lunes, 14 de abril de 2025

Descubrió que foto de su tatuaje es para identificar a miembros del Tren de Aragua en los Estados Unidos

Tanto él como su esposa han contemplado cancelar el viaje por temor. Foto: Instagram Pete Belton / DHS.

https://www.eltiempo.com/mundo/eeuu-y-canada/ciudadano-britanico-descubrio-que-su-tatuaje-lo-utiliza-estados-unidos-para-identificar-miembros-del-tren-de-aragua-3444513

domingo, 13 de abril de 2025

Baños "balnearios" romanos

⚔️🐚🌊🚽🚿Los baños romanos, fundamentales para la higiene y el esparcimiento social en la antigua Roma, eran sofisticadas estructuras de ingeniería que utilizaban un sistema de calefacción llamado hipocausto para mantener constantes la temperatura del agua y del ambiente. Este sistema, que consistía en calentar el aire bajo el suelo y entre las paredes, demostraba la avanzada tecnología de la época. El agua, transportada desde fuentes distantes a través de acueductos, se reutilizaba para limpiar los sistemas de alcantarillado de las letrinas. Los baños eran un lugar de encuentro diario para los romanos, donde además de bañarse, se realizaban ejercicios físicos y se utilizaba el strigilis, un raspador para eliminar el sudor y la suciedad del cuerpo. Los baños también estaban presentes en residencias privadas, y se dividían por género en diferentes horarios para evitar problemas de conducta. Por ejemplo, en el siglo I d.C., el emperador Trajano impuso regulaciones para asegurar la separación de hombres y mujeres en el Baño de Éfeso.

Créditos Conocimientum

LETRINA ROMANA

Time for Change in Prehospital Spinal Immobilization,Suggests a Research

Articulo obsoleto
Te recomiendo leer en el enlace
http://emssolutionsint.blogspot.com/2016/09/es-necesario-inmovilizar-todos-los.html

Jim Morrissey, MA, EMT-P | From the March 2013 Issue | Tuesday, March 19, 2013

Prehospital spinal immobilization has long been held as the standard of care for victims of blunt or penetrating trauma who have experienced a mechanism of injury (MOI) forceful enough to possibly damage the spinal column. The majority of EMS textbooks stress that any significant MOI, regardless of signs and symptoms of spine injury, requires full-body immobilization, which is typically defined as a cervical collar being applied and the patient being secured to a backboard with head stabilizers in place.

This approach to patient immobilization has been accepted and implemented as the standard of care for decades with little scientific evidence justifying the practice.1–3 In addition, scant data shows that immobilization in the field has a positive effect on neurological outcomes in patients with blunt or penetrating trauma.1,4–6 In fact, several studies and articles show that spine immobilization may cause more harm than good in a select sub-set of trauma patients.5–7

Many experts question the current practice of prehospital spinal immobilization.1,2,4–15 There are now some guidelines, textbooks and an increasing number of EMS agencies that support a progressive, evidence-based approach in an effort to lessen unnecessary spinal immobilizations in the field.

It’s problematic to use MOI alone as the key indicator for prehospital spinal immobilization. In addition, the harmful sequelae and potential dangers of spine immobilization need to be considered in any field protocol. We need to examine appropriate spine injury assessment guidelines and algorithms that allow for the selective immobilization of injured patients.

We also should review immobilization devices and techniques that are more appropriate for patients who do require immobilization, or better termed, spinal motion restriction (SMR), by EMS providers.

Outdated Indicators?
It typically takes several years for EMS textbooks to catch up with new evidence and then additional time for the EMS instructional community to modify curricula and change current practice. For example, definitions of mechanisms that require spinal immobilization found in most EMS textbooks are outdated and problematic. Such indicators for potential spine injury as fall, damage to the vehicle, injury above the clavicle and mechanism of injury involving motion, are not particularly helpful when determining the best course of action in the field.

Especially troubling has been the lack of emphasis on the assessment of the patient before making a decision about immobilization. Historically, more emphasis has been placed on what happened to the vehicle or the best guess on how far someone may have fallen, instead of what actually happened to the person.

It isn’t the fall that causes injury; it’s the sudden stop at the end. The more sudden the stop, the more likely an injury results, especially if the kinetic energy was transmitted to the head and/or neck.

The physical condition of the patient must also be considered. A young, athletic person is able to withstand more forces than an elderly patient. So the spectrum of potential injuries is best determined through a detailed history and physical exam.

Vehicle damage has long been considered a strong indicator of potential spine injury, yet improvements in vehicular design and construction should change the way we look at vehicle damage. Vehicle technology and passenger protection is far superior to what it has been, particularly since the 70’s when EMS textbooks began advocating back boarding of patients in vehicles with significant damage.

Vehicle damage zones are now inherently built into newer vehicles, designed to absorb and dissipate the kinetic energy of a collision, and keep the passenger cabin relatively isolated and protected.16 An experienced paramedic once said, “The cake box might be crumpled, but the cake can be fine.”

Some textbooks accurately address this issue. Even as far back as 1990, the American Academy of Orthopaedic Surgeons addressed emergency medical responders in an extended-care environment, stating, “Patients with a positive mechanism of injury, without signs and symptoms, and with a normal pain response may be treated without full spine immobilization, if approved by your medical control physician.”17

Emergency medical personnel who work in extended-care, tactical, combat and wilderness environments have long realized the need to safely and accurately assess and clear patients regarding spinal injuries.18,19

New guidelines from Prehospital Trauma Life Support and the National Association of EMS Physicians have diminished the emphasis on immobilizing victims of penetrating trauma without neurologic deficits.20

In the setting of drowning, the 2010 evidence-based guidelines from the American Heart Association state that “Routine c-spine immobilization is a Class III (potentially harmful) unless clear trauma is evident in the history or exam, because it may unnecessarily delay or impede ventilations."21

Precautionary Immobilization
It isn’t surprising that the term and practice of “precautionary immobilization” has developed. It’s estimated that at least five million patients are immobilized in the prehospital environment in the U.S. each year. Most have no complaints of neck or back pain or other evidence of spine injury.3,11,12(See Photo 2.)

EMS personnel historically have neither been given the tools nor the authority to make informed decisions about objectively determining the need for prehospital spinal immobilization. This may be because the emergency medical community thought immobilization was always safe, conservative and always in the best interest of the patient. However, evidence now shows that, in some cases, spinal immobilization may not be in the patient’s best interest.1–3,7,8,10–13

Some prehospital care providers will admit that they often immobilize patients without evidence of spine injury because they want to avoid being questioned on arrival at the emergency department (ED). This dynamic can (and must) change with education and outreach.

Backboard-Based Immobilization
In addition to patient discomfort and anxiety associated with backboard-based immobilization, there are several potentially significant consequences. Standard immobilization requires the patient’s body to conform to a flat, hard surface. In addition, EMS secures a cervical collar around the patient’s neck and uses tape to secure the patient’s head to the board.

This practice often increases patient anxiety and has the potential to aggravate underlying injuries. Standard spinal immobilization techniques can also take away the patient’s ability to effectively protect their own airway thus significantly increasing the risk of aspiration.3–6,11,13

Patient vomiting, bleeding, airway drainage and swelling are common problems associated with trauma patients. Even with one EMS provider dedicated to the management of the airway and patient suction, it cannot be assumed that a suction catheter can handle the job when significant bleeding and/or vomiting is presented.

The continued spinal stability of a patient who is turned on their side to facilitate airway drainage and control is also questionable. Patients typically experience a significant shift in body weight and distribution, causing more movement to the spine than the immobilization process was intended to prevent.

In a comprehensive review published in Prehospital and Disaster Medicine, healthy volunteers who were immobilized on a backboard were found to be “significantly more likely to complain of pain when compared with immobilization on a vacuum mattress.” Adverse effects of backboard-based immobilization documented in this study include increased ventilatory effort, pain and discomfort.

In addition to pressure injury, the backboard may also be the cause of pain—even in otherwise healthy volunteers. The resultant posterior surface/back pain of immobilized patients has been documented to result in unnecessary radiographs and potential clinical ambiguity regarding the cause of the pain.3,22 There’s an increased cost associated with some of these complications.

It has been documented that supine patient immobilization results in a 15–20% reduction in respiratory capacity, and that respiratory effectiveness is markedly reduced by the strapping systems typically used.3,9,13 Patients are often either strapped securely, thus having diminished respiratory capacity, or loosely secured, facilitating easier breathing. Neither scenario is ideal.

The challenge is exacerbated in obese patients, the elderly and patients with such underlying diseases as congestive heart failure, COPD, asthma and pneumonia.

Done properly, immobilization in the field takes time and multiple personnel. Time delay to the ED or trauma center arrival has been cited as a significant problem for critical trauma victims. Several studies have looked at the risk vs. benefit of prehospital immobilization, with several authors and researchers questioning the value of current practices.1,2,7,8,11,15

Studies have also shown limited or no benefit of prehospital immobilization of penetrating trauma patients. (See photos on pages 32 and 33.) Unnecessary immobilization of this subset of trauma patients can result in prolonged on-scene time and delayed transport to definitive care, which may increase morbidity and mortality.4–6,14,18,23–25

Several studies show that cervical collars by themselves aren’t without risk or significant consequences.4,26–28 One study concludes that cervical collars frequently increase intracranial pressure and may be particularly harmful if used on head-injured patients.26

Another researcher observed that cervical collars “can result in abnormal distraction within the upper cervical spine in the presence of severe injury.”28 In addition, cervical collars hide areas of the head and neck, resulting in the increased possibility of missing injuries or evolving problems, such as swelling, hematoma and tracheal deviation.27,28

In addition, the longer a patient is immobilized, the more likely that cutaneous pressure ulcers will develop, most notably in the occipital, sacral or heel areas.9,12,22,29,30 This is especially true in elderly, unconscious and neurologically impaired patients.

This problem may be significantly reduced with padding or use of a vacuum mattress. Unfortunately, the vast majority of the patients who are immobilized don’t get padding in voids or areas of significant body weight/pressure or a vacuum mattress that distributes beads/padding in voids and uneven body surface areas.

The Penetrating Trauma Patient
As referenced earlier, there is a growing body of evidence that suggests penetrating trauma victims shouldn’t be routinely immobilized. Immobilization has been associated with higher mortality in patients with penetrating trauma.4–6,14,23–25

Independent studies show that whether the penetrating trauma is to the head, neck or torso, immobilization is unnecessary, interferes with and delays emergent care, and should be seriously reconsidered as the standard of care.4–6,14,23

A Journal of Trauma article concluded, “Indirect spinal injury does not occur in patients with gunshot wounds to the head.” The authors state, “Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.”14

Another retrospective study showed similar concerns about the use of a cervical collar with patients who have penetrating injuries to the neck. This study suggests that avoiding the collar should be the rule, and that a provider who chooses to apply a cervical collar should have good justification. The authors also suggest that frequent examination of the underlying structures and tissue is warranted if a cervical collar is used.4

A comprehensive retrospective analysis of gunshot injuries to the torso found that immobilization was of little or no benefit, even if an unstable spine fracture was present. The authors argue that airway management, including intubation, is far more complicated and problematic with prehospital spinal immobilization in place.5,6

In fact, failed airway management was reported to be the second-leading error preceding death of trauma patients, accounting for 16% of mortality in one study. This study also highlights the potential delay to definitive surgical treatment and the lack of neurologic improvement after gunshot injury to the spinal cord, suggesting that prehospital spinal immobilization is unjustified.5,6

Proper Spine Injury Assessment
For many trauma patients, a vetted field assessment criterion that focuses on the assessment of the patient rather than the mechanism of injury would obviate unwarranted immobilization.3,11,31

Many emergency medicine specialists believe an accurate, reliable, simple-to-perform spinal injury assessment could reduce spine immobilizations drastically. Thankfully, there is a trend in this direction across the nation.

The idea of “clearing” a patient of spinal injury in the field has been, and continues to be debated. However, there are prehospital spine assessment protocols that safely and accurately allow EMTs and paramedics to omit prehospital spinal immobilization in certain patients.

Some EMS experts prefer the term “selective immobilization” to “clearing” the c-spine, but the end result is the same. The end result is the reduction of the incidence of unwarranted spinal immobilizations.

For example, the Maine spine injury assessment guidelines, developed by Peter Goth, MD, in the 1990s, have been shown to be accurate and safe.10,31,32 Several states and EMS systems around the nation use this, or a similar protocol, to help decrease the number of trauma patients being subjected to prehospital spinal immobilization.

The origin of this type of spinal assessment was initially intended to help ED physicians clinically decide if they can safely clear patients from prehospital spinal immobilization and reduce or eliminate unnecessary radiographic studies. It has been shown that the proper clinical exam and history is more accurate at predicting spine injuries than X-ray review.10,32–35

The spine injury assessment guidelines that have been adopted by multiple prehospital systems are based on the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria. Each has similar parameters, requiring that the patient be awake, alert, conversant and without significant distracting injury or intoxication.

In addition, the guidelines further state that the physical exam should reveal no pain or tenderness to the posterior neck and back and the neurologic exam must find normal motor and sensory function in the extremities.10,18,31,33–35

Studies show that prehospital care providers can safely apply spine injury assessment criteria and not miss any clinically
significant spine injuries.10,31,32 Although these guidelines are available, training and practice is needed to become proficient at using these criteria.

Alameda County (Calif.) EMS has revised its spine injury assessment protocol to accurately reflect the current literature and research. (See Figure 1, p. 38). Its goals in 2012 were to reduce unnecessary immobilization, and use treatment modalities in the best interest of and provide the most comfort to the patient. In some cases, this meant forgoing prehospital spinal immobilization to expedite transport to a trauma center.

However, long-established norms are hard to break, and extensive training was required to make this new policy successful. EMS schools, fire departments and other EMS providers, as well as emergency department staff, needed to be exposed to the literature and trained in the new protocol.

Initial training and outreach has been well received and the early indicators have shown a significant reduction in spine immobilizations. The end result is:
>> A better understanding of the need for expeditious care under specific circumstances, in particular, the need to move rapidly when penetrating trauma is present;
>> All involved are empowered to break the paradigm of “board them all” as a result of understanding the importance of proper spinal/neurological assessment and assessment parameters that allow crews to assess for serious spinal indications and perform selective immobilization. We did the same process decades ago when we adopted rapid removal techniques for patients in lieu of spending precious minutes placing splints and half backboards on critical patients. Little or no untoward results occurred with that change in procedure;
>> More attention to patient comfort and pain instead of routine placement of trauma patients on a hard, uncomfortable platform that often put them in anatomically-incorrect positions for extended time periods, made patients unnecessarily claustrophobic lying supine and immobile and exacerbation of respiratory distress in patients due to the supine position, strap placement, and existing conditions such as CHF, COPD or morbid obesity; and
>> The ability to deploy and maximize the usage of alternative immobilization and transfer devices and stretchers such as vacuum mattresses, scoop or CombiCarriers and flexible stretchers such as Ferno and SKED stretchers and others that feature lateral patient support slats and multiple handles for convenient movement and transfer of patients. Many of these devices are better suited to patient movement in tight spaces and crew body mechanics when carrying and transferring patients down stairways and other difficult environments.

Of course, crews have to take special caution when dealing with and managing high-risk patients, including pediatric patients, the elderly and those with such degenerative bone disorders as osteoporosis. Field personnel need to be conservative while evaluating these patients and should provide spinal motion restriction when in doubt.33,34

Unconventional Options
Even with appropriate application of spine injury assessment guidelines, some patients still require some degree of prehospital spinal motion restriction. Vacuum mattresses and other break-away and flexible stretchers have been used successfully throughout Europe for years. They score well in several critical areas, including patient comfort, secure immobilization, insulation, lack of pressure sore development and, in the case of some vacuum device configurations, allow crews to utilize them without a cervical collar.12,29,30

When considering adding vacuum mattresses, vacuum stretchers or other immobilization devices to your arsenal, keep in mind that they don’t require more effort or training than using backboards. Vacuum mattresses can also effectively pad voids, distribute weight evenly and immobilize patients on their side because the device can be “molded” around the patient to best package them safely. (See photos on page 36.)

However, keep in mind that backboards still have a place, especially to restrain or slide a patient out of an extrication mess. There is also nothing that precludes you from utilizing a combination of devices such as a backboard or scoop-type stretcher to remove a patient and transfer them to a more moldable or comfortable secure surface such as a vacuum mattresses. Many systems use this combination or deploy vacuum mattresses in conjunction with flexible stretchers. (See photo, top of page 36.)

Another emerging school of thought questions the need for traditional prehospital spinal immobilization at all—even for patients who have positive evidence of a spinal column or spinal cord injury. One group of researchers who compared various extrication tools and methods found that allowing a patient to self-extricate from a vehicle with a cervical collar alone caused less movement of the spine than the use of cervical collar, KED extrication device and standard extrication techniques.36 This triggers a series of questions that are beyond the scope of this article. Groups such as the National Association of EMS Physicians and the U.S. Metropolitan Municipalities Medical Directors and Global Affiliates Consortium are carefully discussing these options and revisions to our traditional approaches to neck and spine immobilization

Conclusion
It’s appropriate for emergency personnel to immobilize certain trauma patients. However, many other trauma patients are unnecessarily immobilized by EMS. Spinal immobilization isn’t always a benign intervention. It can result in increased scene time, delay of delivery to definitive care, problematic airway management, increased patient pain or dyspnea, and unnecessary radiographic testing.

Many trauma patients can be safely and accurately assessed and treated without immobilization if they meet all criteria in prehospital spinal assessment guidelines. Extensive initial training and ongoing review is necessary for an effective selective immobilization protocol.

Science, research and multiple validated articles have changed the way EMS practices. If good patient care is the goal, it’s time that prehospital spinal immobilization be critically examined.

