A heavy flow is not massive hemorrhage: Tampons don’t belong in Trauma/First Aid Kits!

In response, we were surprised by how many people advocated for tactical tampons to control massive hemorrhage in a gunshot wound. “Depending on the bullet hole size, tampon and pads are your best bets…” Or, “A tampon would have done the same thing.” Not true.  It’s not their job and it’s beyond their capability. While many have written on the fallacy of using tampons for hemorrhage control and wound packing in massively bleeding wounds, there are still those on the internet who continue to endorse this misguided technique.

Although anecdotal stories of tampons being used in military settings for hemorrhage control may exist, using a tampon as a bandage or “blood sponge” is very different than trying to stop massive hemorrhage with one.  The military has a long history of one generation handing down unofficial lessons learned to the next generation.  It seems possible some military medic somewhere was told, “it was the way to go,” but it doesn’t mean it works.  One member of a medic team I talked with remembers  specifically being told the instructors had tried tampons for hemorrhage control, but they were never effective.

Named arteries (generally the larger ones such as the axilla, brachial, radial, etc) can bleed several hundred milliliters of blood per minute when perforated.  (200 milliliters is about 40 teaspoons for those metric-adverse, or 4 shot glasses if that’s your preferred unit of measure). Prehospital hemorrhage control options for this kind of bleeding are tourniquets, if the bleeding source is amenable to circumferential pressure, for instance, a limb, or wound-packing if the bleeding is in “junctional areas” like the neck, axilla, and groin.

To control life-threatening hemorrhage anywhere in the body, the goal is to stop the bleeding.  That is generally accomplished by encouraging the blood to clot and essentially “seal the hole” in the bleeding blood vessel.  With wound packing, this is done by tightly packing gauze directly at the point of bleeding.  When enough gauze is packed into the wound, the pressure exerted by the packing will be more than the bleeding blood vessel’s bleeding pressure. This slows or stops the bleeding and allows for clotting to occur. In a ballistic gel wound model, measuring a volume of 53 ml, a Kerlix–like gauze exerted 156 mmHg pressure in the wound when packed by well-trained combat medics.

Still inclined to keep tampons in your IFAK or first aid kit?  The average tampon contains approximately 2 – 2×4 inch pieces of gauze. Kerlix gauze is between 3.6-4.1 yards long. From a cost perspective, tampons also make no sense to stock in an IFAK. If a tampon costs $0.24 each (at bulk Amazon pricing) and is approximately 4” of gauze, it would take $8.64 worth of tampons to equal the length of packing material in one $1.99 roll of Kerlix (at non-bulk pricing). If someone is bleeding to death from a junctional wound, shoving a 4×4 in the wound is not going to accomplish the same thing as 156mmHg pressure from 12 feet of gauze.

Hemostatic gauzes help with clotting by providing pro-coagulant materials or mucoadhesive, thus making it easier for blood to clot.  The goal of the packed gauze isn’t to absorb blood, but to encourage clotting.  That is exactly how direct pressure works. Provide so much pressure on the bleeding site that blood can’t come out, which allows the clot to form. With no pressure, the blood keeps washing the body’s efforts to form a clot out with the blood. If you need to improvise to pack a wound, there are much better and readily available choices than a tampon, including strips of fabric.

Tampons are not designed to stop bleeding, but rather simply absorb it. “The function of the internal tampon is to absorb menstrual blood inside the vagina after it has left the uterus, preventing it from leaking out, and thus providing suitable protection with total discretion.”

How much blood does a woman even lose during menses? “Most women will lose less than 80 ml (16 teaspoons) of blood during their period, with the average being around 6 to 8 teaspoons.  Heavy menstrual bleeding is defined as losing more than 80 ml with each period.” Remember a shot glass is 50 ml. Though inconvenient, this is not a lot of bleeding.

How much blood is the most absorbent tampon made to soak up?  The most absorbent tampons manufactured are “Ultra-absorbency Tampons” which absorb up to 17 ml of menstrual blood.

FUN FACT!
For a little history on the tampon, there are different accounts of its first use.  Women have been fashioning solutions to absorb menstrual flow since the Egyptian era, including intravaginally. The first commercial applicator tampon was created by Dr. Earle Cleveland Hass. Dr. Haas obtained a patent for this tampon in 1933. He combined the terms “tampon” and “vaginal packs” to create “Tampax”.⁸