How to Stop Bleeding from the Scalp

The iTClamp® is a novel hemorrhage control device that has recently become a member of the Tactical Combat Casualty Care (TCCC) list of recommended devices. With the array of hemorrhage control devices becoming more numerous by the day, I feel compelled to give medical providers a glimpse of the lay of this land, and where I believe the iTClamp® best fits into that terrain. Hemorrhage control is at once the most basic of trauma care skills yet becomes more and more nuanced the further one delves into the subject. It is important to remember that there are no one-size-fits-all approaches to hemorrhage control.

Nonmechanical vs Mechanical Hemorrhage Control

I divide hemorrhage control techniques into two broad categories: mechanical and nonmechanical. Nonmechanical techniques function in the abstract and involve manipulation of the blood pressure, capillary constriction, or the blood’s ability to coagulate; a list of these techniques include:

• limited-duration permissive hypotension
• the use of local anesthetics containing epinephrine
• topical or parenteral tranexamic acid
• prevention of hypothermia

By mechanical techniques I am referring to the application of a solid object to the patient, such as a tourniquet. In virtually any scenario involving massive external bleeding and the presence of only one or two caregivers, the application of mechanical techniques should precede nonmechanical techniques, though it is theoretically possible (but seldom practical) to perform them both simultaneously. For example, in a massively hemorrhaging casualty with gunshot wounds to the legs and abdomen, administration of tranexamic acid and hypothermia prevention should happen as soon as possible, but not before tourniquets have been applied to the legs and the body has been fully exposed in the search for additional injuries. Hypothermia prevention in this case may be applied in piecemeal fashion (as soon as a given part of the body has been cleared of injuries). Once vascular access is obtained – following the placement of tourniquets – tranexamic acid may be given in order to mitigate internal abdominal bleeding. In addition, this patient will likely benefit from permissive hypotension, a practice also known as hypotensive resuscitation.

Basic and Intermediate Mechanical Hemorrhage Control

I divide mechanical techniques into basic, intermediate and advanced categories. work most of the time for most types of external bleeding and require minimal technical proficiency or technology to apply. These basic mechanical techniques include:

• direct pressure
• tourniquets
• wound packing (using inert gauze/fabric and/or a gauze-type hemostatic agent)
• simple pressure dressings.

Intermediate mechanical techniques are used in external bleeding cases in which application of a basic mechanical technique won’t work (or is delayed) or serve as adjuncts to a basic mechanical technique. These techniques are more technically demanding and generally require a higher level of knowledge of
human anatomy than do the basic techniques. Some have specific equipment requirements, though
improvisation may overcome a gear shortage in most instances. Intermediate mechanical techniques include:

• arterial pressure points
• junctional tourniquets
• complex pressure dressings
• syringe-injected hemostatic agents and other non-gauze hemostatic agents
• cautery
• indirect pressure of the skull
• traction of the femur
• splinting of impaled objects
• splinting of bone fractures
• urinary catheter balloons
• oversewing
• reapproximation of the superficial tissues (such as the scalp)

Hemmorhage Control and the iTClamp®

Following the rationale of the previous section, I place the iTClamp® mainly into the category of intermediate mechanical techniques. It is my opinion (and experience) that this is a device best used in the management of facial or scalp hemorrhages. Scalp bleeding is usually copious, even when the only severed vessels are capillaries. This has to do with the great abundance of capillaries in the scalp (ostensibly to nourish the hair follicles) and the unique inability of scalp capillaries to constrict when severed. Capillary bleeding from the scalp is therefore high volume yet low pressure, and it is standard clinical practice to stop such bleeding via reapproximation of the scalp – typically performed via fingertip pressure followed by application of sutures, staples, Raney clips, or apposition using the patient’s hair. The iTClamp® can provide quick hemostasis of scalp wounds, after which the device may be replaced (ideally under local anesthesia) with a lower-profile closure device at the practitioner’s earliest convenience.

 

This article originally appeared in the College of Remote and Offshore Medicine (COROM) Spring 2020 newsletter. Author: Jason Jarvis, 

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Published on September 10, 2020