From www.jems.com

You could like to read

POSITION STATEMENT EMS SPINAL PRECAUTIONS AND THE USE OF THE LONG BACKBOARD National Association of EMS Physicians and American College of Surgeons Committee on Trauma. 2013

References

1. Hauswald M, Ong G, Tandberg D, et al. Out-of-hospital spinal immobilization: Its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214–219.
2. Baez AA, Schiebel N. Evidence-based emergency medicine/systematic review abstract. Is routine spinal immobilization an effective intervention for trauma patients? Ann Emerg Med. 2006;47(1):110–112.
3. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med. 2005;20(1):47–53.
4. Barkana Y, Stein M, Scope A, et al. Prehospital stabilization of the cervical spine for penetrating injuries of the neck: Is it necessary? Injury. 2000;31(5):305–309.
5. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma. 2010;68(1):115–120; discussion 120–121.
6. Brown JB, Bankey PE, Sangosanya AT, et al. Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso. J Trauma. 2009;67(4):774–778.
7. Smith JP, Bodai BI, Hill AS, et al. Prehospital stabilization of critically injured patients: A failed concept. J Trauma. 1985;25(1):65–70.
8. Seamon MJ, Fisher CA, Gaughan J, et al. Prehospital procedures before emergency department thoracotomy: ‘Scoop and run’ saves lives. J Trauma. 2007;63(1):113–120.
9. Chan D, Goldberg R, Tascone A, et al. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48–51.
10. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46(2):123–131.
11. Kwan I, Burns F. Spinal immobilization for trauma patients (Cochrane Review). Cochrane Review; 2009; 11 http://summaries.cochrane.org/CD002803/spinal-immobilisation-for-trauma-....
12. McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998;5(3):278–280.
13. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999;3(4):347–352.
14. Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma. 1998;44(5):865–867.
15. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. Sept. 8, 2012. [Epub ahead of print].
16. Centers for Disease Control and Prevention (Sept. 6, 2012). Guidelines for Field Triage of Injured Patients. 2011; Retrieved from www.cdc.gov/Fieldtriage. Accessed Sept. 24, 2012, 2012.
17. Worsing R. Basic Rescue and Emergency Care. First Edition. Ed: American Academy of Orthopaedic Surgeons, Park Ridge, IL; 1990; 253 .
18. Goth P. Spine Injury, Clinical Criteria for Assessment and Management. Augusta, ME: Medical Care Development Publishing; 1994.
19. Morrissey J. Field Guide of Wilderness Medicine and Rescue. Third Edition Ed: Wilderness Medical Associates, Portland, ME; 2000; 30-33.
20. Stuke LE, Pons PT, Guy JS, et al. Prehospital spine immobilization for penetrating trauma: Review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011;71(3):763–769; discussion 769–770.
21. Berg RA, Hemphill R, Abella BS, et al. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S685–S705.
22. March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6(4):421–424.
23. Kennedy FR, Gonzalez P, Beitler A, et al. Incidence of cervical spine injury in patients with gunshot wounds to the head. South Med J. 1994;87(6):621–623.
24. Chong CL, Ware DN, Harris JH, Jr. Is cervical spine imaging indicated in gunshot wounds to the cranium? J Trauma. 1998;44(3):501–502.
25. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma. 1989;29(3):332–337.
26. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996;27(9):647–649.
27. Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Am J Emerg Med. 1999;17(2):135–137.
28. Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010;69(2):447–450.
29. Cordell WH, Hollingsworth JC, Olinger ML, et al. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26(1):31–36.
30. Luscombe MD, Williams JL. Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emerg Med J. 2003;20(5):476–478.
31. Muhr MD, Seabrook DL, Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care. 1999;3(1):1–6.
32. Domeier RM, Evans RW, Swor RA, et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999;3(4):332–337.
33. Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001;37(6):609–615.
34. Barry TB, McNamara RM. Clinical decision rules and cervical spine injury in an elderly patient: a word of caution. J Emerg Med. 2005;29(4):433–436.
35. Burton JH, Dunn MG, Harmon NR, et al. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006;61(1):161–167.
36. Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009;10(2):74–78.

influencia de la dieta mediterránea en los trastornos autoinmunes tiroideos (TAT), como la tiroiditis de Hashimoto y la enfermedad de Graves.

La imagen compara los efectos de la dieta mediterránea y la dieta occidental sobre la autoinmunidad tiroidea, destacando los mecanismos nutricionales que pueden influir en esta condición.

Dieta Mediterránea

Incluye:

Cereales integrales, vegetales, frutas y legumbres

Vino tinto (consumo moderado)

Pescado azul pequeño

Efectos protectores:

Mejora la composición de la microbiota intestinal

Actividad antioxidante gracias a los componentes vegetales y al resveratrol del vino tinto

Ácidos grasos poliinsaturados (PUFA) del pescado, que tienen propiedades antiinflamatorias

Estos factores disminuyen la probabilidad de desarrollar autoinmunidad tiroidea mediante la reducción del estrés oxidativo y la modulación inmune.

Dieta Occidental

Incluye:

Productos animales (como carnes rojas y procesadas)

Alimentos ultraprocesados (como donas, papas fritas, etc.)

Efectos perjudiciales:

Mayor producción de especies reactivas de oxígeno (ROS), que favorecen procesos inflamatorios y autoinmunes

Exposición a nitritos en los ultraprocesados, lo que también estimula el estrés oxidativo

Estos efectos contribuyen a favorecer la autoinmunidad tiroidea, deteriorando la homeostasis redox y promoviendo una disfunción inmune.

Conclusión

Gracias a sus componentes nutricionales, la dieta mediterránea influye positivamente sobre la microbiota intestinal, el equilibrio redox y el sistema inmune, lo cual podría convertirla en una herramienta eficaz dentro de un enfoque de nutrición de precisión para la prevención y el manejo de trastornos autoinmunes tiroideos.

publicado en la revista Nutrients en 2023, analiza la influencia de la dieta mediterránea en los trastornos autoinmunes tiroideos (TAT), como la tiroiditis de Hashimoto y la enfermedad de Graves.

Principales hallazgos

1. Efectos beneficiosos de la dieta mediterránea (DM):

Estos componentes ayudan a mantener la homeostasis redox, modulan el sistema inmunológico y favorecen una microbiota intestinal saludable, lo que puede reducir la inflamación y la autoinmunidad tiroidea.

2. Comparación con la dieta occidental (DO):

La DO, caracterizada por un alto consumo de grasas saturadas, azúcares refinados y alimentos ultraprocesados, se asocia con un aumento del estrés oxidativo, disbiosis intestinal y una respuesta inflamatoria crónica, factores que pueden contribuir al desarrollo de TAT.

3. Enfoque de nutrición de precisión:

Conclusión

Para más detalles, puedes consultar el artículo completo en el siguiente enlace: https://www.mdpi.com/2072-6643/15/18/3953.

Comparación de Potencia Aérea: China vs. EE.UU. contra Rusia

Comparación de Potencia Aérea: China vs. EE.UU. contra rusia

Análisis aeronáutico, militar y geopolítico global

Autor: DrRamonReyesMD

Introducción

La supremacía aérea sigue siendo un pilar fundamental del poder militar en el siglo XXI. Sin control del espacio aéreo, ninguna nación puede proyectar fuerza de manera efectiva, garantizar superioridad táctica o defender sus intereses estratégicos. En el cuadro presentado, se comparan las capacidades aéreas de tres de las principales potencias mundiales: China, Estados Unidos y Rusia. Sin embargo, más allá del número bruto de aeronaves, es esencial analizar la calidad tecnológica, capacidad de proyección global, interoperabilidad, sostenibilidad logística y redes de alianzas. En todos estos aspectos, Estados Unidos se mantiene como la potencia aérea dominante del planeta.

1. Comparación cuantitativa de aeronaves (2024)

2. El número importa, pero la calidad marca la diferencia

La abrumadora superioridad numérica de Estados Unidos no solo se traduce en mayor cantidad de plataformas, sino en mayor diversidad, interoperabilidad y especialización. La letalidad tecnológica estadounidense está impulsada por sistemas avanzados como:

F-22 Raptor y F-35 Lightning II: cazas furtivos de quinta generación con capacidad de penetración en entornos A2/AD.

B-2 Spirit y B-21 Raider: bombarderos estratégicos furtivos con capacidad nuclear y convencional global.

AWACS E-3 Sentry, JSTARS, Rivet Joint: plataformas de inteligencia, vigilancia y control sin equivalente en otras naciones.

Reabastecimiento en vuelo: con más de 600 aviones cisterna, EE.UU. UU. puede mantener operaciones aéreas en cualquier lugar del planeta.

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3. Proyección global: la geografía como ventaja

La capacidad operativa de la Fuerza Aérea de Estados Unidos no está limitada por fronteras nacionales gracias a su presencia estratégica global:

Clave de distribución geográfica:

Europa: Alemania, Reino Unido, Italia, España, Polonia

Asia-Pacífico: Japón, Corea del Sur, Guam, Filipinas

Oriente Medio: Catar, Emiratos Árabes Unidos, Bahréin, Kuwait

América: bases continentales, Alaska y múltiples bases aéreas de reserva

Esta red permite proyección inmediata de poder, despliegue de fuerzas rápidas y acceso a múltiples teatros operativos sin necesidad de sobreextender la logística.

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4. Poder naval y movilidad aérea: los portaviones

Estados Unidos opera 11 portaaviones de propulsión nuclear clase Nimitz y Ford, cada uno con:

Hasta 90 aviones embarcados

Autonomía operativa de más de 25 años sin repostar

Capacidad de operación F-35C, EA-18G Growler, E-2D Hawkeye y helicópteros MH-60

Esta flota permite que Estados Unidos lleve su fuerza aérea a cualquier océano, sin necesidad de acuerdos territoriales o bases terrestres. Ningún otro país posee esta capacidad expedicionaria.

Por el contrario:

China tiene 3 portaviones (Liaoning, Shandong, Fujian), pero ninguna es nuclear ni tiene catapultas electromagnéticas (CATOBAR operativas).

Rusia posee un único portaaviones (Almirante Kuznetsov), obsoleto y fuera de servicio desde 2017 por Múltiples fallos.

---

5. Redes de alianzas: multiplicadores de poder

OTAN: La alianza liderada por EE.UU. UU. Incluye 31 países, la mayoría con fuerzas aéreas modernas interoperables. A esto se suman:

AWACS compartidos

Entrenamiento conjunto

Sistemas integrados de defensa aérea

Planificación estratégica conjunta

Otros aliados globales:

Japón, Corea del Sur, Australia, Israel, Arabia Saudita, Colombia, Filipinas, entre otros

Estas alianzas aseguran que EE.UU. UU. no opere en aislamiento, sino como el núcleo de una red global de defensa colectiva, lo cual amplifica exponencialmente su poder aéreo total.

---

6. Limitaciones de China y Rusia

Porcelana:

Alta tasa de producción, pero limitaciones tecnológicas en motores y radares AESA.

Cazas como el J-20 aún no son plenamente comparables al F-22 en capacidades furtivas o sensoriales.

Déficit crítico en reabastecimiento en vuelo y mando aerotransportado (AWACS).

Rusia:

Su fuerza aérea heredada de la URSS envejece aceleradamente.

Problemas logísticos, falta de modernización y pérdidas significativas en conflictos recientes (Ucrania 2022-2024).

Dependen de armamento de precisión limitada, sin capacidades de guerra en rojo equivalentes a las estadounidenses.

7. Conclusión

Si bien China y Rusia poseen capacidades aéreas relevantes a nivel regional, Estados Unidos es, incuestionablemente, la primera potencia aérea global, no solo por cantidad, sino por:

Calidad tecnológica

Red de alianzas estratégicas

Infraestructura logística y global

Capacidad de movilidad aérea a través de su flota de portaviones

Doctrina de interoperabilidad en tiempo real con aliados OTAN y no OTAN

En cualquier escenario bélico moderno, la superioridad aérea estadounidense no radica únicamente en su poder destructivo, sino en su capacidad de intervenir, sostener y dominar múltiples teatros operacionales simultáneamente, algo que ningún otro país —ni combinado— puede replicar hoy.

Control de Sangrados. STOP THE BLEED BCon

5 MITOS SOBRE EL USO DE TORNIQUETES English/Español Control for the Injured Course "Stop The Bleed" / Control de Sangrados para el Herido

TORNIQUETE TQ DE EXTREMIDAD TIE (TOURNIQUET IN EMERGENCY). Antiguo Torniquete Compresor de Emergencias Ejercito Español "TORNIQUETE DE EXTREMIDAD ADRCE" . Video Estudio del torniquete de dotación del Ejército de Tierra Overview of the tourniquets used by the Army by Valentín González Alonso  emssolutionsint.blogspot.com/2017/01/torniquete-compresor-de-emergencias.html

UnicGuias, Directrices y Protocolos validados cientificamente y endosados en base a medicina basada en evidencias al dia 11 Septiembre del 2018; STOP THE BLEED-Comite de Trauma Colegio Americano de Cirujanos y consenso de Hartford, CTECC, CoTCCC y DoD, TCC-LEFR Dr. Peter Pons, PHTLS, ATLS y los 8 ERRORES en el Control de Sangrados del Dr. Peter Pons, FACEP

Improvisación de un Torniquete TQ como último recurso ante hemorragia masiva de extremidades y sin recursos by CoTCCC.
https://youtu.be/0T0TO-DMTfI

Demostracion by #DrRamonReyesMD https://emssolutionsint.blogspot.com/2022/05/improvisacion-de-un-torniquete-tq-como.html #TQ #Tourniquet #Torniquete #TCCC #CoTCCC #Hemorragia #BleedingControl

Control de Sangrados España. STOPTHEBLEED BCon Basic by TACMED España

emssolutionsint.blogspot.com/2016/07/the-hartford-consensus-iv-compendium.html

Tirador Activo: STOP THE BLEED "StopTheBleed" CONTROL DE SANGRADOS. Bleeding Control Basic. ESPAÑOL

emssolutionsint.blogspot.com/2017/07/stop-bleed-bleeding-control-basic.html

8 trampas "ERRORES" a evitar en el control de hemorragia by Dr. Peter Pons, MD FACEP

emssolutionsint.blogspot.com/2018/09/8-trampas-errores-evitar-en-el-control.html

Tactical Medics vs Rescue Task Force

http://emssolutionsint.blogspot.com/2018/03/tactical-medics-vs-rescue-task-force.html

GUIA DE SOPORTE VITAL PARA SEGURIDAD PRIVADA COMO PRIMER INTERVINIENTE EN INCIDENTES ARMADOS. by Juan Jose Pajuelo Castro y David Grevillen Carretero. SEMES 2018

http://emssolutionsint.blogspot.com.es/2018/02/guia-de-soporte-vital-para-seguridad.html

PROTOCOLO PARA INTERVENCIONES DE SOPORTE VITAL EN INCIDENTES DE MÚLTIPLES VÍCTIMAS POR ATENTADOS TERRORISTAS ABRIL 2016 (Actualizado Marzo 2018) by Juan Jose Pajuelo

http://emssolutionsint.blogspot.com.es/2018/03/protocolo-para-intervenciones-de.html

8 trampas a evitar en el controlhemorragias

http://emssolutionsint.blogspot.com.es/2018/02/8-pitfalls-to-avoid-in-hemorrhage.html

Guia de Soporte en Incidentes con Amenaza para Primer Interviniente Policial by Juan Jose Pajuelo Castro emssolutionsint.blogspot.com/2018/07/guia-de-soporte-en-incidentes-con.html

TACTICAL COMBAT CASUALTY CARE Handbook version 5 May 2017 emssolutionsint.blogspot.com/2017/07/tactical-combat-casualty-care-handbook.html

Updated TCCC Guidelines (31 JAN 2017) "Actualizacion 2017 de las Guias" Tactical Combat Casualty Care emssolutionsint.blogspot.com/2012/07/presentacion-del-programa-phtls-tccc.html

TCCC TACTICAL COMBAT CASUALTY CARE Quick Reference Guide First Edition 2017 FREE PDF emssolutionsint.blogspot.com/2018/07/tccc-tactical-combat-casualty-care.html

Updated TCCC Guidelines (31 JAN 2017) "Actualizacion 2017 de las Guias" Tactical Combat Casualty Care emssolutionsint.blogspot.com.es/2012/07/presentacion-del-programa-phtls-tccc.html

MANUAL DE SOPORTE VITAL AVANZADO EN COMBATE Ministerio de Defensa España 2014 http://emssolutionsint.blogspot.com.es/2016/02/manual-de-soporte-vital-avanzado-en.html

COMTOMS TACTICAL MEDIC HANDBOOK 2013 Edition

http://emssolutionsint.blogspot.com/2018/02/tactical-medic-handbook-2013-edition.html

Guías para el Manejo de Heridos en Incidentes Intencionados con Múltiples Víctimas y Tiradores Activo "MACTAC" emssolutionsint.blogspot.com/2016/12/guias-para-el-manejo-de-heridos-en.html

Manejo de Heridos en Incidentes Intencionados Múltiples Víctimas y Tiradores Activos 09/07/2017 emssolutionsint.blogspot.com/2018/07/manejo-de-heridos-en-incidentes.html

TERRORISMO Y SALUD PÚBLICA - "GESTIÓN SANITARIA DE ATENTADOS TERRORISTAS POR BOMBA"  emssolutionsint.blogspot.com/2013/08/terrorismo-y-salud-publica-gestion.html

TRAUMA DE TORAX: DOCENA DE LA MUERTE en trauma toracico
https://emssolutionsint.blogspot.com.es/2013/01/penetrating-chest-trauma-photo-trauma.html

75th Ranger Regiment Trauma Management Team (Tactical) Ranger Medic Handbook FREE pdf  emssolutionsint.blogspot.com.es/2018/02/75th-ranger-regiment-trauma-management.html

SPECIAL OPERATIONS FORCES Medical Handbook Free PDF  emssolutionsint.blogspot.com/2018/02/special-operations-forces-medical.html

Balística de las heridas: introducción para los profesionales de la salud, del derecho, de las ciencias forenses, de las fuerzas armadas y de las fuerzas encargadas de hacer cumplir la ley http://emssolutionsint.blogspot.com/2017/04/balistica-de-las-heridas-introduccion.html

Guía para el manejo médico-quirúrgico de heridos en situación de conflicto armado by CICR http://emssolutionsint.blogspot.com/2017/09/guia-para-el-manejo-medico-quirurgico.html

CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan CICR http://emssolutionsint.blogspot.com.es/2013/01/cirugia-de-guerra-trabajar-con-recursos.html

Manual Suturas, Ligaduras, Nudos y Drenajes. Hospital Donostia, Pais Vasco. España http://emssolutionsint.blogspot.com/2017/09/manual-suturas-ligaduras-nudos-y.html

Manual CIERRE DE HERIDAS by ETHICON http://emssolutionsint.blogspot.com/2017/09/manual-cierre-de-heridas-by-ethicon.html

