野外與登山醫學-到院前止血-傷口填塞 Wound Packing Essentials (這篇是寫給EMT救護員的)

2025-07-24 08:00AM

重點, 傷口填塞注意事項

1. 腹股溝或腋窩傷口不容易直接加壓止血. 也無法使用一般止血帶. 使用紗布填塞入傷口. 可加強直接加壓止血效果

2. 少量出血不需要填塞紗布

3. 可用於腹股溝, 腋窩, 背部, 四肢的大傷口

4. 禁止使用於頸部、胸部、腹部或骨盆的傷口

5. 填充的紗布可加上止血劑進行填塞

6. 危及生命的狀況. 填充物是否無菌不是很重要. 但仍建議盡量使用乾淨材料

7.  雙手是最好用的加壓工具. 無法長時間用手加壓傷處, 可使用輔助裝備. 例如止血帶. 

Wound Packing Essentials for EMTs and Paramedics
April 1, 2017 Scotty Bolleter, BS, EMT-P. A.J. Heightman, MPA, EMT-P . Peter P. Taillac, MD, FACEP
這篇論文發表於2017年JEMS (Journal of Emergency Medical Services). 

作者 Scotty Bolleter 是美國德州高級救護技術員
Emergency Medical Services, EMS, 緊急醫療服務(也有論文翻譯成緊急醫療系統)

是指確保患者在到院前能得到必要的急救醫療服務以及決策管理運送患者至適當的醫療單位的系統機制，其內容包含傷病現場急救處理、救護車送醫途中的到院前緊急救護以及到院後的急診醫療服務。
剛搜尋了一下 JEMS 的 impact factor 2.3 不算太高但也不低. 

原文太長. 僅節錄幾段. 下面中文是大部分使用 google 中文翻譯. 刪除線的文字是google翻譯的詞.我覺得不恰當而修改的.

前言

無法控制的出血是創傷中可預防死亡的最大原因。當肢體出血無法控制時，許多（即使不是大多數）急救機構已經認識到使用止血帶的益處。

如今，由於全國各地進行的「止血」教育活動強調旁觀者對槍擊事件的反應，許多一般民眾現在開始熟悉簡單但有效的止血技術。 1

對於急救人員來說，使用直接壓迫和止血帶治療肢體出血相對簡單。然而，最棘手的傷口是交界處——腹股溝和腋窩——這些部位無法使用止血帶。這些部位的出血通常較深，維持足夠的外部壓力可能很困難，甚至不可能。 2

多年來，美國軍方一直在向醫護人員傳授使用標準紗布和止血敷料進行傷口填塞的技巧。 3就像止血帶從軍用急救醫療服務到民間急救醫療服務的過渡一樣，這些技能如今也正被戰術急救醫療團隊以及戰地急救醫療隊和護理人員所採用。傷口填塞可以與止血帶搭配使用，也可以單獨作為出血管理處置技術。

何時打包填塞
簡而言之，如果傷口沒有出血（或僅少量出血），則無需填塞。四肢和交界處的傷口可以填塞。如果最初在四肢傷口上放置了止血帶，之後可以換成加壓敷料或填塞物，這樣可能對患者更舒適，並能提供適量的遠端血液循環。

直接按壓通常足以治療頸部出血的傷口。頸部傷口通常不進行包紮傷口填塞，因為有損害呼吸道的風險。

雖然背部傷口的出血通常不會很多，並且可以透過簡單的加壓敷料來控制，但根據以色列的經驗，背部傷口的包紮傷口填塞是成功的。

胸部、腹部或骨盆的傷口不應進行包紮傷口填塞，因為這些傷口的出血通常來自非常深的部位，無法從外部觸及。這些患者必須迅速轉運至外科醫師處進行手術止血。因此，這些部位傷口的包紮傷口填塞應由當地急救醫療服務（EMS）的醫療主任或相關州政府機構酌情決定。

傷口包紮材料
用於止血的填塞材料有很多種選擇。市售的止血紗布產品中浸漬了各種旨在促進血塊形成的物質，包括高嶺土、殼聚醣等。

在 2017 年 1 月的更新中，軍事戰術戰鬥傷亡護理委員會 (CoTCCC) 推薦使用 QuikClot 戰鬥紗布作為「首選止血敷料」。 

CoTCCC 批准的替代方案包括 Celox Gauze、ChitoGauze 和 XStat。軍醫對 Combat Gauze 的使用經驗最豐富，因為它已被廣泛使用多年。

所有止血產品只要使用得當，都非常有效。有趣的是，即使是普通紗布（未浸漬止血劑）也被發現非常有效。 6 如果您沒有止血劑，可以使用普通紗布，這真是太好了。

傷口填塞技術
對於現場提供者施救者來說，使用哪種產品並不重要；更重要的是如何使用產品。

步驟1：止血。立即！立即用紗布、乾淨的布、手肘、膝蓋等任何能減緩或止血的物體直接按壓傷口，直到有時間取出傷口包紮用品。

將戴手套的手指（無論是否包紮敷料）伸入傷口，對目標區域（目標可以是靜脈、動脈或兩者）施加初始壓力，並壓迫出血源。請記住，人體解剖學中，主要血管靠近骨骼。因此，盡可能利用骨骼來輔助控制血管（即出血）。這也能讓你了解傷口的走向，並據此插入紗布。

