M.A.R.C.H. M.A.R.C.H. 10/11/2017. Hartford Consensus 2 April Comparison of Statistics for Battle Casualties,

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1 Presented by: Envision/EM Care 15 th Annual Advanced Emergency and Acute Care Medicine Conference Stop the Bleed EAST COAST TACTICAL MEDICINE Dr. A. Scott Whyte Danny Devlin Emergency Physician Level II Trauma Center Tactical Physician SWAT TCCC/TECC Instructor ACLS/PALS Instructor ATLS Provider (former instructor) EMT Instructor High School Girls Ice Hockey Coach US Army Special Forces Assistant Detachment Commander US Army Ranger Qualified Special Forces Advanced Urban Combat Instructor TCCC/TECC Provider BCON Instructor Evanna Burgwardt BSN, RN, CCRN Emergency Nurse, Level II Trauma Center Cardiac Intensive Care Unit Nurse ACLS/PALS Provider ABLS Provider TCCC Provider BCON Instructor Lawrence Smira US Navy Hospital Corpsman Fleet Marine Force Corpsman Combat Life Saver Instructor EMT TCCC Provider TECC/ BLS Instructor 1

OBJECTIVES Case Studies Data Review Bleeding Control Hands On Tourniquet Application Pressure Dressings Hemostatic Dressings Non-Compressible Bleeding Certify Participants B-Con Providers Bleeding

Boston Marathon bombings April 15, 2013 According to the Boston Public Health Commision: 264 people treated at 27 local hospitals 16people lost limbs at the scene or at the hospital 3lost more than

62x39 AK-47 rounds. Penetrating wounds to arms, legs and chest reported.

2 OBJECTIVES Case Studies Data Review Bleeding Control Hands On Tourniquet Application Pressure Dressings Hemostatic Dressings Non-Compressible Bleeding Certify Participants B-Con Providers Bleeding Control (B-Con) Why is it important and why should Ilearn this? Boston Marathon bombings April 15, 2013 According to the Boston Public Health Commision: 264 people treated at 27 local hospitals 16people lost limbs at the scene or at the hospital 3lost more than 1limb Many had lower limb injuries and shrapnel from explosive devices low to the ground Charlie Hebdo shooting January 7, Fatalities 11 Wounded All injuries by penetrating by 7.62x39 AK-47 rounds. Penetrating wounds to arms, legs and chest reported. Columbine High School April 20, Deaths 24 Wounding's 21 by gunshots 9mm Pistol rounds, 9mm carbine rounds and 12 gauge shotgun. IED s brought by perpetrators never used. Why should Ilearn this? The life you save may be your own! At the end of the day you owe it to yourself, your family, your partner and those that care for and about you to make it home safely! TCCC is the current training based on this learning. Bleeding Control has proven to save lives. 2

Hartford Consensus 2 April 2013 Working group organized by American College of Surgeons Board of Regents and FBI In response to Sandy Hook shootings Excerpt from findings: M.A.R.C.H. Massive hemorrhage control life-threatening bleeding.

3 Hartford Consensus 2 April 2013 Working group organized by American College of Surgeons Board of Regents and FBI In response to Sandy Hook shootings Excerpt from findings: M.A.R.C.H. Massive hemorrhage control life-threatening bleeding. Airway establish and maintain a patent airway. Respiration decompress suspected tension pneumothorax, seal open chest wounds, and support ventilation/oxygenation as required. M.A.R.C.H. Circulation establish IV/IO access and administer fluids as required to treat shock. Head injury/hypothermia prevent/treat hypotension and hypoxia to prevent worsening of traumatic brain injury and prevent/treat hypothermia. Comparison of Statistics for Battle Casualties, Holcomb et al J Trauma 2006 The U.S. casualty survival rate in Iraq and Afghanistan has been the best in U.S. history. World War II Vietnam OIF/OEF CFR 19.1% 15.8% 9.4% Note: CFR is the Case Fatality Rate the percent of those wounded who die Potentially Preventable Deaths (232) in OIF and OEF (Data based on the Wound Data Munitions Effectiveness Team (WDMET) during the Vietnam War between 1967 and 1969) CNS 9% MSOF 4% Airway 14% NEXT Hemorrhage 85% 31% Compressible (prehospital target) 69% Non-Compressible (FST/CSH target) From evaluation of 982 casualties, and casualties could have more than 1 cause of death. (Kelly J., J Trauma 64:S21, 2008) 3