Manual de suturas. Menarini http://emssolutionsint.blogspot.com/2017/09/manual-de-suturas-menarini.html

Técnicas de Suturas para Enfermería ASEPEYO y 7 tipos de suturas que tienen que conocer estudiantes de medicina http://emssolutionsint.blogspot.com/2015/01/tecnicas-de-suturas-para-enfermeria.html

Cuaderno Enfermero.Cirugia Menor Heridas Suturas http://emssolutionsint.blogspot.com/2016/07/cuaderno-enfermerocirugia-menor-heridas.html

Manual Práctico de Cirugía Menor. Grupo de Cirugia Menor y Dermatologia. Societat Valenciana de Medicina Familiar i Comunitaria http://emssolutionsint.blogspot.com/2013/09/manual-practico-de-cirugia-menor.html

Protocolo de Atencion para Cirugia. Ministerio de Salud Publica Rep. Dominicana. Marzo 2016 http://emssolutionsint.blogspot.com/2016/09/protocolo-de-atencion-para-cirugia.html

Manual de esterilización para centros de salud. Organización Panamericana de la Salud http://emssolutionsint.blogspot.com/2016/07/manual-de-esterilizacion-para-centros.html

Asistencia de salud en peligro: la importancia de proteger al personal de salud en zonas de guerra PDF Gratis http://emssolutionsint.blogspot.com/2018/06/asistencia-de-salud-en-peligro-la.html

SERVICIOS PREHOSPITALARIOS Y DE AMBULANCIAS EN SITUACIONES DE RIESGO. PDF GRATIS http://emssolutionsint.blogspot.com/2018/06/servicios-prehospitalarios-y-de.html

PDF Update on Prehospital Trauma Courses, NAEMT, Alex Eastman, Lieutenant and Deputy Medical Director, City of Dallas http://emssolutionsint.blogspot.com.es/2016/12/phtls-prehospital-trauma-life-support.html

Tactical Emergency Casualty Care (TECC) Guidelines for First Responders with a Duty to Act Guías para Primeros Respondedores con Deber de Actuar “En Acto de Servicio” (Fuerzas de Seguridad, Bomberos no SEM) emssolutionsint.blogspot.com/2018/07/tactical-emergency-casualty-care-tecc.html

PAGINA FCEBOOK

https://www.facebook.com/TACMEDEspana/

TACMED Spain Medicina Tactica España GRUPO  https://www.facebook.com/groups/311284402300505/

Stop The Bleed Campaign - App Now Available

May 30, 2018

The Uniformed Services University/National Center for Disaster Medicine and Public Health Stop the Bleed app is now available. The app contains a 5-minute video, Q&A, a quiz, and other resources. Download the free app from Google and Apple iTunes.

https://play.google.com/store/apps/details?id=edu.usuhs.stb&rdid=edu.usuhs.stb

Ahi dejamos para los que se estan tomando el cafe de media mañana y para los que inician el dia del otro lado del charco,,, el #ChamanTacticoMD https://www.youtube.com/watch?v=R4UBk6mtwzI&feature=youtu.be ver detenidamente,,, datos importantes...

Lo único más trágico que una muerte ... Es una muerte que pudo haberse evitado ...

#StopTheBleed

TORNIQUETE DE EXTREMIDAD TIE (TOURNIQUET IN EMERGENCY). Antiguo Torniquete Compresor de Emergencias Ejercito Español "TORNIQUETE DE EXTREMIDAD ADRCE" . Video Estudio del torniquete de dotación del Ejército de Tierra Overview of the tourniquets used by the Army by Valentín González Alonso

by Dr. Ramon Reyes, MD

Informacion en el enlace http://emssolutionsint.blogspot.com.es/2017/01/torniquete-compresor-de-emergencias.html

¿Cómo sobrevivir a un tiroteo en la escuela u oficina? Preparación Contra Tiradores Activos. PREVENCIÓN ATAQUES CON VEHÍCULOS Video

http://emssolutionsint.blogspot.ae/2016/06/como-sobrevivir-un-tiroteo-en-la.html

http://emssolutionsint.blogspot.ae/2017/07/stop-bleed-bleeding-control-basic.html

"StopTheBleed". Tirador Activo: STOP THE BLEED "StopTheBleed" CONTROL DE SANGRADOS. Bleeding Control Basic. ESPAÑOL

http://emssolutionsint.blogspot.ae/2016/07/the-hartford-consensus-iv-compendium.html

Control de Sangrados España. STOPTHEBLEED BCon Basic by TACMED España

Que copien el BCon y cobren 100 Euros, tonto el que paga... by Dr. Ramon Reyes, MD

Hartford Consensus IV by TACMED España

Post by Dr. Ramon REYES, MD

Ep. 1: Cómo sobrevivir a un tiroteo activo http://www.eccpodcast.com/como-sobrevivir-a-un-tiroteo-activo/ via @eccpodcast

El aumento en eventos denominados como tiroteo, o tirador activo (“active shooter”) ha demostrado que los protocolos de las agencias de respuesta a emergencias tienen que ser actualizados.

Un tirador activo es una persona que está determinada a tratar de matar a una o varias personas en un lugar cerrado, o concurrido, mediante el uso de un arma de fuego. En la mayoría de las ocasiones, las víctimas de los tiradores activos ocurren al azar. Simplemente coincidieron en el mismo lugar y a la misma hora. Esta definición contrasta con un secuestrador, quien podría estar interesado en obtener algo a cambio de las víctimas. La mayoría de los tiradores activos cargan suficientes municiones para poder atacar a múltiples víctimas, por lo que mientras más tiempo se tarde en neutralizarlo, mayor será la posibilidad de víctimas. Por esta razón, los procedimientos de las agencias de ley y orden a lo largo de la nación se están viendo modificados para adiestrar y equipar a los primeros respondedores a neutralizar al agresor, en ocasiones mucho antes de que lleguen unidades especializadas (tales como unidades SWAT, entre otras).

Hartford Consensus

El Comité Conjunto para Crear la Política Nacional para Aumentar la Sobrevivencia a Incidentes de Tiroteo con Víctimas en Masa fue iniciado por el Colegio Americano de Cirujanos en un esfuerzo para asegurar que las víctimas reciban el cuidado expedito que necesitan. El Comité incluye representantes del sector de seguridad pública, incluyendo salud, el FBI, agencias de ley y orden, bomberos, cuidado médico prehospitalario, centros de trauma, y el ejército. Se reunieron en Hartford, Connecticut en abril del 2013, julio del 2013 y en abril 2014, publicando en la revista del Colegio Americano de Cirujanos sus conclusiones denominadas el Hartford Consensus, Hartford Consensus II y el Hartford Consensus III.

El curso Tactical Emergency Casualty Care (TECC) enseña a los primeros respondedores a atender a las víctimas de un incidente que todavía no ha sido declarada segura por las fuerzas de ley y orden.

Todos Nuestros VIDEOS en YouTube https://www.youtube.com/c/RamonReyes2015 

Grupo en TELEGRAM Sociedad Iberoamericana de Emergencias
https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA 

Control de Sangrados España. STOPTHEBLEED BCon Basic by TACMED España

DR. RAMON REYES, MD

Enlace Directo al Programa

Bleeding Control Basic by American College of Surgeons

¿Quienes son elegibles para dictar el Bleeding Control Basic?     Eligible Instructors for the BCon Course include:

•         Any EMR, First Responder, EMT (o su homologo), Paramedic (o su homologo) , RN (Enfermeros Profesioanles), Certified Athletic Trainer, PA, NP, Medical Student, or MD/DO who has successfully completed the BCon Basic Course

•         Any PHTLS instructor who has successfully completed the BCon Basic Course

•         Any TCCC/TECC instructor who has successfully completed the BCon Basic Course

•         Any ATCN/TNCC instructor who has successfully completed the BCon Basic Course

•         Any ATLS instructor who has successfully completed the BCon Basic Course

•         Any NAEMT instructor who has successfully completed the BCon Basic Course

http://emssolutionsint.blogspot.com.es/2016/07/the-hartford-consensus-iv-compendium.html

Control de Sangrados España. STOPTHEBLEED BCon Basic by TECC España

Control de Sangrados España. STOPTHEBLEED BCon Basic by TACMED España

El instructor Félix Carmona pone el dedo en la llaga y nos habla de una costumbre que nuestras FCS y FCSE deben adoptar: el material sanitario policial.

GUIA DE SOPORTE VITAL EN INCIDENTES CON AMENAZA ELEVADA PARA PRIMER INTERVINIENTE POLICIAL by Juan Jose Pajuelo. España 2017

Descargate la guia: Guía para Primer Interviniente Policial

El objetivo de estas Guías no es otro que resumir de manera breve y concisa los pasos ideales (en ocasiones lo ideal no es lo real) para una valoración y manejo iniciales de las principales causa de muerte evitable, hasta la llegada de los Servicios de Emergencia, en los compañeros o ciudadanos heridos.

Se pretende que estas Guías aborden la asistencia inicial, en el contexto de una intervención o incidente donde exista un alto nivel de amenaza, en el que se vean involucrados los “policías de a pie”, puesto que ha quedado demostrado que son los primeros (y en ocasiones los únicos) en abordar inicialmente tanto al incidente en sí mismo, como a las víctimas si se han producido.

Un incidente con alto nivel de amenaza no se limita a sucesos como atentados terroristas con múltiples víctimas, si no que contempla también otro tipo de circunstancias como incidentes con individuos armados y/o, aglomeraciones populares con individuos violentos.

Toman como referencia las Directrices para Primeros Intervinientes con la Obligación de Asistir (First Responders with a Duty to Act) del Comité del Tactical Emergency Casualty Care que, al igual que estas Guías, son meras recomendaciones y no protocolos rígidos que deben adaptarse a la legislación vigente y, a las especificidades de cada Institución/Servicio/Organismo.

Con independencia de lo mencionado anteriormente, tienen como objetivo final estandarizar un lenguaje y unas actuaciones a nivel nacional dado que, están basadas en la evidencia científica “in vivo” y, en las lecciones aprendidas de muchos profesionales nacionales e internacionales. Estas recomendaciones/guías, no sustituirán el buen juicio clínico.

Por lo tanto, se espera que las recomendaciones que se presentan a continuación sirvan de ayuda para todo aquél personal policial que se pueda ver involucrado en un incidente con un nivel de amenaza elevado, a la hora de enfrentarse al manejo de las principales causas de muerte evitable que se producen en actuaciones con un alto nivel de amenaza.

GUIA PARA LE MANEJO DE HERIDOS EN INCIDENTES

INTENCIONADOS CON MULTIPLES VICTIMAS Y TIRADORES ACTIVOS

GUIA M.A.C.T.A.C. Actualizacion 2017

Tamaño del archivo en PDF Gratis

2.34 MB

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Enlace para bajar PDF

Este obra cuyo autor es JUAN JOSE PAJUELO CASTRO Y JOSE CARLOS MENESES PARDO está bajo una licencia de Reconocimiento-NoComercial-SinObraDerivada 4.0 Internacional de Creative Commons.

Viendo lo que está sucediendo en estos países más avanzados, podemos hacernos una idea de lo que nos podremos encontrar en Europa en unos años. Por eso, no es raro ver en el cinturón de un agente de policía americano, un torniquete o un kit de primeros auxilios, para heridas de armas de fuego, en el chaleco antibalas interior.

En la actualidad existen cursos para el uso y manejo de estos materiales. Yo hice el año pasado el curso LEFR-TCC (Law Enforcement and First Response Tactical Casualty Care), el cual recomiendo a todo el mundo. En este curso se adquieren las nociones necesarias para el uso y aplicación de los materiales que se exponen en este artículo.

Es un curso que no deja a nadie indiferente, además de dar un punto de vista nuevo y totalmente distinto de lo que es un enfrentamiento armado, en el cual puedes resultar herido de bala, cosa que la mayoría de las veces no lo tenemos en cuenta. Por supuesto, quien lo imparte es un profesional del ejército español, altamente cualificado, con misiones de rescate en zona de conflicto a sus espaldas y llegando a ser, junto a su equipo, los terceros del mundo en el uso y aplicación de estos materiales y extracción de heridos. Creo que decir que es un gran profesional con mucha experiencia, es quedarse corto.

El primer beneficiario del uso de este material vas a ser tú, luego tu compañero y, por último, la ciudadanía. No se puede descartar que, estando de servicio, te llamen a una urgencia por alguien que se está desangrando o algo parecido. Puede pasar.

Pasemos a describir los materiales y usos para los cuales están diseñados:

1) TORNIQUETES

Unos de los medios más usados con heridas hemorrágicas graves es un torniquete. La hemorragia es la causa más importante de muerte en combate. Una bala puede seccionar una arteria y el hecho de morir desangrado es cuestión de minutos, por no decir de segundos.

Se recomienda aplicarlo en la parte superior de las extremidades, ya que existe un solo hueso y la artería deja de sangrar haciendo presión contra él. Se puede cortar una 80% de hemorragia apretando fuertemente el torniquete y el resto con la barra de presión.

Existen varios tipos de torniquetes, unos son más rápidos, otros son sofisticados, pero el consejo que doy es que, a la hora de comprar uno, hay que decantarse por los que hayan sido probados en combate y con éxito. Por lo tanto, sería muy útil ver qué llevan los norteamericanos en su dotación, ya que están presentes en conflictos armados. Seguro que el material es fiable y lo han usado alguna vez con buenos resultados.

Los torniquetes que suelen llevar las tropas son el CAT (Combat Application Tourniquet) y el SOFT Tourniquet (Special Operations Forces Tourniquet):

SAM® XT TOURNIQUET

El torniquete CAT está hecho de materiales ligeros y resistentes, lo que permite contener la hemorragia de la extremidad dañada sin problemas. Según tengo entendido, la marca que lo fabrica asegura sólo un uso del mismo. Además, éste es del que más copias chinas hay extendido. Si un torniquete no te cuesta más de 25 o 28 euros en adelante, no te fíes. Ten cuidado con las copias baratas. Te puede costar la vida.
El torniquete SOFT se encuentra realizado según los consejos de las Fuerzas de Operaciones Especiales Norteamericanas, las cuales querían un torniquete robusto y reutilizable. Por ello, la barra que posee para girar y apretar la cinta de contención de la hemorragia es de aluminio, por lo que el conjunto en sí pesa algo más que el torniquete CAT. Además, es mucho más fácil de colocar a otra persona, gracias a su clip de apertura. Aunque sea reutilizable, sería conveniente no darle más de un uso, por si acaso.

Si tuviera que decidir con cual de los dos me quedo, elegiría el SOFT, pero cada uno puede elegir el que más le convenga.

2) GASA DE COMBATE

La gasa de combate o “Combat Gauze” es un material “hemostático”: esto significa que sirve para parar una hemorragia. Este material ha sido probado por el Instituto del Ejército de los Estados Unidos para la Investigación Quirúrgica (USAISR), el Centro Naval de Investigación Médica (NMRC) y el Comité de Cuidados de los Heridos en Entornos Tácticos y de Combate (TACC).

Este material está de dotación en el Ejército de los Estados Unidos, la Marina, la Fuerza Aérea, el Cuerpo de Marines y los Guardacostas. Creo que el hecho de que lo lleve este gente ya es sinónimo de garantía y fiabilidad. El producto se compone de una gasa que va impregnada en un agente hemostático llamado “caolín”. Es un mineral inorgánico natural derivado de la arcilla. No tiene reacciones alérgicas y tampoco reacciones exotérmicas (que produzcan quemazón o irritaciones en la herida).

Se caracteriza por tener una banda azulada en toda la venda. Esta banda es “radiológica”, es decir, se puede ver en una radiografía. Esto facilita su localización, en caso de que se olvide algún trozo en el cuerpo.
Si la herida no sangra abundantemente, se puede usar en vez del torniquete. Lo malo es que es muy “invasiva” (hay que meterla con los dedos en el interior de la herida) y eso debe ser muy doloroso, aunque si la vida está en juego, es un mal menor.
El mejor uso que se le puede dar es en las heridas de unión de partes del cuerpo (axilas, ingles y cuello), ya que en esos sitios no se puede colocar un torniquete. A la hora de introducir el vendaje en la herida, se debe hacer de dentro hacia fuera y, conforme vamos subiendo, de derecha a izquierda. Así no nos dejaremos ningún hueco sin tapar. Luego, cuando ya tengamos la herida “empaquetada”, la presionaremos (más o menos durante 5 minutos) para contener la hemorragia.
Por supuesto, hay mucho material de este tipo de otras marcas, como puede ser el ChitoGauze o el Celox Rapid Gauze, que realizan la misma función.

3) CELOX

Este nombre corresponde a una marca comercial y es con la cual nos referimos al hemostático que viene en gránulos. Por supuesto, está de dotación en el Ejército Norteamericano y en muchos ejércitos de la OTAN, lo cual da fe de su extendido uso. También puede ser adquirido por particulares para ir a la montaña, deportes de riesgo, ir en bici por el monte o, simplemente, por seguridad. Nunca se sabe.

Funciona de la siguiente manera: los gránulos tienen un compuesto hemostático que cuando entra en contacto con la sangre, se hinchan y se convierten en una especie de gel, pegándose y haciendo que se coagule la que toma contacto con el gránulo, parando la hemorragia. Tengo entendido que se quita fácilmente al lavar la herida con agua.
La forma de usarlo es echar los gránulos en la herida abierta y presionar con una gasa durante unos minutos. Así pararemos la hemorragia. Se sirve en paquetes de 15 y 35 gramos, siendo el paquete más grande la mejor relación calidad-precio.
Lo malo de este granulado es que, cuando hay mucho viento, no se puede aplicar correctamente. Para ello existe otro producto de la misma marca que permite verter el contenido en el interior de la herida. Se llama “Celox A”.
Es como una especie de jeringuilla llena de este gránulo, pero hay que meterlo en el interior de la herida, con lo que debe doler una barbaridad, pero en esos momentos, ya se sabe.

4) PARCHE TORÁCICO

El parche torácico es, básicamente, un adhesivo que pegamos en el pecho cuando tenemos una herida penetrante que afecta a pulmones y pleura, bien sea por una herida de bala o de una puñalada. Este tipo de parche evita que, cuando inspiramos, se introduzca aire por la herida. Con esto, lo que se consigue es evitar que los pulmones se colapsen por efecto de la descompresión, asegurando la estabilidad del herido y dándole a éste un tiempo suficiente como para que lleguen los servicios de urgencia. Con este parche, lo que se pretende es evitar lo que se llama “neumotórax a tensión”.

