Batten Down the Hatches!- Hemorrhage Control
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1 Batten Down the Hatches!- Hemorrhage Control Brandon B. Bleess, MD,
2 PLEASE SHARE! #C3C2018 #FOAMed #FOAMems #FOANed #FOAMpara #StopTheBleed
3 DISCLOSURES Nothing to disclose Will discuss commercially available devices- not an endorsement of any particular product Opinions expressed are my own Always follow local protocols
4 OBJECTIVES Understand out of hospital hemorrhage control options with evidence supporting these methods Discuss public access hemorrhage control and other public health initiatives related to hemorrhage control Understand some controversies related to certain hemorrhage control techniques
5 WHY TALK ABOUT THIS?
6 WHY TALK ABOUT THIS?
7 ZERO PREVENTABLE DEATHS Joint Project in 2016: ACEP ACS NAEMSP NAEMT Trauma Center Association of America Department of Defense Department of Homeland Security Department of Transportation
8 TOURNIQUETS
9 TOURNIQUET HISTORY Tourner: French for to turn 4 th Century BC-Alexander the Great to control bleeding Roman Empire controlled bleeding from limb amputations during warbronze straps with leather for comfort 1785: Sir Gilbert Blane suggested each Royal Navy sailor carry a tourniquet
10 WHAT WOULD JOHNNY AND ROY DO?
11 FIRST EMS TEXTBOOK
12 TOURNIQUET PRESENT Change of thought after Somalia where uncontrolled hemorrhage caused 22% of the fatalities Between 2005 and 2011, 2,000 American lives saved due to tourniquets in Iraq and Afghanistan Frequently noted in recent MCIs
13 SHOW ME THE EVIDENCE 499 patients with 862 tourniquets applied to 651 limbs 87% survival rate 1.7% morbidity rates with nerve palsies 0.4% major limb shortening Survival with prehospital application (89% vs. 78%) Application before the onset of shock (96% vs. 4%) Kragh J, J Emer Med, 2011
14 WHAT ABOUT THE CHILDREN? Retrospective review of 88 pediatric casualties at US military hospitals Average Age 11 years (range 4-17 years) Survival rate 93% (7 dead and 81 survivors) Survivor and dead casualties were similar in all independent variables measured except hospital stay duration (median 5 days vs 1 day) Six casualties (7%) had neither extremity or external injury indicating tourniquet use Survival rate similar to non-pediatric studies Kragh J, Pediatr Emerg Care, 2012
15 PRACTICE MAKES PERFECT
16 MAYBE NOT THE HOLY GRAIL? Retrospective study of 12 public mass shootings Average of 2.7 GSWs, 58% to head and chest vs 20% to extremity Probable fatal wound was head or chest in 77% of cases Only 7% had potentially survivable wounds NO DEATHS FROM EXSANGUINATION FROM AN EXTREMITY Pattern is different from combat--solution goes beyond tourniquets Smith ER, Trauma Acute Care Surg, 2016
17 COMBAT COMPRESSION BANDAGES
18 ISRAELI BANDAGE Invented by Israeli military medic, Bernard Bar-Natan in 1998 First used in Bosnia and Herzegovina with NATO Standard in US Army since 2003 Allows pressure to be placed on the wound site
19 OLAES MODULAR BANDAGE Developed by Ross Johnson, Special Forces Medic in 2006 Named after Tony Olaes, Special Forces Medic KIA in Afghanistan Contains: Occlusive plastic sheet Removable gauze Pressure bar that doubles as eye cup
20 SHOW ME THE EVIDENCE 10 healthy volunteers as representatives of medics and soldiers Evaluated the amount of pressure exerted by bandage with pressure bar over wound and surrounding areas (90 increments) Pressure bar very effective in elevating applied pressure while not applying unnecessary pressure over other areas (11.26 vs PSI) Adding 2 twists increases pressure (14.18 vs PSI) Perfusion of capillaries in hand and fingers found to be adequate (radial pulse and capillary refill) Shipman N, Mil Med, 2009
21 WOUND PACKING
22 WOUND PACKING Step 1: Stop the bleeding Immediately apply direct pressure to the wound and place your gloved fingers-with or without a dressing-into the wound to apply initial pressure to the target area and compress the source of bleeding. Step 2: Pack the wound with gauze 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.