U.S. Combat Fatalities: Death from Hemorrhage Extremity [119/888] = 13.5% Junctional [171/888] = 19.2% Truncal [598/888] = 67.

it rarely controls bleeding no matter how tightly applied. Eastridge BJ, Mabry RL, Seguin PG, et al.

Vietnam Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. These casualties had no other injuries. Tourniquets in U.

Medics and corpsmen were being trained in courses where they were taught notto use them.

4 U.S. Combat Fatalities: Death from Hemorrhage Extremity [119/888] = 13.5% Junctional [171/888] = 19.2% Truncal [598/888] = 67.3% Tourniquets in WWII Wolff AMEDD J April 1945 We believe that the strap-and-buckle tourniquet in common use is ineffective in most instances under field conditions it rarely controls bleeding no matter how tightly applied. Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield ( ): implications for the future of combat casualty care. Journal of Trauma 2012, 73(6) Suppl 5: Vietnam Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. These casualties had no other injuries. Tourniquets in U.S Military Mid-1990s Old strap-and-buckle tourniquets were still being issued. Medics and corpsmen were being trained in courses where they were taught notto use them. Tourniquets Beekley et al Journal of Trauma st CSH in casualties with severe extremity trauma 67 with prehospital tourniquets; 98 without Seven deaths Four of the seven deaths were potentially preventable had an adequate prehospital tourniquet been placed Eliminating Preventable Death on the Battlefield TCCC in the 75 th Ranger Regiment AllRangers and docs trained in TCCC Ranger preventable death incidence: 3% Overall U.S. military preventable deaths: 24% 4

5 Danny Devlin US Army Special Forces Assistant Detachment Commander US Army Ranger Qualified Special Forces Advanced Urban Combat Instructor TCCC/TECC Provider BCON Instructor 5

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9 Lawrence Smira US Navy Hospital Corpsman Fleet Marine Force Corpsman Combat Life Saver Instructor EMT TCCC Provider TECC/ BLS Instructor 9

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JunctionalHemorrhage Junctional hemorrhage

Buttocks Perineum Axilla Base of neck Junctional

Hemorrhage Groin hemorrhage is the most common

tourniquets cannot work. Kelly JF, et al.

12 JunctionalHemorrhage Junctional hemorrhage includes hemorrhage in the following areas: Groin Buttocks Perineum Axilla Base of neck Junctional Hemorrhage Wounds That May Result in Junctional Hemorrhage Groin hemorrhage is the most common type of junctional bleeding where regular tourniquets cannot work. Kelly JF, et al. J Trauma. 2008;64(suppl 2) Typically caused by dismounted IED attacks 12

Junctional Hemorrhage Control Evanna Burgwardt BSN, RN, CCRN Emergency Nurse, Level II Trauma Center Cardiac Intensive Care Unit Nurse ACLS/PALS Provider ABLS Provider TCCC Provider BCON Instructor

13 Junctional Hemorrhage Control Evanna Burgwardt BSN, RN, CCRN Emergency Nurse, Level II Trauma Center Cardiac Intensive Care Unit Nurse ACLS/PALS Provider ABLS Provider TCCC Provider BCON Instructor Blood Loss and Shock Question: How does your body react to blood loss? Answer: It depends on how much blood is lost. 5 Liters Blood Volume Normal Adult Blood Volume: 5 Liters 1 liter by volume 1 liter by volume 1 liter by volume 1 liter by volume 1 liter by volume 4.5 Liters Blood Volume 500 cc Blood Loss 500 cc Blood Loss Mental state: Alert Radial pulse: Full Heart rate: Normal or slightly increased Systolic blood pressure: Normal Respiratory rate: Normal Is the casualty going to die from this? NO 13