Según la web www.msdmanuals.com, la descripción de un neumotórax es la siguiente: “En un neumotórax ordinario, la lesión del pulmón permite que cierta cantidad de aire penetre en el espacio existente entre el pulmón y la pared torácica (espacio pleural). Típicamente, el aire deja de acumularse. Sin embargo, en el neumotórax a tensión, el aire continúa entrando en el espacio pleural conforme el paciente respira, con lo que aumenta la presión en el interior del tórax. El aumento de la presión reduce la cantidad de sangre que regresa al corazón debido a que la sangre no puede forzar su regreso al corazón según circula por el tórax. Como resultado, el corazón tiene menos sangre para bombear, lo que ocasiona un shock. (...) Un neumotórax a tensión puede causar la muerte de forma rápida.” Creo que queda claro lo que podemos evitar si llevamos un parche de este tipo con nosotros.

Existen de varios tipos:

El básico solamente es un adhesivo que se pone sobre la herida. Con éste hay que vigilar al herido por si se agobia y hay que despegárselo un poco durante unos segundos, volviéndoselo a poner bien, rápidamente.
Hay otros modelos que tienen una especie de canales o válvulas que permiten la salida del aire durante la exhalación, pero impide su entrada en la inspiración. Se suelen vender en pack de 2 parches, pero también existen paquetes individuales. El pack de 2 parches está bien, por si existe orificio de entrada y salida.

Cada parche suele llevar una pequeña venda que se usa para limpiar un poco la herida antes de ponerlo. El modo de uso es muy sencillo: se limpia la herida y se pone el centro del parche sobre ella. El adhesivo es de muy buena calidad y se pega sobre la piel, aunque tenga mucho pelo o esté sudada.

A mí, el que más me gusta es el “Hyfin Vent Chest”, hecho por North American Rescue y que posee 3 canales para su mejor funcionamiento. Pero existen más marcas y modelos, para que todo el mundo elija el que más le convenga, como son el “Foxseal” de Celox, el “Halo” de PMI, etc.

5) VENDAJES

Los vendajes más comunes para heridas, suelen tener el tamaño estándar de 4 o 6 pulgadas de ancho. Ambos se pueden usar para cualquier parte del cuerpo pero, lógicamente, el tamaño menor se usaría para heridas pequeñas y el tamaño mayor para heridas más grandes o con mayor longitud.

Suelen venir en paquetes termosellados de plástico opaco grueso y al vacío, lo que le da mayor protección y durabilidad. Tienen fecha de caducidad y suele ser de unos 4 o 5 años.

Todos son vendajes elásticos y, al final de la venda, contienen un enganche de plástico para fijar el extremo final a la misma, lo que evita la necesidad de tener que llevar esparadrapo o algo para impedir que se desate. Estos paquetes vienen con instrucciones y con unos cortes predeterminados en las cuatro esquinas, cosa que facilita la apertura del paquete sin necesidad de estar buscando un único corte de apertura. Al principio de la venda hay un apósito que no se adhiere a la herida, lo que permite retirarlo con facilidad y sin crear más daños.

En vendajes, una de las marcas es North American Rescue. Posee una venda elástica que tiene unas pequeñas bandas internas de velcro, las cuales facilitan la adherencia para evitar que se destense. Si queremos hacer presión sobre la herida con esta venda, lo que tenemos que hacer es, después de haber dado 2 o 3 vueltas al vendaje, la giramos 180 grados, para crear una especie de “nudo” y, así, con éste hacer presión sobre la herida. Seguidamente, continuamos vendando hasta terminar.

Otro tipo de vendaje es el comúnmente llamado “Vendaje Israelí”. Es el que más me gusta, ya que tiene varios modelos y es más fácil de encontrar. También es elástico y posee un enganche al final de la venda. Se caracteriza por tener una pieza de plástico, con la cual se puede generar bastante presión sobre la herida, lo que facilitará el corte del sangrado.

Hay modelos que poseen un apósito fijo y otro móvil, que son muy útiles para heridas con orificio de entrada y salida. Si tenemos ese modelo, podemos retirar el apósito móvil y usarlo como gasa extra, lo que puede venirnos muy bien en algún momento.

6) HERRAMIENTA MULTIUSO

Este es un utensilio que puede servir para cortar cinturones de seguridad de cualquier vehículo, para cortar calzado grueso y, por supuesto, ropa. Esto va bien porque, muchas veces, no se puede ver de donde viene la sangre y, por lo tanto, se desconoce la situación exacta de la herida. Despejando la zona de ropa, podremos encontrar la herida o heridas, ya que puede que haya más y no nos demos cuenta.

El utensilio debe estar construido de una manera que, a la hora de utilizarlo, no provoque heridas de ningún tipo a nadie. Por eso deberíamos desechar las típicas navajas, ya que, por accidente, podríamos herir a la persona o cortarnos nosotros mismos.
Algunos de estos cortadores llevan su propia funda que se puede acoplar al cinturón de servicio, lo cual es una ventaja, ya que siempre lo llevaremos encima. Existen de varios tipos y tamaños, por lo que nos da un abanico amplio para su elección. Muchos de ellos incorporan una punta, en el extremo opuesto, que permite romper cristales de vehículos. La marca Gerber parece ser la que mejor precio tiene.

Conclusión

Si quieres ver cómo se utilizan cada uno de los elementos que aquí se exponen, sólo tienen que ver los innumerables vídeos sobre ellos en “Youtube”. Pero, por supuesto, antes de nada, lo más sensato es hacer algún curso donde te enseñen cómo se deben usar todos estos materiales correctamente y el conocimiento necesario de ellos. Así adquirirás capacidades que te serán de mucha utilidad.
Es importante recibir formación y si no la recibes, búscala por tu cuenta. Puede que algún día lo agradezcas.

Ejemplo de un Sangrado Arterial con potencial de mortalidad y tratable con Torniquete si es en Extremidades y Empaquetamiento en caso de ser en una localizacion en donde no sea posible el torniquete

Ahora para dar Cursos de Control de Sangrados "BCon" debes de estar registrado en el Coelgio Americano de Cirujanos, por medio de su Comite de Trauma y el programa Stop the Bleed

In September of 2014, NAEMT announced a new education course to teach civilians evidence-based, life-saving bleeding control techniques shown to dramatically increase casualty survival.  Called “Bleeding Control for the Injured,” aka “B-Con,” this course was developed in response to the Hartford Consensus led by Dr. Lenworth Jacobs, and at the request of Dr. Norman McSwain, who served as a member of the Hartford Consensus working group.

B-Con teaches participants the basic life-saving medical interventions, including bleeding control with a tourniquet, bleeding control with gauze packs or topical hemostatic agents, and opening an airway to allow a casualty to breathe. The course is designed for NON tactical law enforcement officers, firefighters, security personnel, teachers and other civilians requiring this basic training. B-Con is consistent with the recommendations of the Hartford Consensus on Improving Survival from Active Shooter Events.

NAEMT partners on this and all other trauma initiatives with the American College of Surgeons (ACS).  Recently, ACS launched a new website, bleedingcontrol.org that includes a new instructor portal for the B-Con course.  This new portal houses all of the B-Con course materials, and will allow B-Con courses to be registered so that ACS and NAEMT can track our progress in training the public in basic bleeding control. There is no cost to use this portal, to access the course materials, or to register courses.

Es sin duda uno de los temas más controversiales del manejo inicial del trauma. La medicina militar nos entrega interesantes conclusiones.

La indicación de uso del torniquete ha sido el tema más controversial en el tratamiento de los primeros auxilios, pero el reciente uso de este dispositivo en la guerra ha tenido resultados muy favorables en términos de control de hemorragias y mayor sobrevivencia, con poco riesgos de morbilidad. El asunto más importante en referencia al uso del torniquete de emergencia es la decisión del cuándo usarlo. En otras palabras, ¿cuál es la indicación? Varios estudios ofrecen una mirada interna más allá de la experiencia clínica en la indicación de este dispositivo. En definitiva, los análisis han sido limitados.

Referente a esto, se ha completado un gran estudio clínico en un Hospital de Soporte al Combate en Baghdad, Iraq: “Análisis de las indicaciones para el uso del torniquete de emergencias” (1) Este inmenso trabajo de reporte, con nueva evidencia, nos permite tener una mirada fresca de este controversial dispositivo de primeros auxilios. Los proponentes del TCCC (Táctical Combat Casualty Care) abogan que la indicación de uso del torniquete es: “Cualquier herida en extremidad, que pudiese producir una hemorragia posiblemente letal”. De cualquier forma, no había existido ningún dato que evidenciara esta premisa. El propósito del estudio fue analizar las indicaciones del torniquete.

Métodos: Los datos sobre uso del torniquete de emergencia se analizaron a partir de un estudio clínico a gran escala (en ClinicalTrials.gov NCT00517166). Este estudio fue conducido bajo protocolo revisado y aprobado por un instituto del Ejército de los EEUU (Brooke Army Medical Center Institutional Review Board).

El estudio incluyó a 728 víctimas con 953 extremidades en las que se usó torniquetes. La edad promedio de las víctima fue de 26 años (con rango, 4-70).

Resultados: El uso del torniquete fue de 70% en el prehospitalario , 11% en el intrahospitalario y 18% en ambos.

Las lesiones en que se indicó torniquete, fueron de dos tipos: Anatómicas y Situacionales.

– Anatómicas: Las indicaciones anatómicas son lesiones de tejidos blandos con sangramiento de extremidades con riesgo vital, tales como: herida por arma de fuego con sección de arteria femoral, amputaciones, fracturas expuestas, etc. Definidas médicamente y que pueden ser confirmadas quirúrgicamente.

– Situacionales: son situaciones en las cuales se escogió el uso del torniquete como el mejor tratamiento, por otras razones que no fueron la herida misma. (por ej. en la fase de cuidados bajo fuego enemigo en el campo de batalla) y son definidas y determinadas por el rescatista.

Conclusión: El principal hallazgo de este estudio fue que es correcto utilizar como indicación para el uso del torniquete la frase: “Cualquier herida en extremidad, que pudiese producir una hemorragia posiblemente letal”.

Con este set de datos de indicaciones de uso del torniquete se llenó el vacío de conocimiento en referencia a la frecuencia de varias indicaciones.

Posteriormente se recibe información a través de un nuevo reporte publicado como “Sobrevivencia de heridos en combate con el uso del torniquete de emergencia para detener el sangrado de extremidades” (2) cuyo objetivo fue “analizar con mayor profundidad el uso del torniquete de emergencia en los cuidados de heridos en combate”. Este reporte es una continuación del estudio previo (NCT00517166 en ClinicalTrials.gov).

Métodos: Tras la verificación de las metodologías para el primer estudio y el siguiente, se compararon los resultados de estos dos períodos de tiempo. Luego se agruparon los datos para analizar los resultados con una muestra de mayor tamaño.

Resultados:
– La población total abarcada por el estudio fue de 499. En todos, 862 torniquetes fueron aplicados en 651 extremidades. La sobrevivencia fue de 87% para ambos periodos de estudio.

– Las tasas de parálisis a nivel del torniquete fue de 1,7% para el estudio 1 y 1,5% para el estudio 2.

– La sobrevida aumentó con el uso prehospitalario (89% vs 78% hospitalaria, p < 0.01) y la aplicación previa al desarrollo del shock.

Conclusión: Este segundo estudio demuestra beneficios consistentes y bajo riesgo en el uso de torniquetes para detener hemorragias masivas en trauma de extremidades.

Otro reporte (US Army ISR) hace referencia a que:

– El uso del torniquete, previo al estado de shock, estuvo fuertemente asociado con las vidas salvadas.

– No se perdieron extremidades debido al uso del torniquete

– La educación y puesta en servicio del torniquete en el ámbito militar, debe continuar.

Comentarios
Estas indicaciones han demostrado buenos resultados sólo cuando la formación ha sido específica y actualizada, se han utilizado los dispositivos adecuados y la evacuación ha sido rápida y oportuna.

Dispositivos adecuados
Un punto fundamental en el avance y evolución de los dispositivos adecuados,  ha sido la transición desde el improvisado cordón de zapato o venda enrollada con un “palito”  hasta el actual CAT (Combat Application Torniquet/ Torniquete de Aplicación en Combate).

Este es un dispositivo diseñado para uso militar, que ha revolucionado los cuidados médicos en el campo de batalla. Es muy liviano, de fácil aplicación e incluso posee la particularidad de poder ser utilizado por el mismo herido. Todas estas virtudes cobran vital importancia, y bien digo ???vital???, durante los enfrentamientos, donde una de las tres causas principales de muertes prevenibles es la hemorragia incontrolada (Las otras dos son neumotórax y obstrucción de la vía aérea).

Es tal la confianza que las Fuerzas Armadas han depositado en este instrumento, que se ha dispuesto que cada soldado desplegado en zona de combate, debe transportarlo en su equipo individual de Primeros Auxilios.

En los recientes conflictos en Iraq y Afghanistan, no solo personal militar lo ha utilizado.  Han sido incalculables los Operadores de Seguridad Privada (Private Security Contractors), que han logrado salvar sus vidas gracias al entrenamiento en el uso del CAT. Todos y cada uno de los integrantes de estos equipos transporta al menos 2 y es responsabilidad del Medic del equipo instruir a sus compañeros en el uso adecuado de este. Ha sido tal el interés y confianza depositado en el uso del torniquete, que incluso se han diseñado uniformes que lo traen incorporados, uno en cada extremidad, discretamente disimulados bajos unos pliegues adheridos con velcro.

Y finalmente debo mencionar que como todo avance médico en el terreno militar, rápidamente se traslada al área civil,  el CAT ya está siendo utilizado por varios Sistemas de Emergencias Médicas en los EEUU.

En el contexto actual de nuestras realidades sociales, donde estamos expuestos a catástrofes naturales o accidentes masivos, este elemento nos podría prestar una ayuda invaluable al momento de tratar múltiples heridos, donde la sola contención de una hemorragia nos puede entregar minutos valiosos para multiplicar nuestros esfuerzos en salvar la mayor cantidad de vidas posibles.

Tal vez es tiempo que empecemos a mirar con más respeto este dispositivo, ya que lo podríamos necesitar.

Referencias:

(1)  http://www.socom.mil/JSOMDocs/Winter%2011%20Vol%2011%20Ed%201.pdf

(2)  http://www.ncbi.nlm.nih.gov/pubmed/19106667

NCT00517166 AT ClinicalTrials.gov

STOP THE BLEED

Presentacion para Descarga. B-Con es GRATIS y se ha diseñado para que profesionales sanitarios puedan convertirse en multiplicadores, para asi reducir las muertes prevenibles por sangrados producidos por heridas exanguinantes, fue deseo del Dr. Norman McSwain que estos conocimientos quedaran libres, bajo la custudia cientifica del Colegio Americano de Cirujanos y ha sido desarrollado el contenido por el Dr. Peter Pons bajo los Protocolos y Sistemas de Educacion del PHTLS-NAEMT. http://emssolutionsint.blogspot.com.es/2016/07/the-hartford-consensus-iv-compendium.html

COMPARTIR CONOCIMIENTO
Compartimos gratuitamente http://emssolutionsint.blogspot.com/2017/02/bajar-presentaciones-y-material-curso-b.html

JORNADAS GRATUITAS DE REDUCCION DE MUERTES POR SANGRADO EN TRAUMA CURSOS B-CON BLEEDING CONTROL FOR THE INJURED

http://emssolutionsint.blogspot.com.es/2017/01/propuesta-jornada-de-reduccion-de.html
http://emssolutionsint.blogspot.com.es/2016/07/the-hartford-consensus-iv-compendium.html
#BCon #PHTLS #EMS #STOPTHEBLEED #TRAUMA

Dr. Ramon REYES MD probando torniquete RUSO de la Segunda Guerra Mundial, en Mali Africa
Mision Medico Encargado de TACEVAC para la Union Europea

Torniquetes la controversia

En la foto el Dr. Ramon Reyes Diaz y el Mayor Medico Cirujano Toracico y Cardiovascular Георги Кесов

del Ejercito Bulgaro, Director Medico de las Fuerzas Especiales Bulgaras. Mali-Africa Mayo 2016.

@drramonreyesdiaz

Guías para el Manejo de Heridos en Incidentes Intencionados con Múltiples Víctimas y Tiradores Activo

http://emssolutionsint.blogspot.com.es/.../guias-para-el...

Bleeding Control by American College of Surgeons and The Hartford Consensus IV

http://emssolutionsint.blogspot.com.es/.../the-hartford...

#STOPTHEBLEED #EMS #TCCC #PHTLS #ESPAÑA #EJERCITOESPAÑOL #TORNIQUETE #CAT #STAT #RAT #BCON #NAEMT #NATO #OTAN

#CoTCCC

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"STOP THE BLEED SAVE A LIFE" by TACMED España

The American College of Surgeons has a number of resources available on their BleedingControl.org website to help the public learn more about bleeding control and how to act in a situation that requires immediate responders.

Stop the Bleed Resources

Download Hartdford Consensus Compendium

Download poster 1

Visit BleedingControl.org for:

The Hartford Consensus IV: A Call for Increased National Resilience

by LENWORTH M. JACOBS, JR., MD, MPH, FACS; AND JOINT COMMITTEE TO CREATE A NATIONAL POLICY TO ENHANCE SURVIVABILITY FROM INTENTIONAL MASS CASUALTY SHOOTING EVENTS

PUBLISHED MARCH 1, 2016

New Website and Twitter Feed Target Bleeding Control

The American College of Surgeons (ACS) and the Hartford Consensus™have launched a new website, BleedingControl.org, that is designed to assist the public and first responders in the event of a mass casualty or other bleeding control emergency. The site contains easily understood diagrams, videos, and other resources that may be useful in responding quickly to these life-threatening events. As the site evolves, it is anticipated that it also will list bleeding control training courses offered under the auspices of the ACS Committee on Trauma. In addition to the ACS and the Hartford Consensus, the site has a number of notable partners, including the Department of Homeland Security, the Federal Emergency Management Agency, and the Federal Bureau of Investigation. To further the site’s reach, the College also has created a Twitter handle: @bleedingcontrol. Members of the College are urged to visit the new website and follow the Twitter feed to keep apprised of the growth of this initiative.

http://www.bleedingcontrol.org/

Download the full Compendium

Compressing the Zones of Care

The Hartford Consensus recommends that an integrated active shooter response should include the critical actions contained in the acronym THREAT:

Threat suppression

Hemorrhage control

Rapid Extrication to safety

Assessment by medical providers

Transport to definitive care

A key component of the Hartford Consensus is this:

In the immediate aftermath of a mass casualty event, some lives may be lost through caution. The standard approach has been to cordon off the zone of casualties, a wide “hot zone,” until it’s been ensured that all threats are  suppressed. The Hartford Consensus suggested that the plan be modified to allow earlier access to victims outside the real hot zone, the location of the active shooter, or a possible bomb. Thus, agreement on new systems of integration and coordination between law enforcement and other teams of responders is needed to ensure the mutual understanding and sequencing of roles.*

By compressing the “hot zone” with the two other zones of care, the “warm zone” and the “cold zone,” less time is lost and more time is made available to begin bleeding control techniques so that more lives are saved (see diagram below).

