Prehospital Hemorrhage Control LCOL Edward Tan, MD PhD Military Traumasurgeon Radboud University Medical center, LCOL Edward C.T.H. Tan, MD PhD Nijmegen, The Netherlands Military traumasurgeon Radboud University Medical Center, Nijmegen November 12 th, 2014
Overview Control of hemorrhage Prehospital Focus on Haemostatic bandages Field testing: Afghanistan - The Netherlands 2
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Prehospitale hemorrhage OIF en OEF 2001-2011 4596 US Deaths 87.3% pre-hospital 24% preventable Causes 91 % Hemorrhage 8 % Airway obstruction 1 % Tensionpneumothorax 4
Trauma induced coagulopathy Trauma itself induces coagulopathy Admission INR >1.3 Resuscitation with clear fluids >>> Dilutional effect Worsened by hypothermia Clotting factor consumption 5
Keypoints Stop the bleeding! Restore blood loss (massive transfusion protocols) (prehospital blood transfusion) Reverse trauma induced coagulopathy Prehospital Tranexamic acid, Fresh Frozen Plasma, Freeze Dried Plasma (Lyoplas) 6
Stop the bleeding: Head and face Emergency bandage Haemostatic agents Foley catheter itclamp 7
itclamp 8
Stop the Bleeding: Neck Do NOT probe if it is not bleeding! If hole is large - Finger If hole is small - Foley 9
Stop the Bleeding: Chest Anterolateral Thoracotomy 10
Stop the Bleeding: Chest The clamshell incision is an extension of the left anterolateral thoracotomy 11
Stop the bleeding: intra abdominal AAT FOAM REBOA 12
AAT Abdominal Aortic Tourniquet 13
Arsenal Abdominal Delivery Device ( Foam) Defence Advanced Research Projects Agency Wound Stasis System program 14
Reboa Resuscitative Endovascular Balloon Occlusion of the Aorta 15
Reboa 16
Stop the bleeding: Junctional bleed Several devices (JETT, Croc, SAM JT) Local pressure with haemostatic agent 17
CRoC Combat Ready Clamp 18
JETT Junctional Emergency Treatment Tool 19
SAM Junctional Tourniquet 20
Stop the bleeding: Pelvis 21
Stop the bleeding: extremity Splinting Traction device Tourniquet Haemostatic Agent 22
Stop the bleeding; Femur 23
CAT Combat Application Tourniquet 24
Haemostatic Agents Factor concentrators Mucoadhesive agents Procoagulant supplementors Factor Concentrators Quikclot ACS, Responder, Traumadex, Self-Expanding Haemostatic Polymer, X-Stat Granville-Chapman J, Jacobs N, Midwinter MJ: Pre-hospital haemostatic dressings: a systematic review. Injury. 2011 May;42(5):447-59. 25
Haemostatic Agents Procoagulant supplementors Combat Gauze, Dry fibrin sealant dressing 26
Haemostatic Agents Mucoadhesive agents (Chitosan) Hemcon Chitogauze (Chitoflex) Celox Chito Sam -100 27
Chitosan Made of chitine, complex carbohydraat Small positive particles Cross react with red bloodcells clott Absorbs water 28
Chitosan Function not influenced by hypothermia and also works on patients using anticoagulans. No exotherme reaction No allergic reaction 29
Example: Hemcon Chitogauze (mucoadhesive) 30
Field testing Afghanistan 31 Role 2 E Uruzgan Medical Center
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Celox use in Afghanistan Stopped all bleeding in all 7 patients IED with shrapnel, arteriel bleed groin, bleeding buttock after GSW, intra operateive pelvic fracture Rebleed after guillotine amputation. 33
Field testing in The Netherlands 34
The Netherlands Eleven trauma centers 4 deliver a stand-by Mobile Medical Team (by helicopter) = HEMS 24 / 7 standby with Helicopter (or Car), within 2 minutes airborne 35
The Netherlands Dispatch criteria: problems vital functions, fall of height > 5 meters, collision with bus/train/airplane/ship, multiple casualties, expected extrication > 15 minutes, drowning, diving accident, explosion, hypothermia, pediatric resuscitation, traumatic amputation, severe burns, inhalation injury, Hazmat etc 36
Field testing Celox Since 2009 use of Chitosan based haemostatic dressing (first Celox, later Hemcon Chitogauze) 3 patients treated with Celox - MVA Soft tissue bleeding upper leg; Successful - Neck wound after cycle collision; Successful - Fractured skull base, Fall from height; Unsuccessful 37
Field testing Chitogauze 24 persons treated prehospital after trauma (MVA, Fall of height, GSW, stabwound, entrapment) 24 times successful; 75% bleeding stopped (18) 25% bleeding under controlled (6) 38 38
Field testing Chitogauze Location; 14x Head/Face, 1x neck, 5 extremities, 3 groin, 1 abdomen 13 major venous bleeding, 11 combined arterial/venous At available follow up (85.7%) No side effects documented 39 39
Discussion Field testing is purely observational and descriptive Many confounding variables, No long-term follow up. Further studies are necessary 40
Conclusion and recommendations Chitosan-based haemostatic dressings are a safe and useful tool in stopping or controlling external blood loss. No side effects or wound healing problems documented in this short follow up Future studies should be conducted 41
Future Study All ambulances and fast responding vehicles of the EMS services of the regions Gelderland-Middle and Gelderland-South (service area of 1,18 million people). We expect that the HemCon bandage will be successful for at least 90% of the patients. We expect to treat a total of 100 patients with the bandage Current status 76 inclusions 42 >90% successful
Questions? 43 edward.tan@radboudumc.nl
What is the best hemostatic bandage? 44 44
Idealy The ideal haemostatic dressing needs no training to use, does not decay, is flexible and cheap, attaches only to the bleeding wound, has no side effects, has no risk of infection has no effect on wound healing and effectively stops arterial, venous and soft tissue bleeding Pusetari AE et al: Effects of a chitosan-based hemostatic dressing on blood loss and survival in a model of severe venous hemorrhage and hepatic injury in swine. J of Trauma 2003; 54: 177-82 45