23 WOUND PACKING Step 3: Keep packing The wound should 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. Step 4: Apply very firm pressure to the packed wound This step pushes the packing firmly against the bleeding vessel and aids in clotting. Step 5: Secure a snug pressure dressing Place a snug pressure dressing over the wound. You may consider splinting or immobilizing the area--possible movement can dislodge the packing and allow hemorrhage to restart.
24 WOUND PACKING
25 HEMOSTATIC GAUZE
26 IDF RESEARCH 122 patients--133 hemostatic dressing applications 37 dressings (27.8%) junctional areas 92 dressings (72.1%) non-junctional areas 88.6% (31 of 35 available) successful in junctional areas 91.9% (57 of 62 available) successful in extremity applications Shina A, J Trauma, 2015
27 HEMOSTATIC DRESSING IN SWINE 80 swine in five treatment groups (16 animals each) 5 different agents applied with 5 minutes of manual pressure Hemodynamic parameters were recorded over 180 minutes Primary endpoints-initial hemostasis &incidence of rebleeding 15% (12/80) failed to achieve initial hemostasis Not significantly different between groups (p= 0.11) Rebleeding rate 33% Not significantly different between groups (p= 0.25) Littlejohn LF, Acad Emerg Med, 2011
28 STOP THE BLEED Launched in October of 2015 Partnership between: The White House Department of Defense ACEP ACS-COT Effort to encourage bystanders to become trained, equipped, and empowered to help before professional help arrives
29 UNTIL HELP ARRIVES Program teaching the public to take these five steps in situations where someone may have a lifethreatening injury due to trauma: Call Protect the injured from harm Stop bleeding Position people so they can breathe Provide comfort
30 WOUND CLAMP
31 itclamp
32 SWINE STUDY Lethal hemorrhagic injury to 20 swine 100% (10/10) of swine treated with itclamp survived (Early & Late) 60% (3/5) treated with packing with standard gauze survived 0% (0/5) survival if the wound was left untreated itclamp Superior: Overall survival (p<0.009) Total blood loss (p=0.008) Survival time (p=0.003)
33 JUNCTIONAL TOURNIQUETS
34 JUNCTIONAL TOURNIQUETS
35 EVIDENCE FOR USE 14 medics used 4 junctional tourniquets: Combat Ready Clamp (CRoC) Abdominal Aortic Junctional Tourniquet (AAJT) Junctional Emergency Treatment Tool (JETT) SAM Junctional Tourniquet (SJT) Assessment categories Safety Effectiveness Time to effectiveness Two categories of user preference All tourniquet uses were safe CRoC and AAJT had the highest percentage effectiveness SJT and JETT had fastest mean times to effectiveness SJT, AAJT, and JETT most preferred Chen J, J Spec Oper Med, 2016
36 JUNCTIONAL TOURNIQUETS
37 REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta
38 EVIDENCE FOR USE REBOA vs. Resuscitative Thoracotomy (REBOA n=24, RT n=72) No differences in injury severity scores or mechanism of injury Overall survival: REBOA vs. RT (37.5% vs. 9.7%; p=0.03) More deaths in the ED for RT (45/72) vs. REBOA (4/24) (62.5% vs. 16.7%; p< 0.001) REBOA had fewer early deaths and improved overall survival (37.5% vs. 9.7%, p = 0.003) Moore L, J Trauma, 2015
39 NOT SO FAST Retrospective analysis of the Japan Trauma Data Bank (196 centers) 1807 patients: REBOA (n=351) vs. No REBOA (n=1456) REBOA demonstrated absolute higher in-hospital mortality (61.8% vs. 45.3%; 95% CI 10.9% to 22.0%); p=<0.0001) Adjusted in-hospital mortality in REBOA subjects not significant (16.4%; 95% CI, -0.6% to 33.3%) Inoue J, J Trauma, 2016