--

*Source: The Hartford Consensus. Improving Survival Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events:A Compendium. Published by American College of Surgeons, September 2015.

https://www.facs.org/~/media/files/publications/bulletin/hartford%20consensus%20compendium.ashx. Retrieved July 25, 2016.

Editor’s note: The Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events developed the following call to action at its January 7–8 meeting in Dallas, TX. This committee meeting, chaired by American College of Surgeons (ACS) Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, focused on the implementation of strategies to empower bystanders to help victims of mass casualty events. The following is the Hartford Consensus IV, edited to conform with Bulletin style.

Despite advances in the response to active shooter and intentional mass casualty events, a gap remains in our national preparedness and resilience. Drawing from experiences at myriad mass casualty events, the immediate responder (volunteer responder) represents an underutilized resource, yet one capable of dramatically increasing our all-hazards (injuries from all natural and man-made causes) national resilience. The overarching principle of the Hartford Consensus, outlined in previous reports, is that no one should die from uncontrolled bleeding. We have championed the following acronym to summarize what we have determined are appropriate steps to ensure that the maximum number of victims of these tragic events can be saved:

THREAT:

Threat suppression

Hemorrhage control

Rapid Extrication to safety

Assessment by medical providers

Transport to definitive care

Status update

Continuing in our efforts to improve survival from these events and the more common traumatic injuries that occur daily in the U.S., the Hartford Consensus met for the fourth time in January. The discussion at this meeting was focused on the role of individuals in immediate proximity to victims of injury, whatever the etiology.

Based on foundational work by the U.S. Department of Defense and the Committee on Tactical Combat Casualty Care (CoTCCC), previous Hartford Consensus reports have centered on improvements in the professional responder’s role in providing care to individuals wounded in active shooter and intentional mass casualty events. We submit that harnessing the power of immediate responders is not a new concept, as the public has been used to successfully initiate cardiopulmonary resuscitation (CPR) in the event of an out-of-hospital cardiac arrest. Furthermore, seminal work describing the lifesaving benefit of TCCC training in maximizing casualty survival among our troops wounded in combat in Iraq and Afghanistan has uniformly emphasized the importance of all personnel in dangerous environments, not just medics, being trained and equipped to control external hemorrhage when their unit members are injured (also known as Buddy Care). Because the public, by and large, has the will to help in these situations, this report seeks to outline the next steps necessary to continue to fortify our national resilience for a public response to hemorrhage control.

To date, the professional first responder community, including emergency medical services (EMS), law enforcement officers, fire and rescue personnel, and public safety officials, have widely accepted the Hartford Consensus’ principles. For example, the concept of immediateThreat suppression, which maximizes survival from life-threatening injuries, has been embraced and implemented on a national level.

External Hemorrhage control is the intervention that has proven most effective in the prehospital setting. The victim, an immediate responder, or a professional first responder should use this technique as quickly as possible once the immediate threat of further injury has been mitigated.

The concept of Rapid Extrication of casualties from areas of direct threat (hot zones) to less dangerous but not completely secure areas (warm zones) or secure areas (cold zones) expedites Assessment andTransport to definitive care. Furthermore, casualties no longer are expected to remain untreated for significant periods of time until the area is completely secure.

It is clear that the immediate responder has a role to play in rendering aid between the time of injury and the arrival of the professional first responder. The immediate responder can and should be actively involved in hemorrhage control until care is transferred to the professional first responder. Hemorrhage control kits, much like automatic external defibrillators, should be widely available in public places for immediate responder use. The professional first responder will have medical training and be equipped with bleeding control kits containing hemostatic dressings and tourniquets.

Prehospital and hospital emergency medical services have made substantial improvements in their ability to respond to mass casualty events by taking part in multi-agency drills and training scenarios, which allow hospitals to immediately assemble appropriate teams to receive and manage trauma patients. Sophisticated triage networks must be exercised to evenly distribute the injured so that individual hospitals are not overwhelmed. Hospitals located further from the incident should be seamlessly involved in the preparation and management of significant numbers of severely injured patients.

Current national opinion

The Hartford Consensus III focused on empowering the public to provide care. In intentional mass casualty events, those individuals present at the point of wounding have proven invaluable in responding to the initial hemorrhage control needs of the injured. While traditionally described as “bystanders,” these immediate responders need not be passive observers and can provide effective lifesaving first-line treatment. Examples of the effectiveness of such actions by immediate responders have been observed not only in the aftermath of the Boston Marathon bombings, multiple active shooter events, and the recent attacks in Paris, France, but also in the wake of hurricanes, tornadoes, industrial accidents, and everyday incidents, such as motor vehicle collisions. The Hartford Consensus IV meeting focused on building national resilience by outlining strategies to educate the public to become immediate responders.

When the Hartford Consensus called for the public to assume the role of immediate responder, it was uncertain how capable the average person would be at carrying out this charge. To determine the public’s ability and willingness to serve as immediate responders, a nationally representative survey was conducted to assess public opinion regarding the following:

Current level of training in first aid, including bleeding control

Willingness to render first aid for severe bleeding

Potential impediments to willingness to act

Support for changes in first responder policy to allow police and emergency medical services to render aid more quickly

Willingness to be trained in bleeding control

Support for the distribution of bleeding control kits in public places

The survey was conducted by a professional survey firm using established and validated sampling techniques. The questionnaire was administered via landline and cellular telephone interviews to a random sample of 1,051 adults in all 50 states on November 6–11, 2015. The survey findings are as follows:*

There is broad support for initiatives to train and equip first responders and for the public to render first aid for bleeding control in mass casualty incidents.

Large majorities of able-bodied Americans report that they are willing to offer such aid, especially if training and supplies are made available.

Training, including instruction in bleeding control, is strongly associated with the following:

Greater willingness to give aid
Fewer concerns about reasons not to give aid
Interest in receiving further, updated training

Concerns to be addressed include:

Getting injured during an active shooter event
Causing greater pain or injury
Bearing responsibility for bad outcomes
Contracting disease

Support for policies and procedures to make hemorrhage control training and equipment widely available is overwhelming. Specific examples include the following:

Near unanimous support for deployment of kits into public spaces (93 percent)
Strong support for training police to provide bleeding control as a part of their duties (91 percent)
Substantial support for faster access to active shooter and intentional mass casualty events (65 percent)

Current state of readiness and national resilience

The Hartford Consensus intends to create a vision for best-practice hemorrhage control for increasing survival after all-hazards injuries including active shooter and intentional mass casualty events. The goal is to inform and inspire decision makers around the country to effect this vision by establishing appropriate metrics, applying these metrics, and using this information to motivate decision makers.

Metrics for readiness

Metrics to assess readiness include course completion records for TCCC-based medical training. Examples of these training programs include the following:

Tactical Emergency Casualty Care

Bleeding Control for the Injured (B-Con)

Available through the ACS and the National Association of Emergency Medical Technicians (NAEMT)

Law Enforcement and First Response Tactical Casualty Care

Available through the ACS and NAEMT

Specialized Tactics for Operational Rescue and Medicine (STORM)

Available through Georgia Regents University, Augusta

Advanced Law Enforcement Rapid Response Training (ALERRT)

Available through Texas State University, San Marcos

Metrics for resilience

Metrics to assess resilience include the following:

Registry data for all wounded law enforcement officers and all casualties from active shooter and intentional mass casualty events

Case series reports describing injuries, treatments, and outcomes for all casualties, including reports on wounded law enforcement officers and all victims wounded in mass casualty events

Preventable death analyses for law enforcement officers killed in the line of duty and victims of active shooter and intentional mass casualty events

Many trauma deaths result from injuries that are intrinsically non-survivable, whereas others occur from injuries that were potentially survivable had optimal care been rendered. Obtaining a clear understanding of the proximate cause of all law enforcement officer deaths that result from trauma as well as all fatalities in active shooter or intentional mass casualty events will identify opportunities to improve care for officers wounded in the line of duty.

Enhancing citizen resilience

All potential responders to victims of a trauma event should be able to recognize the signs that indicate that bleeding is life-threatening, including the following:

Pulsatile or steady bleeding is coming from the wound.

Blood is pooling on the ground.

The overlying clothes are soaked in blood.

Bandages or makeshift bandages used to cover the wound are ineffective and steadily become soaked with blood.

An arm or leg is traumatically amputated.

The patient was bleeding and is now in shock (unconscious, confused, pale).

Immediate responders should attempt to stop or slow massive hemorrhaging initially by using their hands (gloved whenever possible) to initiate primary compression. This compression should be applied directly or just proximal to the site of hemorrhage and with the use of sustained, direct pressure. Performing this task may be difficult for someone without any first aid training, but it will significantly enhance the survival of the actively hemorrhaging injured victim.

Once the professional responder arrives at the scene, care should be transferred to this individual because he or she will be equipped with and trained in the use of more sophisticated hemorrhage control methods, such as hemostatic dressings and tourniquets.

In a manner similar to the presentation of CPR training, hemorrhage control training programs should be available to the public and offered by employers, civic and religious groups, schools, and the health care community at large.

As an increasing number of public and private locations implement plans to preplace hemorrhage control equipment or co-locate this equipment with automatic external defibrillators, clear messaging and signage should be posted so people can easily and rapidly access this equipment.

Training considerations

The primary components of enhancing citizen resilience must focus on training considerations including:

Determination of terminal learning objectives for bleeding control courses

Establishment of standard curriculum for bleeding control

Education of the public in bleeding control using multiple teaching methods, including:
- Didactic education programs
- Online modules
- Smartphone applications

Tiered bleeding control education for the following:

Immediate responders with no equipment other than their hands
Immediate responders with bleeding control kits (hemostatic dressings and tourniquets)
Professional first responders with bleeding control kits

Creation of public awareness through “Bleeding Safe” communities similar to the “Heart Safe” communities that were designed to promote survival from sudden out-of-hospital cardiac arrest

Specifically, the Hartford Consensus recommends developing a curriculum for the immediate responder. The curriculum would feature a tiered approach that uses the hands of the immediate responder followed by hemostatic dressings and tourniquets when these lifesaving interventions become available. This curriculum should also outline the specific anatomic locations for effective compression of large vessels to stop massive life-threatening hemorrhage. In most cases, control of external hemorrhage can be accomplished by applying direct pressure on the bleeding vessel—even major vessels such as the carotid or femoral arteries. However, victims with life-threatening hemorrhage often bleed to death when direct pressure is the only treatment available to achieve hemostasis. For direct pressure to be effective, it must be applied with both hands using significant sustained and direct force. The patient should be stationary on a surface firm enough to provide effective counter pressure. Frequently, direct pressure cannot be effectively applied while the patient is being moved. Discontinuation of pressure to check the status of the bleeding site during transport must be avoided to ensure bleeding control.

In addition, immediate responders should be taught how to apply hemostatic dressings. For life-threatening hemorrhage from an extremity, immediate responders should be taught to apply a tourniquet. Application of direct pressure, a hemostatic dressing, or a tourniquet must be maintained without interruption until the patient reaches a location where the damaged vessel can be repaired surgically. Wounds with minimal external bleeding, suggesting no major blood vessels have been injured, may be dressed with gauze or a hemostatic dressing until the patient arrives at definitive care.

The curriculum also should include techniques to open and maintain an airway, especially in cases of massive oral hemorrhage. If the victim is conscious, this technique is usually best accomplished by having the victim sit up and lean forward to allow gravity or coughing to clear the blood from the upper airway.

The successful completion of this curriculum should result in the receipt of merit-type badges for scouts and explorer posts and certification in bleeding control.

Dissemination and implementation of a national resilience plan

A critical first step to achieving national resilience is training and equipping immediate responders and professional first responders to control external hemorrhage, along with the strategic positioning of bleeding control kits in locations where active shooter or intentional mass casualty incidents have been observed to occur.

The next step is a campaign to inspire the public to obtain bleeding control training and sustain that training. This should be actively promoted through the following:

Emotional appeals such as, “When you stop the bleed, you save a life”

Simple, consistent messaging

Messages that can be delivered across diverse platforms

To achieve sustainable changes in behavior aimed at immediate control of life-threatening external hemorrhage, the implementation plan should take into account the following considerations:

The content of the plan should include:

The immediate responder concept
An all-hazards approach
A standard curriculum
Funding for implementation and sustainability

The audience for bleeding control courses are:

Immediate first responders (public)
Professional first responders
Law enforcement officers
Firefighters
EMS personnel

Potential content distribution networks include:

The Medical Response Corps
The Red Cross
The National Disaster Medical System
The National Guard
Boy and Girl Scouts
Professional medical societies and organizations
Federal, regional, and local health departments
Emergency service agencies

Strategies to promote these concepts include:

Work with other groups concerned with safety
Gather stakeholder input and explain the value of prospective buy-in by all
Develop a strategic communications plan that drives demand and builds community acceptance
Deliver a message of health literacy and cultural competence that informs but does not inflame
Explain the political barriers and facilitators of implementation
Establish a liaison with state legal authorities to guarantee the validity of Good Samaritan protections as applied to immediate responders and first responders to encourage their participation in bleeding control.

Summary

National implementation of the Hartford Consensus is a meticulous and incremental process. It consists of many elements that require collaboration and strategic leadership to achieve an efficient, effective, knowledgeable, resilient, and prepared citizenry.

We strongly believe the public can and should act as immediate responders to stop bleeding from all hazards, including active shooter and intentional mass casualty events. The ACS has a long history of setting standards and educating responders through its Committee on Trauma and its programs. The ACS is therefore well-positioned to use its national and international networks to implement bleeding control education to improve survival and enhance resilience.

Author’s note:

All text and images in this article are copyright of the Hartford Consensus. For permission to reprint or for more information, contact Dr. Jacobs atLenworth.jacobs@hhchealth.org.

The “Stop the Bleed” poster show above was developed for public education purposes and will be available for wide distribution. To obtain copies, contact Dr. Jacobs.

The Hartford Consensus IV: A Call for Increased National Resilience

Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events

Participants

Lenworth M. Jacobs, Jr., MD, MPH, FACS

Chairman, Hartford Consensus

Vice-President, Academic Affairs

Hartford Hospital

Board of Regents,

American College of Surgeons (ACS)

Richard Carmona, MD, MPH, FACS

17th U.S. Surgeon General

Frank Butler, MD, FAAO, FUHM

Chairman, Committee on Tactical Combat Casualty Care

Department of Defense Joint Trauma System

Andrew L. Warshaw, MD, FACS, FRCSEd(Hon)

Immediate Past-President,

ACS

Massachusetts General Hospital, Boston

David B. Hoyt, MD, FACS

Executive Director,

ACS

Margaret Knudson, MD, FACS

Medical Director, Military Health System Strategic Partnership ACS

San Francisco General Hospital and Trauma Center

Jonathan Woodson, MD, FACS

Assistant Secretary of Defense for Health Affairs, Department of Defense

Alexander Eastman, MD, MPH, FACS

Major Cities Police Chiefs Association

chief of trauma,

Parkland Memorial Hospital

University of Texas Southwestern Medical Center

Kathryn Brinsfield, MD, MPH, FACEP

Assistant Secretary, Health Affairs

Chief Medical Officer,

Department of Homeland Security

William Fabbri, MD, FACEP

Director, Emergency Medical Services

Federal Bureau of Investigation

Karyl Burns, PhD

Research scientist, Hartford Hospital

Matthew Levy, DO, MSc, FACEP

Senior medical officer,

Johns Hopkins Center for Law Enforcement Medicine,

Johns Hopkins University

John Holcomb, MD, FACS

Chief, Division of Acute Care Surgery

University of Texas Health Science Center

Ronald Stewart, MD, FACS

Chair, Committee on Trauma

American College of Surgeons

The University of Texas Health Science Center at San Antonio

Peter Pons, MD, FACEP

Associate Medical Director,

Prehospital Trauma Life Support, International

National Association of EMTs

CDR Todd Lewis, MSC, USN

Military Assistant to the Assistant Secretary of Defense for Health Affairs

Ray Mollers

Workforce Health and Medical

Support Division

Office of Health Affairs

Department of Homeland Security

Michael Marquis

General manager,

Johnson & Johnson Consumer Products, Inc.

Stephen Fanning

President and chief executive officer,

Z-Medica

Gary Langer

President,

Langer Research Associates, LLC

*Note: A full report on the survey will be published in an upcoming issue of the Journal of the American College of Surgeons.

Link to FACS

American College of Surgeons Releases Hartford Consensus Compendium

Wed, Sep 16, 2015

By A.J. Heightman, MPA, EMT P

Editor-in-Chief, JEMS

The September 2015 American College of Surgeons Bulletin is devoted to active shooter and intentional MCI preparedness and response. Entitled “Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium,” this 92-page document should be downloaded, distributed and read by all EMS managers, supervisors, manufacturers and providers because it illustrates best practices, equipment needs and benefits, and tactical approaches that EMS, fire and law enforcement agencies need to focus on.

Blood gushes from virtual leg injury to help train combat medics

Fittingly, the American College of Surgeons, through an introduction by Hartford Consensus Chairman Lenworth M. Jacobs, Jr., MD, MPH, FACS, dedicated this epic document to Norman McSwain, MD, who recently passed away. I paraphrase Dr. Jacobs dedication message here:

Immediately following the active shooter disaster at the Sandy Hook Elementary School in Newtown, CT, Dr. Norman McSwain agreed to be a founding member of the Joint Committee to Develop a National Policy to Increase Survival from Active Shooter and Intentional Mass Casualty Events. Dr. McSwain brought the dedication, passion, and intellect for which he was famous to the Hartford Consensus deliberations.