14 1000 cc Blood Loss 1000 cc Blood Loss 4.0 Liters Blood Volume Mental state: Alert Radial pulse: Full Heart rate: 100+ Systolic blood pressure: Normal when supine Respiratory rate: May be normal Is the casualty going to die from this? NO 1500 cc Blood Loss 3.5 Liters Blood 3.5 Volume Liters Blood Volume 1500 cc Blood Loss Mental state: Alert but anxious Radial pulse: May be weak Heart rate: 100+ Systolic blood pressure: May be decreased Respiratory rate: 30 Is the casualty going to die from this? PROBABLY NOT 3.0 Liters Blood Volume 2000 cc Blood Loss 2000 cc Blood Loss Mental state: Confused/lethargic Radial pulse: Weak Heart rate: 120+ Systolic blood pressure: Decreased Respiratory rate: > 35 Is the casualty going to die from this? MAYBE 14

15 2.5 Liters Blood Volume 2500 cc Blood Loss 2500 cc Blood Loss Mental state: Unconscious Radial pulse: Absent Heart rate: 140+ Systolic blood pressure: Markedly decreased Respiratory rate: Over 35 Is the casualty going to die from this? MOST LIKELY Danny Devlin US Army Special Forces Assistant Detachment Commander US Army Ranger Qualified Special Forces Advanced Urban Combat Instructor TCCC/TECC Provider BCON Instructor 15

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The Medical Director must decide the agent of choice. Courtesy Dr. Bijan Kheirabadi Quick Clot Combat Gauze Dr. A.

17 Hemostatic Agent There are many hemostatic agents available. These agents have varying levels of evidence supporting a single agent. The Medical Director must decide the agent of choice. Courtesy Dr. Bijan Kheirabadi Quick Clot Combat Gauze Dr. A. Scott Whyte Emergency Physician Level II Trauma Center Tactical Physician SWAT TCCC/TECC Instructor ACLS/PALS Instructor ATLS Provider (former instructor) EMT Instructor High School Girls Ice Hockey Coach 17

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TranexamicAcid (TXA) Hemorrhage is the leading cause of preventable death in the tactical environment. Tourniquets and Tactical Gauze do not work for internal bleeding.

19 TranexamicAcid (TXA) Hemorrhage is the leading cause of preventable death in the tactical environment. Tourniquets and Tactical Gauze do not work for internal bleeding. TXA is shown to slow or stop some internal bleeding. Tranexamic Acid (TXA) Does not promote new clot formation Prevents clots which are forming from being broken down by the body Helps prevent death from hemorrhage Two major studies have shown a survival benefit from TXA, especially in casualties that require a massive transfusion of blood products. Hemostasis Blood normally flows unimpeded thru intact endothelial blood vessel walls If a wall is damaged, a fast, localized, controlled response tries to stop the bleeding. Three phases of hemostasis: 1. Vascular spasm and retraction 2. Platelet plug formation 3. Coagulation This is followed by fibrinolysis. 1. Vascular Spasm and Retraction Stimuli cause vasospasm: 1. Direct injury to smooth muscle 2. Chemicals released by endothelial cells and platelets 3. Reflexes initiated by local pain receptors Spasm becomes more efficient with increased tissue damage. 2. Platelet Plug Formation Platelets normally inactive When exposed to damaged endothelium and underlying exposed collagen, platelets swell and form spikes, become sticky and adhere to collagen Plates release serotonin (enhances vascular spasm), ADP (attracts more platelets), etc. Platelet plug limited to immediate area of injury by prostacyclin (released by endothelial cells) 19

20 Clotting Cascade 3. Coagulation Phase Intrinsic Pathway All clotting factors are within the blood vessels. Slower clotting Extrinsic Pathway Initiating factor is outside the blood vessels - tissue factor Faster clotting in seconds Clotting Cascade Clotting Cascade Clotting Cascade Transforms blood from a liquid to a gel Begins in 30 seconds Hemostasis 20