40 PREHOSPITAL REBOA Dr. Gareth Davies-Chair and Medical Director of the London Air Ambulance May 2014, 32-year-old male fell 15 meters Doctor-paramedic team arrived 34 min after the injury Pelvic, ribs, lumbar spine, and dissection of descending aorta (ISS 45) Transfused 12 units PRBC, 8 units FFP, 2 units Cryoprecipitate, and 1 unit of platelets. 15 days in ICU and discharged on day 52 with a full recovery
41 QUESTIONS? BBBleess
42 REFERENCES Elster EA, Butler FK, Rasmussen TE. Implications of Combat Casualty Care for Mass Casualty Events. JAMA.2013;310(5): National Academies of Sciences, Engineering, and Medicine A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med Dec;41(6): Committee on Injuries, American Academy of Orthopedic Surgeons. Emergency care and transportation of the sick and injured. W.B Saunders Co.: Philadelphia, Pa., Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg Jul;81(1): Mabry RL, Holcomb JB, Baker AM, et al. United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma. 2000;49: ; discussion
43 REFERENCES Heldenberg E, Aharon S, Wolf T, Vishne T. Evaluating new types of tourniquets by the Israeli Naval special warfare unit. Disaster Mil Med Jan 27;1:1. Gibson R, Housler GJ, Rush SC, Aden JK 3rd, Kragh JF Jr, Dubick MA. Preliminary Comparison of New and Established Tacticla Tourniquets in Manikin Hemorrhage. J Spec Oper Med Spring;16(1): Shipman N, Lessard CS. Pressure applied by the emergency/israeli bandage. Mil Med Jan;174(1): Kragh JF Jr, Cooper A, Aden JK, Dubick MA, Baer DG, Wade CE, Blackbourne LH. Survey of trauma registry data on tourniquet use in pediatric war casualties. Pediatr Emerg Care Dec;28(12): Blane G(1785). Observations on the diseases incident to seamen. London: Joseph Cooper; Edinburgh: William Creech. pp Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma. 2003;54(5 suppl):s221 S225.
44 REFERENCES Hunter C. #OrlandoUnited: Coordinating the medical response to the Pulse nightclub shooting. Lecture presented at; 2017; NAEMSP Annual Conference. Wipfler III, E. John; Wipler, E. John; Campbell, John E.; Lawrence E. Heiskell (2010). Tactical Medicine Essentials. Jones & Bartlett Learning. p Horowitz D. ( ). "Editor's Notes: The guy with the bandage". The Jerusalem Post. Retrieved Jan 17, Schmidt MS. (January 19, 2014). "Reviving a Life Saver, the Tourniquet". New York Times. Fischer PE, Bulger EM, Perina DG, Delbridge TR, et al. Guidance Document for the Prehospital Use of Tranexamic Acid in Injured Patients. Prehosp Emerg Care Sep- Oct;20(5): Roberts I, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011; 377(9771):
45 REFERENCES Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012;147(2): Gayet-Ageron A et al. Effect of Treatment Delay on the Effectiveness and Safety of Antifibrinolytics in Acute Severe Haemorrhage: A Meta-Analysis of Individual Patient-Level Data From Bleeding Patients. Lancet Shina A, Lipsky AM, NAdler R, Levi M, et al. Prehospital use of hemostatic dressings by the Isreal Defense Forces Medical Corps: A case series of 122 patients. J Trauma Acute Care Surg Oct;79(4 Suppl 2):S Filips, D., Logsetty, S., Tan, J., Atkinson, I., & Mottet, K. (2013). The itclamp Controls Junctional Bleeding in a Lethal Swine Exsanguination Model. Prehospital Emergency Care, 17(4), Wandling MW, Nathens AB, Shapiro MB, Haut ER. Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes. J Trauma Acute Care Surg Nov;81(5): Trauma medicine has learned lessons from the battlefield". The Economist. 12 October 2017.