He fiercely advocated for an organized coordinated prehospital response that incorporated hemorrhage control by immediate bystander responders, a change in focus of the mission of law enforcement to include immediate stopping of life-threatening hemorrhage of victims, and an urgent response by emergency medical personnel to treat and transport trauma patients to the appropriate trauma hospitals. He recognized that time was a critical factor for patients who had massive bleeding.

Dr. McSwain has had a lifelong commitment to improving the care of trauma patients. He personally cared for thousands of trauma patients irrespective of who they were and what their station in life was. His dedication and commitment to the education of prehospital personnel was exemplified by the creation of the Prehospital Trauma Life Support course which has been taught to more than a million students in more than 60 countries. These principles have also been embraced by the military in the Tactical Combat Casualty Care courses.

Through this work, his commitment to excellent prehospital care has been given to millions of trauma patients worldwide. Throughout his career Dr. McSwain was been honored by the American College of Surgeons Committee on Trauma and numerous other professional organizations. However, it was his personal commitment to excellent individual care of the patient, his personal example of the compassionate trauma surgeon, and his kind, caring desire to help people from all walks of life that will always be remembered.

He was a good friend, an excellent person, and an example for all of us that will be forever captured by his greeting to everyone: “What have you done for the good of mankind today?” May he rest in peace.

Please DOWNLOAD and distribute this important document to your friends and colleagues.

American College of Surgeons "Hartford Consensus Compendium" Logo

One-handed tourniquet application and immediate responder hemorrhage control
PHTLS B-Con Bleeding Control for the Injured Course
Hartford Consensus III

Download the B-Con presentation y PDF (English)

ACS Partners with NAEMT in the Development and Release of a Civilian Training Course on Hemorrhage Control Techniques

Joint effort aims to expand public participation in saving lives in the wake of an active shooter or other mass casualty event as recommended by the Hartford Consensus

NEWS FROM THE AMERICAN COLLEGE OF SURGEONS | FOR IMMEDIATE RELEASE

CHICAGO (July 9, 2015): The American College of Surgeons (ACS) has partnered with the National Association of Emergency Medical Technicians (NAEMT) in the development of a medical preparedness training course that empowers bystanders to become immediate responders who treat severely bleeding victims of active shooter or other mass casualty events. The Bleeding Control for the Injured (B-Con) course was jointly developed by the members of NAEMT’s Prehospital Trauma Life Support (PHTLS) Committee and the American College of Surgeons Committee on Trauma (ACS COT) to provide a foundation for first-response care that bystanders (immediate responders) can administer until professional first responders arrive on the scene (i.e.: law enforcement, paramedics, firefighters).

The course was developed to expand public education in the area of hemorrhage control so that bystanders can be empowered to engage in life-saving actions in their own communities. Civilians are taught the same life-saving bleeding control techniques used by military personnel in Iraq and Afghanistan that are shown to dramatically increase casualty survival.

“Advocacy and education are two key principles for our Committee on Trauma activities, and the B-Con course embodies both of them,” said Ronald M. Stewart, MD, FACS, Chair, ACS-COT. “We were very eager to partner with NAEMT on this important educational project. They responded quickly to the need for this type of public education program by extracting and modifying the information contained in their excellent Prehospital Trauma Life Support (PHTLS) course and adapting it for the lay public.”

The two-and-a-half hour educational course combines didactic lectures with hands-on training and teaches the initial steps that bystanders should take to care for bleeding victims. Participants learn why it is important to use a tourniquet to control life-threatening bleeding from an arm or leg; how to correctly apply a tourniquet to the arm and leg; how to pack a wound and apply pressure to control bleeding; the importance of identifying injuries to the chest and abdomen; and the need for victims with these traumatic injuries to be transported immediately to an appropriate hospital for trauma care.

“Our collaboration with the ACS Committee on Trauma follows a long-standing partnership in ensuring quality patient care and improving casualty survivability,” said Conrad “Chuck” Kearns, MBA, Paramedic, A-EMD, President of NAEMT. “B-Con provides bleeding control techniques that can be performed by any observer of a tragic incident, similar to the way bystanders respond with CPR.”

The development and release of B-Con training is part of an interdisciplinary public safety initiative on the part of medical leaders and law enforcement to enhance the resilience of the general public when confronted with mass-casualty events so that no victims will bleed to death while awaiting the arrival of first responders on the scene.

The goals of this initiative are part of a larger effort put forth by the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events, which first met in Hartford, Conn. in 2013. Representatives of this collaborative committee, whose recommendations are called the Hartford Consensus, note that the number one cause of preventable death in victims of penetrating trauma is hemorrhage, making hemorrhage control a major priority in improving survivability of victims from active shooter events.

The B-Con course embodies a key principle of the Hartford Consensus III–empowering the public to provide lifesaving, first-line care,” said Lenworth M. Jacobs, Jr., MD, MPH, FACS, Regent, American College of Surgeons, and Chairman of the Joint Committee that developed the Hartford Consensus. “Our ultimate goal is to educate individuals and communities about the use of effective external hemorrhage control techniques and to ensure access to bleeding control bags in public places in much the same way that automatic external defibrillators are now accessible to the public. We also advocate extending Good Samaritan protections to individuals who use tourniquets and lifesaving devices to control the bleeding of victims at mass-casualty events.”

The Hartford Consensus recommends that an integrated active shooter response should include the critical actions contained in the acronym THREAT:

· Threat suppression

· Hemorrhage control

· Rapid Extrication to safety

· Assessment by medical providers

· Transport to definitive care

Hemorrhage control is addressed by offering B-Con training for public education and use, and is part of the third installment of the Committees’ recommendations, known as Hartford Consensus III. In order to improve survivability, victims with life-threatening external bleeding must be treated immediately at the point of wounding by trained bystanders who have first determined that it is safe to act. Further, all bystanders who assume the role of immediate responders must be trained and have the necessary equipment to provide effective external hemorrhage control until emergency medical personnel arrive on the scene.

“We view care of the victims as a shared responsibility between law enforcement, fire/rescue, and EMS,” said Norman McSwain, MD, FACS, from the Joint Committee. “The Bleeding Control course takes that role a step further by engaging trained bystanders in the process as well. The course defines their role in this process so that those bystanders can recognize life-threatening bleeding and learn how to administer the proper medical treatment. We also recommend that law enforcement and fire and rescue personnel carry tourniquets with them after they’ve completed the training.”

The Hartford Consensus III report on implementing bleeding control is published in the July 2015 Bulletin of the American College of Surgeons.

# # #

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.

About the National Association of Emergency Medical Technicians

Formed in 1975 and more than 50,000 members strong, the National Association of Emergency Medical Technicians (NAEMT) is the only national association representing the professional interests of all emergency and mobile healthcare practitioners, including emergency medical technicians, advanced emergency medical technicians, emergency medical responders, paramedics, advanced practice paramedics, critical care paramedics, flight paramedics, community paramedics, and mobile integrated healthcare practitioners. NAEMT members work in all sectors of EMS, including government agencies, fire departments, hospital-based ambulance services, private companies, industrial and special operations settings, and in the military. For more information visit: www.naemt.org.

Contact

Dan Hamilton
312-202-5328
or
Sally Garneski
312-202-5409
pressinquiry@facs.org

Hyper-Realistic simulation doing a Combat Medic/EMT-B course at PPA-International Medical

See more at: https://www.facs.org/media/press-releases/2015/naemt0715#sthash.yuZZYbgX.dpuf

Hartford Consensus III participants. Seated, left to right: Drs. McSwain, Warshaw, Jacobs, Woodson, Brinsfield, and Levy; and Mr. Elliott. Standing left to right: Dr. Rhee, Mr. Mitchell, Drs. Eastman, Conn, O’Connor, Stewart, Butler, Burns, Weireter, Hunt, Holcomb, and Fabbri; and Commander Anderson.

The Hartford Consensus III: Implementation of Bleeding Control

by LENWORTH M. JACOBS, JR., MD, MPH, FACS; AND JOINT COMMITTEE TO CREATE A NATIONAL POLICY TO ENHANCE SURVIVABILITY FROM MASS-CASUALTY SHOOTING EVENTS
PUBLISHED JULY 1, 2015

The Hartford Consensus III recognizes the vital role that immediate responders play in responding to mass-casualty events. They make major contributions to improving survival from these incidents. However, the Hartford Consensus III does not advocate that members of the public enter areas of direct threat or imminent danger.

Good Samaritan laws have been effective in empowering the public to become involved in the immediate response to a victim of cardiac arrest or choking by the initiation of cardiopulmonary resuscitation and the Heimlich maneuver, respectively. The Hartford Consensus recommends that these legal protections be extended to include the provision of bleeding control.

Professional first responders

Professional first responders include law enforcement and EMS/fire/rescue. As indicated by THREAT, law enforcement must suppress the source of wounding if the shooter is still active and then, because they are usually the initial first responders on the scene, must act to control external hemorrhage. Victims with life-threatening external bleeding must be treated immediately at the point of wounding. All responders should be educated and have the necessary equipment to provide effective external hemorrhage control. Continued emphasis must be on the integration of the immediate responders, law enforcement, and EMS/fire/rescue to optimize rapid patient assessment, treatment, and transport to definitive care at the nearest appropriate hospital.

Building educational capabilities

Education in hemorrhage control can take many forms and should be offered using various modalities. Established education programs for individuals, communities, and professional responders can be modified to include effective external hemorrhage control techniques. The Bleeding Control for the Injured (B-Con) course offered by the National Association of Emergency Medical Technicians is an example of a newly created program that is appropriate for training individuals who have little or no medical background. Other methods such as public service announcements, slogans, advertising, and entertainment media should be used to convey the message that bleeding control is a responsibility of the public and is within their capabilities.

The public needs to be empowered to engage in lifesaving actions. This training should be included as part of preparing for situations involving other potential hazards, including everyday events that may produce trauma and hemorrhage. For professional first responders, more advanced courses may offer additional options to control life-threatening external hemorrhage. All formal training should have specific objectives and train to competency. For professional responders, the training must be efficient and cost-effective. Ultimately, integrated training exercises must be conducted that include all levels of responders.

April 29, 2015

Roundtable on bystanders: Our nation’s immediate responders

Participants

Air Medical Physician Association
American Academy of Physician Assistants
American Ambulance Association
American Association of Critical Care Nurses
American Association for the Surgery of Trauma
American College of Emergency Physicians
American College of Surgeons
American Heart Association
American Hospital Association
American Nurses Association
American Osteopathic Association
American Physical Therapy Association
American Public Health Association
American Trauma Society
Association of Air Medical Services
Association of State and Territorial Health Officials
Eastern Association for the Surgery of Trauma
Emergency Nurses Association
Emergency Medical Services Labor Alliance
International Academies of Emergency Dispatch
International Association of Chiefs of Police
International Association of Emergency Managers
International Association of Emergency Medical Services Chiefs
International Association of Firefighters
International Association of Fire Chiefs
Major Cities Chiefs Association
National Association of Emergency Medical Technicians
National Association of School Nurses
National Association of State EMS Officials
National Athletic Trainers Association
National Emergency Management Association
National Volunteer Fire Council
Society of Emergency Medicine Physician Assistants
Society of Trauma Nurses
Trauma Center Association of America
White House personnel
Interagency Bystander Workgroup team leaders
Federal invitees

The Hartford Consensus III: Implementation of Bleeding Control

Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events

Participants

Lenworth M. Jacobs, Jr., MD, MPH, FACS
Chairman, Hartford Consensus
Vice-President, Academic Affairs
Hartford Hospital
Board of Regents,
American College of Surgeons

Richard Carmona, MD, MPH, FACS
17th U.S. Surgeon General

Norman McSwain, MD, FACS
Medical Director, Prehospital Trauma Life Support
Tulane University

Frank Butler, MD, FAAO, FUHM
Chairman, Committee on Tactical Combat Casualty Care
Department of Defense Joint Trauma Systems

Doug Elliot
President, The Hartford
Chair, Board of Directors
Hartford Hospital

Andrew L. Warshaw, MD, FACS, FRCSEd(Hon)
President, American College of Surgeons
Massachusetts General Hospital, Boston

Jonathan Woodson, MD, FACS
Assistant Secretary of Defense for Health Affairs, Department of Defense

Richard C. Hunt, MD, FACEP
Director for Medical Preparedness Policy,
National Security Council Staff
The White House

Ernest Mitchell
Administrator, U.S. Fire Administration
Federal Emergency Management Agency
Department of Homeland Security

Alexander Eastman, MD, MPH, FACS
Major Cities Police Chiefs Association
Chief of Trauma, Parkland Memorial Hospital
University of Texas Southwestern Medical Center

Kathryn Brinsfield, MD, MPH, FACEP
Assistant Secretary, Health Affairs
Chief Medical Officer,
Department of Homeland Security

Colonel Kevin O’Connor, DO, FAAFP
Physician to the Vice-President
The White House

William Fabbri, MD, FACEP
Director, Emergency Medical Services
Federal Bureau of Investigation

Richard Serino
Distinguished Visiting Fellow,
Harvard University, School of Public Health
8th Deputy Administrator,
Federal Emergency Management Agency

Alasdair Conn, MD
Chief Emeritus, Emergency Medicine
Massachusetts General Hospital

Karyl Burns, PhD
Research Scientist, Hartford Hospital

Matthew Levy, DO, MSc, FACEP
Johns Hopkins University
Senior Medical Officer,
Johns Hopkins Center for Law Enforcement Medicine

Leonard Weireter, MD, FACS
Vice-Chair, Committee on Trauma
American College of Surgeons
Eastern Virginia Medical School

John Holcomb, MD, FACS
Chief, Division of Acute Care Surgery
University of Texas Health Science Center

Peter Rhee, MD, MPH, FACS
Department of Surgery
University of Arizona

Ronald Stewart, MD, FACS
Chair, Committee on Trauma
American College of Surgeons
The University of Texas Health Science Center at San Antonio

Robert Anderson, CDR, MSC, USN
Military Assistant to the Assistant Secretary of Defense for Health Affairs
Department of Defense

Thomas M. Scalea, MD, FACS
Physician-in-Chief,
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine

Donald Jenkins, MD, FACS
Medical Director, Trauma Center
Mayo Clinic

David R. King, MD, FACS
Trauma, Emergency Surgery and Surgical Critical Care
Department of Surgery
Massachusetts General Hospital

The Bleeding Control for the Injured (B-Con) course was developed by NAEMT's PHTLS Committee with leadership provided by Dr. Peter Pons and Dr. Norman McSwain.

The course was developed in response to efforts by the U.S. Departments of Homeland Security and Health and Human Services to increase collaboration between law enforcement, the fire service and EMS in responding to active shooter/IED/mass casualty events. B-Con is consistent with the recommendations of the Hartford Consensus on Improving Survival from Active Shooter Events. The Hartford Consensus recommends that an integrated active shooter response should include the critical actions contained in the acronym THREAT: 1.Threat
2.Hemorrhage control
3.Rapid Extrication to safety
4.Assessment by medical providers
5.Transport to definitive care

The Hartford Consensus Group recommends that the response to a traumatic incident, whether involving an active shooter or some other cause of injury, in fact begins with bystander response. It is with this in mind that the B-Con course was developed and is now being offered.
This new 2 ½ hour course teaches participants the basic life-saving medical interventions, including bleeding control with a tourniquet, bleeding control with gauze packs or topical hemostatic agents, and opening an airway to allow a casualty to breathe. The course is designed for NON tactical law enforcement officers, firefighters, security personnel, teachers and other civilians requiring this basic training. Course materials include a PowerPoint presentation and instructor notes, instructor’s guide, and skill station guide.

A separate, additional PowerPoint module is included in the course materials specifically for law enforcement participants. This module provides an orientation to the content of the Hartford Consensus and the changing approach to active shooter and other complex and hazardous responses.

At the completion of the course, participants will be able to:

•Explain the rationale for early use of a tourniquet for life-threatening extremity bleeding.
•Demonstrate the appropriate application of a tourniquet to the arm and leg.
•Describe the progressive strategy for controlling hemorrhage.
•Describe appropriate airway control techniques and devices. •Demonstrate the correct application of a topical hemostatic dressing (combat gauze).

STOP THE BLEED

"Stop The Bleed"

The Obama Administration launched the "Stop The Bleed" campaign Wednesday, October 6, 2015 to provide people with the tools to stop life threatening bleeding in the event of an emergency, saying:

"Severe bleeding can lead to death in five minutes or less. A victim can bleed to death much faster than trained public safety personnel can arrive. The person standing or sitting next to that individual may be the ONLY one who can make the difference between life and death."

No matter how rapid the arrival of professional emergency responders, bystanders will always be first on the scene. A person who is bleeding can die from blood loss within five minutes, therefore it is important to quickly stop the blood loss.

"Stop the Bleed" is a nationwide campaign to empower individuals to act quickly and save lives.

Remember to be aware of your surroundings and move yourself and the injured person to safety, if necessary.

Call 911.

Bystanders can take simple steps to keep the injured person alive until appropriate medical care is available. Here are three actions you can take to help save a life:

Compress

Find where the bleeding is coming from and apply firm, steady pressure to the bleeding site with bandages or clothing

Tourniquet

If the bleeding doesn't stop, place a tourniquet 2-3 inches closer to the torso from the bleeding. (The tourniquet may be applied and secured over clothing.)

Pull the strap through the buckle, twist the rod tightly, clip and secure the rod with the clasp or the Velcro strap.

Compress Again

If the bleeding still doesn't stop, place a second tourniquet closer to the torso from the first tourniquet.

Pull the strap through the buckle, twist the rod tightly, clip and secure the rod with the clasp or the Velcro strap.

* One type of tourniquet is depicted in the illustrations.

More Information

You can learn more about how to “Stop the Bleed” and help save a life by accessing these training and resources:

‘A Perfect Stranger’ tells the story of Kinneil and Angelia and the event that brought the two women together. When a motorcycle accident left a frightened Angelia on the street alone and bleeding, Kinneil didn’t just stand by, she cared enough to stop and provide a comforting hand and a reassuring voice. It is a powerful reminder that at a moment’s notice, any one of us might find ourselves in a situation where we are the help until help arrives. In the end, this film calls on all Americans to remake what it means to be a bystander. Learn more at www.ready.gov/prepare

FEMA Training Video | Watch on YouTube

Download the steps above as a shareable infographic (229 KB JPG)
Download a high resolution copy of the "Stop the Bleed" logo (152 KB JPG)
Army Combat Casualty Care Research Program

To learn more or to get involved in the Stop the Bleed Campaign, contact us at stopthebleed@hq.dhs.gov.