第二步：用紗布填塞傷口。一定要填塞緊實！目標是將傷口完全填塞嚴實，以止血。用手指將紗布填塞進傷口，同時保持對傷口的壓力。

至關重要的是，紗布必須盡可能深入傷口，確保其直接接觸出血血管。這樣，既能直接壓迫出血血管，又能讓止血劑發揮其神奇功效。

第三步：繼續包紮！成功包紮傷口的關鍵在於將傷口包紮得非常緊密，並盡可能對出血血管施加壓力。這種對血管的壓力是控制出血最重要的因素。這解釋了為什麼普通紗布（未浸漬止血劑）在緊密包紮的情況下也非常有效。

步驟4：用力按壓包紮好的傷口3分鐘。此步驟可將包紮物牢固地壓在出血血管上，並有助於凝血。

步驟5：固定貼合的壓力敷料並轉運。加壓3分鐘後，將貼合的壓力敷料覆蓋在傷口上。如果可能的話，可以考慮用夾板固定或固定傷口，因為轉運過程中的移動可能會使敷料移位，導致再次出血。

When to Pack
Simply stated, if there’s no (or only minimal) bleeding, the wound doesn’t need packing. Wounds of the extremities and junctional areas are amenable to packing. If a tourniquet is initially placed on an extremity wound, it may later be replaced with a pressure dressing or with packing, which may be more comfortable for the patient and provide for a moderate amount of distal circulation.

Direct pressure will usually suffice for bleeding neck wounds. Wounds of the neck aren’t generally packed because of the risk for airway compromise.

Although the bleeding from a back wound will typically not be profuse and may be controlled with a simple pressure dressing, in the Israeli experience, wounds of the back were packed successfully.

Wounds of the chest, abdomen or pelvis shouldn’t be packed because bleeding from these wounds is generally from a very deep source that can’t be reached from the outside. These patients must be rapidly transported to a surgeon for operative bleeding control. Packing of wounds in these areas should therefore be performed at the discretion of local EMS Medical Directors or the appropriate state agencies where applicable.

Wound Packing Material
There are many choices for packing material designed to control hemorrhage. The commercial hemostatic gauze products are impregnated with a variety of substances designed to enhance clot formation, including kaolin, chitosan and others.

In its January 2017 update, the military’s Committee on Tactical Combat Casualty Care (CoTCCC) recommended QuikClot Combat Gauze as the “hemostatic dressing of choice.”5

Alternatives approved by the CoTCCC include Celox Gauze, ChitoGauze and XStat. Military medics have the most experience with Combat Gauze, as it has been widely deployed for years.

All the hemostatic products are highly effective when used properly. Interestingly, even plain gauze (without an impregnated hemostatic agent) has been found to be highly effective.6 It’s nice to know you can use plain gauze if hemostatic agents are not available to you.

Wound Packing Technique
It’s less important to the field provider which product is used; what’s more important is how the product is used.

Step 1: Stop the bleeding. Now! Immediately apply direct pressure to the wound, using gauze, clean cloth, elbow, knee-whatever it takes to slow or stop the hemorrhage-until you have time to get out your wound packing supplies.

Place your gloved fingers-with or without a dressing-into the wound to apply initial pressure to the target area (with your target being the vein, artery or both) and compress the source of bleeding. Keep in mind that the body’s anatomy presents with major vessels running close to bones. So, whenever possible, utilize a bone to assist with vessel (i.e., bleeding) control. This will also give you an idea of which direction the wound travels and you can insert the gauze accordingly.

Step 2: Pack the wound with gauze. Tightly! Your goal is to completely and tightly pack the wound cavity to stop hemorrhage. Begin packing the gauze into the wound with your finger, while simultaneously maintaining pressure on the wound.

It’s critical that the gauze be packed as deeply into the wound as possible to put the gauze into direct contact with the bleeding vessel. By doing so, you’re simultaneously putting direct pressure onto the bleeding vessel and allowing the hemostatic agent to do work its magic.

Step 3: Keep packing! The key to successful wound packing is that the wound be very tightly packed, applying as much pressure as possible to the bleeding vessel. This pressure against the vessel is the most important component of hemorrhage control. This explains why plain gauze (without an impregnated hemostatic agent), when tightly packed, is also quite effective.

Step 4: Apply very firm pressure to the packed wound for 3 minutes. This step pushes the packing firmly against the bleeding vessel and aids in clotting.

Step 5: Secure a snug pressure dressing and transport. After applying pressure for 3 minutes, place a snug pressure dressing over the wound. You may consider splinting or immobilizing the area, if possible because movement during transport can dislodge the packing and allow hemorrhage to restart.