46 REFERENCES Galvan, Steven. Tourniquets of the Future: Intelligent. U.S. Institute of Surgical Research, 3 May 2012, Hardesty, Abe. Army Medic's Tactical Equipment Company Saves Lives on the Battlefield. EMS1, 7 Aug. 2015, Korompilas AV, Beris AE, et al. The mangled extremity and attempt for limb salvage. J Orthop Surg Res Feb 13;4:4. Taillac P, Bolleter S, Heightman AJ. Wound packing essentials for EMTs and Paramedics. JEMS. 42 (4), Littlejohn LF, Devlin JJ, Kircher SS, Lueken R, Melia MR, Johnson AS. Comparison of Celox-A, ChitoFlex, WoundStat, and combat gauze hemostatic agents versus standard gauze dressing in control of hemorrhage in a swine model of penetrating trauma. Acad Emerg Med Apr;18(4): Royal College of Paediatrics and Child Health: Evidence statement. Major trauma and the use of tranexamic acid in children. November v2.pdf.
47 REFERENCES Eckert MJ, Wertin TM, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg Dec;77(6): Howard JT, Stockinger ZT, et al. Military use of tranexamic acid in combat trauma: Does it matter? J Trauma Acute Care Surg Oct;83(4): Keller M. Battlefield ER: Combat Medicine Fights To Keep More Troops Alive. Txchnologist, 24 Oct. 2013, txchnologist.com/post/ /battlefield-er-combat-medicine-fights-to-keep. Kragh JF Jr, Lunati MP, Kharod CU, Cunningham CW, Bailey JA, Stockinger ZT, Cap AP, Chen J, Aden JK 3d, CancioLC. Assessment of Groin Application of Junctional Tourniquets in a Manikin Model. Prehosp Disaster Med. 2016;31(4): Chen J, Benov A, et al. Testing of Junctional Tourniquets by Medics of the Israeli Defense Force in Control of Simulated Groin Hemorrhage. J Spec Oper Med Spring;16(1): Sadek S, Lockey DJ, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the prehospital setting: An additional resuscitation option for uncontrolled catastrophic haemorrhage. Resuscitation Oct;107:135-8.
48 REFERENCES Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4): Dubose JJ, Scalea TM, Brenner M, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3): Inoue J, Shiraishi A, Yoshiyuki A, Haruta K, Matsui H, Otomo Y. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis. J Trauma Acute Care Surg. 2016;80(4): Vartanian L. Blood on the Ground. EMS World, 17 Jan. 2017, Escott MEA, Bank EA, et al. Blood Therapy: Considerations for using blood products for prehospital trauma patients. JEMS Mar;42(3):47-51, 67. Holcomb JB, Donathan DP, et al. Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients. Prehosp Emerg Care January-March;19(1):1-9.
49 REFERENCES HockeyFeed. Minor League Player Suffers Gruesome Injury (VIDEO). HockeyFeed, HockeyFeed, 26 Oct. 2014, ucial_in_implementing_new_stop_the%20bleed_initiative.html TomoNewsUS. Hair Clip-Inspired Clamp Device Controls Traumatic Bleeding. YouTube, YouTube, 28 Oct. 2013, SurvivalMetrics. Trauma & Emergency Bandage, Combat, Israeli Battle Dressing. YouTube, YouTube, 22 Nov. 2011, OLAES Modular Bandage Basic Instructions. YouTube, YouTube, 1 Sept. 2008, Narescue. Jett Junctional Emergency Treatment Tool Overview/Instructions for Use. YouTube, YouTube, 8 Jan. 2013,
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