Last Published Date: October 7, 2015

Control de Sangrados para el Herido By NAEMT. The Hartford Consensus III

Control de Sangrados para el Herido By NAEMT.

5 MITOS SOBRE LOS TORNIQUETES

En los últimos años cada vez más se habla de los torniquetes. Algo que originalmente parecía destinado únicamente a los terrenos de batalla, e incluso allí era tratado como algo tabú (sobre todo por la medicina de nuestro país) se va implantando cada vez más, pero no solo en tierras lejanas y por nuestras tropas, si no en la vida civil y de cada día. Los últimos atentados indiscriminados están demostrando la utilidad de un útil que tiene un coste bajo, no pesa y se puede transportar en cualquier sitio.

Pero, ¿Hay que aflojarlo? ¿Sólo lo puedes usar en caso de riesgo extremo para la vida? Vamos con los 5 mitos más habituales sobre los torniquetes.

Los torniquetes se deben utilizar solamente como último recurso.

Este es un enfoque peligroso y anticuado. Hay una cantidad abrumadora de datos contrastados que tumban este mito. Si estas está asistiendo a una clase y eso es lo que están diciendo, te aconsejamos que busques una segunda opinión.

Existen multitud de ejemplos en el mundo real que atestiguan la normalidad en el uso de torniquetes y como salvan vidas a diario en la vida civil.

En un marco táctico o de tirador activo, el torniquete se convierte en un “must” y se debe utilizar ante la simple sospecha de que una víctima está sangrando por una extremidad. Durante muchos años las hemorragias de las extremidades fueron la principal causa de muerte prevenible en el campo de batalla, ahora ya superada por las hemorragias en las zonas de unión (axila, ingle, y el cuello).

Mejoras significativas en la formación, junto con la disponibilidad de torniquetes han dado como resultado una marcada disminución de la mortalidad. A través de la educación en sistemas como el TCCC y la persistencia de los militares han cambiado la forma en que vemos los torniquetes a pesar de las veces que se ha repetido lo de “sólo como último recurso”.

Durante un estudio de 7 meses en 2006 en el Combat Support Hospital en Bagdag, publicado en The Journal of TRAUMA Injury,Infection, and Critical Care en Febrero de 2008, se realizó un estudio sobre la incidencia de la aplicación de los torniquetes :

232 pacientes
428 torniquetes aplicados
El torniquete CAT fue aplicado un 79% de las veces
No se apreciaron lesiones causadas por su aplicación (necrosis, fallo renal, amputaciones, necesidad de fasciotomia)
No se realizó una sola amputación debido al uso del torniquete

ACTUALIZACIÓN- Existe una gran diferencia entre un escenario civil urbano y uno militar. Mientras en un escenario civil, el paciente será atendido y/o evacuado durante la hora siguiente al incidente que ha conllevado la aplicación del torniquete, reduciendo a casi 0 el riesgo de lesiones en las extremidades, en un escenario militar puede ser distinto. Como hace constar la National Association of Emergency Medical Technicians (NAEMT) en su informe Optimizing the use of Limb Tourniquets in TCCC, su utilización en Irak y Afganistan es común y sin incidencias remarcables para los pacientes, ya que cuentan con un protocolo de extracción de heridos MEDEVAC con unos periodos de respuesta muy cortos. Pero bien distinto puede ser para su uso en escenarios donde los tiempos de extracción necesitan de un tiempo prolongado. En general y como se sigue constatando en la última revisión de Noviembre de 2015 de las Tactical Combat Casualty Care Guidelines El uso del torniquete es seguro hasta las 2 horas de aplicación y debe ser revisado por personal especializado lo antes posible desde su aplicación. NUNCA se debe retirar, aflojar, o mover de sitio un torniquete por personal que no tenga los conocimientos acreditados para ello. Si no cesa el sangrado, se debe aplicar un segundo torniquete, o la combinación de torniquete y hemostáticos. MUY IMPORTANTE siempre siempre, SIEMPRE, marcar la hora de aplicación del torniquete.

La aplicación de torniquetes debe ser realizada de una manera consciente y selectiva, únicamente en pacientes con hemorragias exanguinantes y recibir atención médica lo antes posible.

En el mundo civil, a nivel mundial se aplica el algoritmo THREAT contenido en el Consenso Hartford (ya por su tercera edición)

Eliminar la amenaza (Threat supression)
Control de la hemorragia (Hemorrhage control)
Extracción rápida a un lugar seguro (Rapid Extrication to safety)
Evaluación por personal sanitario (Assessment by medical providers)
Traslado para el tratamiento definitivo (Transport to definitive care)

La colocación de un torniquete es igual a la pérdida de la extremidad.

La perdida de una extremidad por el uso de un torniquete es extremadamente rara. En cualquier caso es mucho menor que el riesgo de los efectos de una hemorragia. Es de total aplicación “Vida sobre la extremidad”. Existen multitud de casos documentados donde pacientes con torniquetes comerciales lo han tenido durante 8 horas y más y no han perdido la extremidad. En los casos que se ha producido, ha sido atribuido a una herida de bala, lesión por estallido, metralla, fragmentación, traumatismos de alta velocidad y no como resultado del flujo sanguíneo restringido de la colocación del torniquete.

ACTUALIZACIÓN- Si bien se han constatado algunos casos donde el uso del torniquete ha superado varias horas de aplicación sin lesiones graves e irreversibles para el paciente, se debe aplicar de una manera consciente y únicamente en casos de hemorragias exanguinantes y buscar atención médica especializada en un periodo que no debería superar las dos horas desde su aplicación.

Los cinturones son el mejor torniquete.

Este es un completo disparate. El cinturón es un terrible torniquete; es extremadamente difícil, si no imposible para ocluir completamente el flujo de sangre arterial utilizando un cinturón. La utilización de un cinturón de hebilla nunca estará suficientemente apretado y tratar de apretar el cinturón retorciéndolo es un problema debido a su rigidez. El palo para poder apretarlo debería ser algo tan grande como la pata de una silla. Si es mejor que nada, pero lo importante es concienciarse que es mucho mejor un torniquete comercial.

Los torniquetes improvisados constituyen equipación médica adecuada.

Usar medios de fortuna en caso de urgencia no sólo es aceptable es encomiable. Existen multitud de historias de personas que han actuado como primer interviniente proporcionando unos primeros auxilios fundamentales. Brian Ludmer, un maestro de escuela que fue disparado en la pierna durante el tiroteo de Los Angeles, se arrastró hasta una tienda y consiguió encerrarse en el almacén. Encontró una sudadera y se la ató alrededor de la pierna para frenar la hemorragia. Frenar la hemorragia es exactamente lo que pueden hacer los medios de fortuna, no detener. Instituciones sanitarias, bomberos, policías, protección civil y cualquier otra institución al cuidado de los ciudadanos se comportarían de manera negligente si no están equipados con torniquetes de fabricación comercial, que SI detienen las hemorragias.

Tras el atentado del maratón de Bostón, donde muchas vidas se salvaron gracias a la improvisación, la policía ha sido dotada de torniquetes. Cuando alguien esta sangrando significativamente, no es el momento para el arte y la artesanía.

Este es el mejor torniquete.

Los torniquetes comerciales al igual que cualquier otro elemento de la equipación tienen ventajas y desventajas, fortalezas y debilidades. Todos ellos tienen matices sutiles y reglas generales con respecto a su uso. Si buscamos el más recomendable la pregunta sería “¿El más recomendable para quién, cuándo y dónde?”
~~El torniquete que funciona bien para un infante de marina en su chaleco balístico, puede no ser la mejor opción para alguien que hace trabajo de paisano.~~ ACTUALIZACIÓN. El torniquete prehospitalario empleado en adultos es igual para cualquier escenario o situación.
~~El torniquete que se lleva en operaciones policiales de equipos especiales, sería una mala elección en un tiroteo en la escuela con pacientes pediátricos esperados~~. Existen torniquetes específicos pediátricos pero son de aplicación hospitalaria mayoritariamente. El uso de torniquetes estandar en caso de emergencia, en niños, esta plenamente extendido. El torniquete que se utiliza en un área controlada de urgencias sería difícil de utilizar en un ambiente estresante con poca luz.

Aplicación de torniquete CAT en niños

Los torniquetes vienen en todas las formas, tamaños, colores, y realizan el trabajo de múltiples formas. Al igual que con cualquier otro trabajo, una tarea o misión la respuesta sensata es elegir la herramienta más adecuada para el.

ACTUALIZACIÓN Podríamos concluir que el uso del torniquete en los primeros intervinientes en escenarios urbanos es altamente recomendable y no requiere de una gran formación o conocimientos sanitarios. En un caso de tirador activo, o atentado indiscriminado, el primer interviniente puede ser decisivo con la simple aplicación de torniquetes a los civiles que hayan sido gravemente heridos en sus extremidades.

Recomendamos encarecidamente a todo aquel que realice algún servicio público de seguridad a tomar parte de algún curso LEFRTCC de los que se vienen realizando periódicamente en nuestro país.

Este artículo fue publicado en la revista Tactical Online en su número de Mayo de 2016

CELOX Stops Bleeding. Saves Lives Español PPT

T-H-R-E-A-T (THREAT) B-Con PHTLS
Hartford Consensus III

PHTLS B-Con Bleeding Control for the Injured Course / Control de Sangrados para el Herido By NAEMT

Español
Mejorando la supervivencia en Incidentes con Tiradores Activos (B-Con Course) Curso Control de Sangrados en el Herido

(Active Shooter Events): El Consenso Hartford

Comité Conjunto para Crear una Política Nacional para Mejorar la Supervivencia en
Incidentes De Múltiples Víctimas en Tiroteos
Hartford, CT 2 de Abril de 2013
Dr. Lenworth Jacobs, Hartford Hospital, Board of Regents, American College of Surgeons
Dr. Norman McSwain, Medical Director, Prehospital Trauma Life Support
Dr. Michael Rotondo, Chair, American College of Surgeons Committee on Trauma
Dr. David Wade, Chief Medical Officer, FBI
Dr. William Fabbri, Medical Director, Emergency Medical Support Program, FBI
Dr. Alexander Eastman, Major Cities Chiefs Association (Lt. Dallas Police Department)
Dr. Frank Butler, Chairman, Committee on Tactical Combat Casualty Care
John Sinclair, International Director and Immediate Past Chair International Association of Fire Chiefs- EMS Section (Fire Chief, Kittitas Valley Fire and Rescue)
Introducción
Los recientes sucesos de múltiples víctimas en tiroteos ocurridos en América han tenido un
profundo efecto en todos los sectores de la sociedad. Las comunidades médicas, de las
Fuerzas de Seguridad, de rescate/bomberos y de los SEM han sentido la necesidad de dar
respuestas. Es importante que estos esfuerzos se realicen de manera coordinada para crear
políticas que puedan mejorar la supervivencia de las víctimas producidas en estos
incidentes. Tales políticas deben proporcionar una aproximación sincronizada entre las
múltiples agencias que se encuentre inmediatamente disponible para las comunidades
afectadas por dichas tragedias.
El Colegio Americano de Cirujanos y el Federal Bureau of Investigation (FBI) han
colaborado conjuntamente para proporcionar altos representantes de todas las disciplinas
anteriormente mencionadas, para elaborar un documento que estimule el debate y en última
instancia conduzca a estrategias para mejorar la supervivencia de las víctimas. La
conferencia de un día de duración, el 2 de Abril de 2013 en Hartford, Connecticut, recibió
contribuciones de expertos médicos, de las Fuerzas de Seguridad, de
bomberos/rescatadores, de primeros intervinientes del SEM y de militares. La conferencia
consistió en actualizaciones de datos y evidencias extraídos de experiencias civiles y
militares recientes y, fue sensible al papel desempeñado por múltiples agencias que
participaron en incidentes de múltiples víctimas por tiroteo. La reunión, conocida como
Conferencia del Consenso Hartford (Hartford Consensus Conference), generó un
documento conceptual titulado “Mejora de la Supervivencia en Incidentes de Tiradores
Activos” (“Improving Survival from Active Shooter Events.”) El propósito de este
documento es promover las políticas locales, estatales y nacionales para mejorar la
supervivencia en estas situaciones poco comunes, pero terroríficas. Este ensayo corto
describe métodos para minimizar la pérdida de vidas humanas en estos terribles incidentes.
Planteamiento del Problema
Los incidentes de tiradores activos/múltiples víctimas son una realidad en la vida actual
americana. A medida que nuestra experiencia en este tipo de eventos se va acumulando, va
quedando claro que las respuestas tradicionales por parte de las Fuerzas de Seguridad,
bomberos/rescatadores y SEM no están adecuadamente alineadas para maximizar la
supervivencia de las víctimas.
Control Precoz de la Hemorragia para Mejorar la Supervivencia
Históricamente, la respuesta a los tiroteos ha consistido en una operación segmentada y
secuencial de seguridad pública, con la priorización de la seguridad como uno de los
objetivos de las Fuerzas de Seguridad (detener el tiroteo), seguido por el resto de medidas
de respuesta y recuperación. A medida que evolucionamos, las acciones iniciales para el
control de la hemorragia deben formar parte de la respuesta de las Fuerzas de Seguridad y,
los conocimientos para el control de la hemorragia, tienen que ser una parte central de sus
habilidades. Maximizar la supervivencia implica un sistema actualizado e integrado que
pueda alcanzar múltiples objetivos de forma simultánea.
Las lesiones de riesgo vital en incidentes con tiradores activos, como los producidos en Fort
Hood, Tucson y en Aurora, son similares a las que nos podemos encontrar en combate. La
experiencia militar nos ha enseñado que la causa principal de muerte evitable en una
víctima con trauma penetrante es la hemorragia. Los programas Tactical Combat Casualty
Care (TCCC), cuando son implementados con un apoyo sólido de los jefes, han producido
una reducción drástica de las muertes evitables. Reconociendo que los incidentes con
tiradores activos pueden ocurrir en cualquier comunidad, el Consenso Hartford anima al uso
de las técnicas y equipos existentes, validados por más de una década de evidencia clínica
bien documentada.
El Consenso Hartford recomienda que una respuesta integrada para tirador activo debe
incluir las acciones críticas contenidas en el acrónimo THREAT:
1. Eliminar la amenaza (Threat suppression)
2. Control del la Hemorragia (Hemorrhage control)
3. Extracción Rápida a zona segura (Rapid Extrication to safety)
4. Evaluación por personal sanitario (Assessment by medical providers)
5. Traslado para el tratamiento definitivo (Transport to definitive care)
Mientras que algunos pueden considerar añadir habilidades para el control de la hemorragia
como otro requisito en la formación en tiempos de recursos económicos limitados, los
conceptos son simples, probados y relativamente económicos; ya han sido adoptadas como
la mejor práctica por muchas agencias de las fuerzas de seguridad. La mejor forma de
controlar la hemorragia exanguinante por lesiones en extremidades se consigue mediante el
uso de torniquetes, mientras que la mejor forma de controlar la hemorragia interna
producida por heridas penetrantes en el tórax y el tronco se consigue mediante el traslado
rápido al hospital. Una respuesta óptima a un suceso con tirador activo incluye la
identificación y la enseñanza de conjuntos de habilidades apropiados a cada nivel de
respuesta, sin tener en cuenta la afiliación de las Fuerzas de Seguridad o de los
bomberos/rescatadores/SEM. El algoritmo THREAT incorpora los conceptos probados de
autoayuda y de ayuda por el compañero (self-care and buddy-care).

Respuesta Integrada
La asistencia a las víctimas es una responsabilidad compartida por las Fuerzas de
Seguridad, bomberos/rescatadores, y SEM. Los resultados óptimos dependen de la
comunicación entre el personal de seguridad pública. La respuesta a un incidente con
tirador activo es un proceso que requiere la coordinación entre las Fuerzas de Seguridad y el
personal sanitario/de evacuación. Dicha coordinación incluye:
 Definiciones compartidas de términos empleados en incidentes con heridos en tiroteos.
 Desarrollo conjunto de protocolos locales para la respuesta a incidentes con tiradores activos.
 Prioridad de la inclusión de incidentes con tiradores activos en el entrenamiento y simulacros para mejorar la familiarización con los protocolos conjuntos desarrollados.

Conclusión
El Consenso Hartford busca mejorar la supervivencia en los incidentes con tiradores activos. El uso del algoritmo THREAT y una mejor respuesta integrada por parte de las Fuerzas de Seguridad, bombeos/rescatadores y SEM, ofrecen a las comunidades un mecanismo para minimizar la pérdida de vidas humanas en estos incidentes.

La Asociación Nacional de Técnicos de Emergencias Médicas (NAEMT) anunció la publicación de un curso para enseñar al personal civil las mismas técnicas de control de sangrados aprendidas en Iraq y Afganistán que han demostrado aumentar la supervivencia a lesiones mortalmente peligrosas. El curso “Bleeding Control for the Injured”, o mejor conocido como B-Con, está basado en la evidencia más actualizada de cómo atender una persona severamente herida.

El curso Bleeding Control for the Injured (B-Con) enseña a los participantes intervenciones que salvan vidas, incluyendo el control de sangrados con un torniquete, cómo empacar una herida con gazas o agentes hemostáticos, y a abrir una vía aérea para permitir que la víctima respire.

