use allows a school nurse the flexibility to prioritize their patients with greater effect, allowing the school staff can successfully intervene with higher degree injuries in the event of a crisis, leaving the more skilled nurse to spend more time on more critical victims. Application of Findings In the case of whether to use Quikclot Combat Gauze in schools, I find that the benefits are far reaching. The hemostatic gauze increases survivability in those with wounds that without treatment lead to hemorrhage and death. The gauze meets the newly developed standards to which fire departments now adhere, and likely schools will see as well. Currently, schools are advised to lockdown the facility and remain in place (Department of Education, 2013). While that may prevent a potential shooter from entering another section of school, it may prevent a nurse from entering. This could leave a sizeable gap in care for any wounded. However, with QCG easily applied with minimal training, this allows for greater flexibility in the provider of such crucial care. The placement of a trauma kit, including hemostatic bandages should be in each section of school. This will allow for readily accessible supplies, for staff members who are easily trained by the nurse. While bandages may solve part of the hemorrhage related death, an additional tool used extensively in combat is the tourniquet. According to an article in OR Manager, a pressure bandage, tourniquet, and hemostatic gauze “can take care of probably 95 percent of wounds” (Wood, 2014). Literature on hemostatic bandages primarily focuses on wounds that need to be packed, however, wounds on distal extremities can be addressed highly effectively with a tourniquet and pressure bandage. Proper training by the nurse to staff members can help them to identify types of wounds, locations, and skill in applying a tourniquet. While several of the articles and studies were completed using swine instead of human subjects, it is worth noting that pigs have similar anatomy to humans, resulting in using pig heart valves in current medical practice. Additionally, for hemorrhagic purposes, in an experiment by Fearn, et al (2006), surgeons sought out 30 kilogram pigs because their arteries and veins are the same size as a humans. This similarity in size translates to very comparable hemorrhage and hypovolemic results. I feel that within this document we have answered our question. In victims of active shooter scenarios at schools, does Quikclot Combat Gauze use for hemorrhage occlusion improve survival rates? Yes, a school nurse can indeed increase survival rates during an active shooter scenario.Reference:Conley, S. P., Littlejohn, L. F., Henao, J., DeVito, S. S., & Zarow, G. J. (2015). Control of Junctional Hemorrhage in a Consensus Swine Model With Hemostatic Gauze Products Following Minimal Training. Military Medicine, 180(11), 1189-1195. doi:10.7205/MILMEDD-14-00541Fearn, S., Burke, K., Hartley, D., Semmens, J., & Lawrence-Brown, M. (2006). A laparoscopic access technique for endovascular procedures: surgeon training in an animal model. Journal Of Endovascular Therapy (Allen Press Publishing Services Inc.), 13(3), 350-356 7p.Federal Bureau of Investigation, Critical Incident Response Group, Active Shooter Event/Mass Casualty Events, November 2013, . gov/about-us/cirg/active-shooter-and- mass-casualty- incidents; DHS Active Shooter Pocket Guide, HYPERLINK "". New Hampshire Department of SafetyDivision of Fire Standards and Training and Emergency Medical ServicesPatient Care Protocols – 2013 – Version 1.7 (last updated 05/01/2014)Rall, J. M., Cox, J. M., Songer, A. G., Cestero, R. F., & Ross, J. D. (2013). Comparison of novel hemostatic dressings with QuikClot combat gauze in a standardized swine model of uncontrolled hemorrhage. Journal Of Trauma & Acute Care Surgery, 75(2), S150-6 1p. doi:10.1097/TA.0b013e318299d909Smith, A. H., Laird, C., Porter, K., & Bloch, M. (2013). Haemostatic dressings in prehospital care. Emergency Medicine Journal, 30(10), 784-789 6p. doi:10.1136/emermed-2012- 201581Wood, E. (2014). Surgeons call for community response to mass casualty incidents. OR Manager, 30(1),1. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download