21 TranexamicAcid Synthetic amino acid, first introduced in Sweden in Prevents fibrinolysis and breakdown of clot. It is also a very weak inhibitor of thrombin. Tranexamic Acid Mechanism of action: TXA inhibits conversion of plasminogen to plasmin, hence prevents breakdown of clot. Increases collagen synthesis which preserves the fibrin matrix and increases the tensile strength of the clot. These actions help to stabilize the clot. Hemostasis with TXA Tranexamic Acid CRASH-2 Study MATTERS Study To see if tranexamicacid saves lives in bleeding trauma patients CRASH-2: Methods Study Included all adult trauma patients who were within 8 hours of their injury, if their doctor thought that they had or could have significant hemorrhage Patients were randomly allocated to get tranexamic acid or placebo End point: Death in hospital within 4 weeks of injury and all important side effects 20,211 patients 274 hospitals 40 countries (but not the U.S.) 21

22 Results Cause of death TXA Placebo Risk of death P value 10,060 10,067 Bleeding ( ) Thrombosis ( ) Organ failure ( ) 0.25 Head injury ( ) 0.60 CRASH-2 Conclusions Tranexamicacid: Reduces mortality in bleeding trauma patients Does not seem to increase unwanted clotting Must be given early within 3 hours of injury, preferably within 1 hour Is inexpensive Could save hundreds of thousands of lives each year around the world Other ( ) 0.63 Any death ( ) Tranexamic Acid After the CRASH-2 trial, tranexamicacid was added to the WHO List of Essential Medicines (March 2011). Some countries military are using tranexamicacid to treat combat casualties. The U.K. military has been using TXA since Tranexamicacid is being used in many hospitals around the world. Tranexamic acid could (should?) be given in ambulances. CRASH-2 Study Limitations Entry criteria: Adult trauma patients within 8 hours of injury who had or could have significant hemorrhage. BUT Only 50% of patients in each group actually needed transfusion. Participating sites: Many countries with less developed EMS and trauma care systems. No information about prehospital time or care given. CRASH-2 Study Limitations Military Application of TranexamicAcid in Trauma Emergency Resuscitation TXA No TXA P value # Patients (896) Inj. Severity Score TXA MATTERS Study (1 of 2) (NS) Overall Mortality 17.4% 23.9% 0.03 Retrospective Review by U.S. Military TXA vsno TXA in trauma patients receiving 1 or more units of packed RBCs # Pts Massive Transfusion Mortality Massive Transfusion % 28.1% Complications Pulmonary Emb. 2.7% 0.3% DVT 2.4% 0.2%

23 TXA Survival benefit GREATEST when given within 1 hour of injury. Survival benefit still present when given within 3 hours of injury. DO NOT GIVE TXA if more than 3 hours have passed since the casualty was injured survival is DECREASED by TXA given after this point. DON T DELAY WITH TXA! TXAAdministration: 1st Dose Supplied in 1 gram (1000 mg) ampoules. Inject 1 gram of TXA into a 100-cc bag of normal saline or lactated ringer s Infuse slowly over 10 minutes. Rapid IV push may cause hypotension If there is a new-onset drop in BP during the infusion, SLOW DOWN the TXA infusion. Then administer crystalloid or blood products, per local protocol. TXAAdministration: 2nd Dose Typically given after the casualty arrives at Trauma Center. May be given in field if evacuation is delayed and fluid resuscitation has been completed before arrival at the medical facility. If still in field or in evacuation mode when fluid resuscitation is complete, give second dose of TXA as directed for the first dose. SUMMARY Case Studies Data Review Bleeding Control Hands On Tourniquet Application Pressure Dressings Hemostatic Dressings Non-Compressible Bleeding Certify Participants B-Con Providers Congratulations -You are all now certified B-Con Providers! 23

Hemorrhage Control. Chapter 6

Hemorrhage Control. Chapter 6 Chapter 6 The hemorrhage that take[s] place when a main artery is divided is usually so rapid and so copious that the wounded man dies before help can reach him. Colonel H. M. Gray, 1919 Stop the Bleeding!