Ampliar información sobre el Curso PHTLS PreHospital Trauma Life Support

Contacto en Republica Dominicana: Alexander Pacheco eeiird@gmail.com +1809 849 9295

The following are links to news items relating to bleeding control and the use of tourniquets:

http://www.navytimes.com/article/20140820/NEWS/308200048/

http://www.jems.com/video/news/university-pittsburgh-staamp-trial

https://www.facs.org/media/press-releases/jacs/hartford0214

http://www.ems1.com/ems-products/Bleeding-Control/articles/1649473-5-triage-lessons-learned-from-the-Boston-Marathon-Bombing/

http://www.ems1.com/ems-products/Bleeding-Control/articles/1646165-New-police-issued-tourniquets-save-2-lives/

PHTLS Medical Director Attends Hartford Consensus III
Dr. Norman McSwain (front left), medical director of the Prehospital Trauma Life Support (PHTLS) Committee and professor of Surgery at Tulane University, attended the third meeting of the Hartford Consensus group last month in Hartford, Conn. Participants from public safety and the medical community developed strategies to increase survivability in mass casualty shootings. This third meeting builds on documents known as the Hartford Consensus I and II, which outline the needed response to active shooters as THREAT (Threat suppression; Hemorrhage control; Rapid Extrication to safety; Assessment by medical providers; and Transport to definitive care). Learn more about the Hartford Consensushttp://goo.gl/omWXQb

Curso PHTLS Bcon Bleeding Control for the Injured Course / Control de Sangrados para el Herido By NAEMT

‪#‎NAEMT‬ ‪#‎PHTLSDominicana‬ ‪#‎BCon‬ ‪#‎Trauma‬ ‪#‎Sistema911‬

Stop the Bleed Initiative: How You Can Help in an Emergency Situation

December 21, 2017

Joseph Ibrahim, MD

Trauma is the leading cause of death for people between the ages of 1 to 46.

Between unintentional injuries, homicide and other violent crimes, there may be instances when someone who is bleeding needs immediate care. That’s why two years ago the federal government launched the Stop the Bleed Initiative. Here’s what you should know about this national effort:

What is “Stop the Bleed”?

The White House launched “Stop the Bleed,” a national awareness campaign, in the fall of 2015. The campaign was a direct response to the tragedy at Sandy Hook Elementary School in Newtown, CT in 2012 and is designed to help bystanders become trained and equipped to help someone in a bleeding emergency before EMS or first responders arrive. “Stop the Bleed” mobilizes grassroots efforts and brings together the private sector and nonprofit organizations to train civilians in lifesaving tactics typically used by first responders and the military.

“Stop the Bleed” at Orlando Health

This past February, we started to provide this training locally in the Central Florida area. With the help of Orange County’s Office of the EMS, Orlando Health’s trauma team delivers the medical training component of “Stop the Bleed.” Orlando Health and coordinates the training for individuals, organizations and local businesses.

During the one to two-hour training course, participants learn the basics of bleeding control, including how to apply pressure to the wound or injury site and how to use a tourniquet. They also learn the fundamentals of responding for bleeding — or what we call the ABCs. A stands for Alert (call 9-1-1); B is for Bleeding (find the bleeding injury) and C is for Compress (apply pressure or a tourniquet).

Participants also have access to a bleeding control kit during training, which includes gloves, tourniquets, a gauze coated with special medication to help with blood clotting, a pressure bandage or a compression application. Some municipalities throughout the state also have begun supplying these kits and automatic defibrillator boxes in various public places.

Dr. Michael Chatham, chief surgical quality officer and trauma surgeon at Orlando Regional Medical Center, organized Orlando Health’s local efforts. He said in an interview last fall that the initiative will empower regular people to save a life in an emergency situation.

"You can literally go grab a kit or use the shirt off your back or whatever you have available to hold pressure on the wound and stop the bleeding," he told the Orlando Sentinel.

I couldn’t agree more. Initiatives like “Stop the Bleed” can make a huge difference. Every second counts in an emergency situation, and people who are closest in proximity to the injured person are in an optimal position to deliver immediate care in the event of uncontrolled bleeding. The goal of first responders is to arrive on the scene as quickly as possible, but this often can take several minutes.

Hemorrhage is responsible for more than 35 percent of traumatic injury deaths before someone makes it to the hospital, and over 40 percent of deaths within the first 24 hours of a traumatic injury. If we can empower people to stop the bleed, we can save more lives. A person who is bleeding can die from blood loss within five minutes, so in addition to calling 911, take the time to learn the ABCs of responding to uncontrolled bleeding. If you’re ever in this situation, practice safety first and make sure the scene is safe before you assist anyone who is injured. After this, find the source of the bleeding and open or remove the person’s clothing so you can clearly see where blood is coming from. Next, apply compression to the bleeding wound to stop the bleeding.

While this is a skill none of us ever hope to use, remembering these steps and having this knowledge could make all the difference if you’re ever faced with a trauma emergency. Now come take the course and be a hero!

IPSA InfoBrief: Stop the Bleed

06 Mar 2018 11:33 AM
International Public Safety Association

This International Public Safety Association InfoBrief discusses how and why the Stop the Bleed program was developed and how it is being implemented and recognized globally. Further, it examines funding strategies discusses how to get involved in the Stop the Bleed movement.

Download the complete IPSA Stop the Bleed InfoBrief PDF
March 2018

Stop the Bleed is a national awareness campaign and a call to action. It is intended to promote community efforts that encourage bystanders to become trained, equipped and empowered to help in a bleeding emergency because a person with a life-threatening injury from a motor vehicle collision, a stab wound or a gunshot wound can bleed to death before first responders arrive. The bystander acts as the first responder and are the first point of contact in the chain of survival.

Download the The Hartford Consensus III, July 2015 in PDF

Animation of gunshot wound
PHTLS B-Con Bleeding Control for the Injured Course

Tiny sponges close up gunshot wound in 15 seconds

PHTLS B-Con Bleeding Control for the Injured Course http://goo.gl/A4PyNB

5 MITOS SOBRE EL USO DE TORNIQUETES English/Español Control for the Injured Course "Stop The Bleed" / Control de Sangrados para el Herido

MAS LIBROS MEDICINA Y SALUD

https://www.facebook.com/pg/DrRamonReyesMD/photos/?tab=album&album_id=620883388254594

Dr. Ramon Reyes, MD

http://emssolutionsint.blogspot.com.es/2016/12/dr-ramon-reyes-diaz-md-emt-t-dmo.html

Les Esperamos en nuestro Grupo en TELEGRAM Soc. IberoAmericana de Emergencias

https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

Todos Nuestros VIDEOS en YouTube

https://www.youtube.com/c/RamonReyes2015

TCC-LEFR

http://emssolutionsint.blogspot.com/2017/09/curso-tcc-lefr-tactical-casualty-care_4.html

TECC

http://emssolutionsint.blogspot.com/2017/09/curso-tecc-espana-28-septiembre-2017.html

TCCC Tactical Combat Casualty Care Handbook

http://emssolutionsint.blogspot.com/2017/07/tactical-combat-casualty-care-handbook.html

TACMED España

http://emssolutionsint.blogspot.com/2017/09/tactical-medicine-tacmed-espana-by-ems.html

BCon Saber un poco mas sobre control de sangrados

http://emssolutionsint.blogspot.com/2017/07/stop-bleed-bleeding-control-basic.html

Hartford

http://emssolutionsint.blogspot.com/2016/07/the-hartford-consensus-iv-compendium.html

5 MITOS SOBRE EL USO DE TORNIQUETES English/ Español Control for the Injured Course "Stop The Bleed" / Control de Sangrados para el Herido

By Dr. Ramon REYES, MD

Faculty PHTLS-TCCC

https://es.linkedin.com/in/drramonreyes

Dr. Ramon Reyes, MD
Faculty TECC, TCCC, PHTLSEn Alabama, EUA
como Instructor y Facultado internacional

PARÍS, 23 Agosto 2015 (Reuters/EP)

Gracias al entrenamiento B-Con Control de Sangrados para el Herido By NAEMT

"El militar herido en el tren francés taponó la herida de otro pasajero con sus dedos "

ampliar información: http://www.europapress.es/internacional/noticia-militar-herido-tren-frances-tapono-herida-otro-pasajero-dedos-20150823224052.html

MANUAL DE ATENCIÓN AL PARTO EN EL ÁMBITO EXTRAHOSPITALARIO. Ministerio de Sanidad, Servicios Sociales e Igualdad. España

Viajar y volar durante el embarazo. INFOGRAFIA

Facilitador de parto ODON Autorizado por la OMS. Video

DOCUMENTACIÓN ESTRATEGIA DE ATENCIÓN AL PARTO NORMAL. MINISTERIO DE SANIDAD, POLÍTICA SOCIAL E IGUALDAD

Plan de Parto y Nacimiento Consejeria de Salud JUNTA de ANDALUCIA España

Parada Cardio-Respiratoria "PCR" en Embarazadas "REANIMACION CARDIO-PULMONAR, RCP EN EMBARAZADAS 2015-2020

Posiciones de Traslado y asistencia de pacientes by SERRALCO.es

EMBARAZO, PARTO y PUERPERIO Recomendaciones para Madres y Padres. Junta de Andalucia, España

MANUAL BASICO DE OBSTETRICIA Y GINECOLOGIA Gratis PDF. Ministerio de Sanidad, Servicios Sociales e Igualdad. España

¿Qué es el parto velado "Parto Empelicado" o nacer con bolsa intacta? by NATALBEN.com

Enfermería gineco-obstétrica - Noelia Socarrás Ibáñez

Balística de las heridas: introducción para los profesionales de la salud, del derecho, de las ciencias forenses, de las fuerzas armadas y de las fuerzas encargadas de hacer cumplir la ley http://emssolutionsint.blogspot.com/2017/04/balistica-de-las-heridas-introduccion.html

Guía para el manejo médico-quirúrgico de heridos en situación de conflicto armado by CICR http://emssolutionsint.blogspot.com/2017/09/guia-para-el-manejo-medico-quirurgico.html 

CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan CICR http://emssolutionsint.blogspot.com.es/2013/01/cirugia-de-guerra-trabajar-con-recursos.html 

Manual Suturas, Ligaduras, Nudos y Drenajes. Hospital Donostia, Pais Vasco. España http://emssolutionsint.blogspot.com/2017/09/manual-suturas-ligaduras-nudos-y.html

Manual CIERRE DE HERIDAS by ETHICON http://emssolutionsint.blogspot.com/2017/09/manual-cierre-de-heridas-by-ethicon.html

Manual de suturas. Menarini http://emssolutionsint.blogspot.com/2017/09/manual-de-suturas-menarini.html 

Técnicas de Suturas para Enfermería ASEPEYO y 7 tipos de suturas que tienen que conocer estudiantes de medicina http://emssolutionsint.blogspot.com/2015/01/tecnicas-de-suturas-para-enfermeria.html 

Cuaderno Enfermero.Cirugia Menor Heridas Suturas http://emssolutionsint.blogspot.com/2016/07/cuaderno-enfermerocirugia-menor-heridas.html 

Manual Práctico de Cirugía Menor. Grupo de Cirugia Menor y Dermatologia. Societat Valenciana de Medicina Familiar i Comunitaria http://emssolutionsint.blogspot.com/2013/09/manual-practico-de-cirugia-menor.html

Protocolo de Atencion para Cirugia. Ministerio de Salud Publica Rep. Dominicana. Marzo 2016 http://emssolutionsint.blogspot.com/2016/09/protocolo-de-atencion-para-cirugia.html 

Manual de esterilización para centros de salud. Organización Panamericana de la Salud http://emssolutionsint.blogspot.com/2016/07/manual-de-esterilizacion-para-centros.html

CURSO

Bleeding Control for the Injured Course "Stop The Bleed" / Control de Sangrados para el Herido

Curso TACMED Tactical Medicine España  and TECC-NAEMT Tactical Emergency Casualty Care  

Antiguo BCon Bleeding Control Course de la NAEMT Pack 

Hemos estado entrenando al personal de escolta del Ministro de Defensa de Republica Dominicana y en las practicas del uso del torniquetes hemos utilizado el CAT, SAM XT, SICH, TIE, DINPRO, los Mejores valorados por instructores y más de 48 Estudiantes;
1. DINPRO ganador Ucrania https://emssolutionsint.blogspot.com/2022/12/torniquete-dinpro-hecho-en-ucrania.html
2. SICH Ucrania https://emssolutionsint.blogspot.com/2023/05/torniquete-strengthened-individual.html
3. TIE España https://emssolutionsint.blogspot.com/2017/01/torniquete-compresor-de-emergencias.html
Mayo 23-25 del 2023 
Ministerio de Defensa de la Republica Dominicana 

Advertencia: El Dr. Ramon Reyes, MD no tiene compromisos personales, ni comerciales con ninguna de las marcas anteriormente mencionada
Contactos con el Dr. Ramon Reyes, MD https://emssolutionsint.blogspot.com/2016/12/dr-ramon-reyes-diaz-md-emt-t-dmo.html

RevMedx PARABELT® Tourniquet Belthttps://emssolutionsint.blogspot.com/2017/03/revmedx-parabelt-tourniquet-belt.html

TOURNIQUET SICH. STRENGTHENED INDIVIDUAL COMBAT HYBRID TOURNIQUET . TQhttps://emssolutionsint.blogspot.com/2019/01/tq-tourniquet-sich-strengthened.html
TOURNIQUET LAST INFORMATION / CAT COMBAT APPLICATION TOURNIQUET tm
http://emssolutionsint.blogspot.com/2017/02/tourniquet-last-information-cat-combat.html
El uso del torniquete en niños TQ Pediatrico/ Do commercially available tourniquets work on kids? UPDATED May 20 2019
http://emssolutionsint.blogspot.com/2018/09/el-uso-del-torniquete-en-ninos-by-c-tecc.html

SWAT Tourniquet 
https://emssolutionsint.blogspot.com/2015/02/swat-tourniquet-swat-t.html

R.A.T.S. Tourniquet Applicationhttp://emssolutionsint.blogspot.com/2015/12/rats-tourniquet-application.htmlMilitary Emergency Tourniquet (MET) Gen III by H&H Medical
http://emssolutionsint.blogspot.com/2017/06/military-emergency-tourniquet-met-gen.htmlSAM® XT TOURNIQUET RECALL: Torniquete SAM XT
http://emssolutionsint.blogspot.com/2017/07/sam-xt-tourniquet.html
STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINEhttp://emssolutionsint.blogspot.com/2018/11/stat-tourniquet-21-of-24-applications.htmlXstat Instructional "SEALS A GUNSHOT WOUND IN 15 SECONDS". Cleared to Stop Gun and Knife Wounds in Arms and Legs
http://emssolutionsint.blogspot.com/2015/12/xstat-instructional-seals-gunshot-wound.htmlCELOX RAPID Gaza con Agente Hemostatico que actua en menos de 60 Segundos
https://emssolutionsint.blogspot.com/2018/01/celox-rapid-gaza-con-agente-hemostatico.html

VISITAS RECIENTES

AUTISMO TEA PDF

We Support The Free Share of the Medical Information

Enlaces PDF por Temas

Nota Importante

Niveles de Alerta Antiterrorista en España. Nivel Actual 4 de 5.

lunes, 14 de abril de 2025

domingo, 13 de abril de 2025

GUIA DE SOPORTE VITAL PARA SEGURIDAD PRIVADA COMO PRIMER INTERVINIENTE EN INCIDENTES ARMADOS. by Juan Jose Pajuelo Castro y David Grevillen Carretero. SEMES 2018

PROTOCOLO PARA INTERVENCIONES DE SOPORTE VITAL EN INCIDENTES DE MÚLTIPLES VÍCTIMAS POR ATENTADOS TERRORISTAS ABRIL 2016 (Actualizado Marzo 2018) by Juan Jose Pajuelo

Stop The Bleed Campaign - App Now Available

GUIA DE SOPORTE VITAL EN INCIDENTES CON AMENAZA ELEVADA PARA PRIMER INTERVINIENTE POLICIAL by Juan Jose Pajuelo. España 2017

1) TORNIQUETES

2) GASA DE COMBATE

3) CELOX

4) PARCHE TORÁCICO

5) VENDAJES

6) HERRAMIENTA MULTIUSO

Conclusión

Resultados:

Comentarios

Dispositivos adecuados

Stop the Bleed Resources

The Hartford Consensus IV: A Call for Increased National Resilience

by LENWORTH M. JACOBS, JR., MD, MPH, FACS; AND JOINT COMMITTEE TO CREATE A NATIONAL POLICY TO ENHANCE SURVIVABILITY FROM INTENTIONAL MASS CASUALTY SHOOTING EVENTS PUBLISHED MARCH 1, 2016

Status update

Current national opinion

Current state of readiness and national resilience

Metrics for readiness

Metrics for resilience

Enhancing citizen resilience

Training considerations

Dissemination and implementation of a national resilience plan

Summary

Author’s note:

The Hartford Consensus IV: A Call for Increased National Resilience

Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events

Participants

American College of Surgeons Releases Hartford Consensus Compendium

Blood gushes from virtual leg injury to help train combat medics

American College of Surgeons "Hartford Consensus Compendium" Logo

The Hartford Consensus III: Implementation of Bleeding Control

Professional first responders

Building educational capabilities

Roundtable on bystanders: Our nation’s immediate responders

The Hartford Consensus III: Implementation of Bleeding Control

Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events

Compress

Tourniquet

Compress Again

More Information

Control de Sangrados para el Herido By NAEMT.

5 MITOS SOBRE LOS TORNIQUETES

Stop the Bleed Initiative: How You Can Help in an Emergency Situation

What is “Stop the Bleed”?

“Stop the Bleed” at Orlando Health

IPSA InfoBrief: Stop the Bleed

06 Mar 2018 11:33 AM International Public Safety Association

RevMedx PARABELT® Tourniquet Belt

TOURNIQUET SICH. STRENGTHENED INDIVIDUAL COMBAT HYBRID TOURNIQUET . TQ

TOURNIQUET LAST INFORMATION / CAT COMBAT APPLICATION TOURNIQUET tm

El uso del torniquete en niños TQ Pediatrico/ Do commercially available tourniquets work on kids? UPDATED May 20 2019

R.A.T.S. Tourniquet Application

Military Emergency Tourniquet (MET) Gen III by H&H Medical

SAM® XT TOURNIQUET RECALL: Torniquete SAM XT

STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINE

Xstat Instructional "SEALS A GUNSHOT WOUND IN 15 SECONDS". Cleared to Stop Gun and Knife Wounds in Arms and Legs

CELOX RAPID Gaza con Agente Hemostatico que actua en menos de 60 Segundos

PRINCIPIOS DEL BLOG

NORMAS DE USO DEL BLOG

by LENWORTH M. JACOBS, JR., MD, MPH, FACS; AND JOINT COMMITTEE TO CREATE A NATIONAL POLICY TO ENHANCE SURVIVABILITY FROM INTENTIONAL MASS CASUALTY SHOOTING EVENTS

PUBLISHED MARCH 1, 2016

06 Mar 2018 11:33 AM
International Public Safety Association