Point of injury tourniquet application during Operation Protective Edge - what do we learn?
Hemorrhage is a leading cause of preventable death on the battlefield. Timely tourniquet application to massively bleeding extremity wounds is critical for casualty survival albeit with reported adverse effects to extremity integrity. The aim of this study was to describe the immediate and short term outcomes of point of injury (POI) tourniquet applications during 'Operation Protective Edge' (OPE).
A case series study regarding tourniquet application at the POI during OPE was collected. The data gathered included reports by medical providers at the POI, aerial and land evacuation vehicles, and receiving hospitals. Variables collected included, the number of tourniquet applications, caregiver level, tourniquet type, limb characters, tourniquet effectiveness, in-hospital procedures, complications and short term limb outcome.
During OPE, the Israeli Defense Forces Medical Corps (IDF-MC) treated 704 casualties. Out of these, 90 casualties were treated with 119 tourniquets out of which 79 survived. Penetrating trauma was the mechanism of injury in 97.8% (88/90) of the casualties. Injuries sustained from Improvised explosive devices (IED) and shrapnel were related to the use of more than one tourniquet per casualty and per limb (p=0.034). The success rate of the first tourniquet was reported to be 70% (84/119), regardless of caregiver level (P=0.56), tourniquet type (P=0.16) or limb characters (p=0.48). two of the conversions failed and thus a new tourniquet was applied. Fasciotomy was performed on 8 casualties (a single limb in each). Vascular injury was presumed to be the indication for fasciotomy in three of these cases, in the other five limbs (6%, 5/85) no vascular involvement was discovered during surgery and the fasciotomy is suspected as tourniquet related. 7%) 6/85) suffered from neurological sequela that could not be explained by their primary injury. Total complication rate was 11.7% (10/85) (one patient had both fasciotomy and neural complication without vascular injury)
Tourniquet use on the battlefield is a simple method of eliminating preventable death, we believe that clinical practice guidelines should promote liberal use of tourniquets by trained combatants and medical personnel with abilities to convert to direct pressure hemorrhage control when possible since an unjustified tourniquet application risks low rates minor morbidity whereas a justifiable tourniquet not applied may be lethal.
Uncontrolled hemorrhage remains one of the leading causes of trauma deaths and one of the most challenging problems facing emergency medical professionals. Several hemostatic agents have emerged as effective adjuncts in controlling extremity hemorrhage. However, a review of the current literature indicates that none of these agents have proven superior under all conditions and in all wound types. This study compared several hemostatic agents in a lethal penetrating groin wound model where the bleeding site could not be visualized.
A complex groin injury with a small penetrating wound, followed by transection of the femoral vessels and 45 seconds of uncontrolled hemorrhage, was created in 80 swine. The animals were then randomized to five treatment groups (16 animals each). Group 1 was Celox-A (CA), group 2 was combat gauze (CG), group 3 was Chitoflex (CF), group 4 was WoundStat (WS), and group 5 was standard gauze (SG) dressing. Each agent was applied with 5 minutes of manual pressure. Hetastarch (500 mL) was infused over 30 minutes. Hemodynamic parameters were recorded over 180 minutes. Primary endpoints were attainment of initial hemostasis and incidence of rebleeding.
Overall, no difference was found among the agents with respect to initial hemostasis, rebleeding, and survival. Localizing effects among the granular agents, with and without delivery mechanisms, revealed that WS performed more poorly in initial hemostasis and survival when compared to CA.
In this swine model of uncontrolled penetrating hemorrhage, SG dressing performed similarly to the hemostatic agents tested. This supports the concept that proper wound packing and pressure may be more important than the use of a hemostatic agent in small penetrating wounds with severe vascular trauma.
Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrhagic shock as an adjunct to haemostatic procedures in the acute care setting
Le principe d'occlusion artérielle n'est pas nouveau. L'occlusion endovasculaire de l'aorte trouve sa place dans la gestion des hémorragies abdominales incontrôlable. Son intérêt en traumatologie ballistique de guerre est probable (1). Cette technique a été récemment décrite en phase préhospitalière (2). Nos conditions d'exercice méritent que l'on s'intéresse à cette technique (3).
Haemorrhagic shock is a major cause of death in the acute care setting. Since 2009, our emergency department has used intra-aortic balloon occlusion (IABO) catheters for resuscitative endovascular balloon occlusion of the aorta (REBOA).
Methods: REBOA procedures were performed by one or two trained acute care physicians in the emergency room (ER) and intensive care unit (ICU). IABO catheters were positioned using ultrasonography. Collected data included clinical characteristics, haemorrhagic severity, blood cultures, metabolic values, blood transfusions, REBOA-related complications and mortality.
Results: Subjects comprised 25 patients (trauma, n = 16; non-trauma, n = 9) with a median age of 69 years and a median shock index of 1.4. REBOA was achieved in 22 patients, but failed in three elderly trauma patients. Systolic blood pressure significantly increased after REBOA (107 vs. 71 mmHg, p < 0.01). Five trauma patients (20 %) died in ER, and mortality rates within 24 h and 60 days were 20 % and 12 %, respectively. No REBOA-related complications were encountered. The total occlusion time of REBOA was significantly lesser in survivors than that in non-survivors (52 vs. 97 min, p < 0.01). Significantly positive correlations were found between total occlusion time of REBOA and shock index (Spearman’s r = 0.6) and lactate concentration (Spearman’s r = 0.7) in survivors.
Conclusion: REBOA can be performed in ER and ICU with a high degree of technical success. Furthermore, correlations between occlusion time and initial high lactate levels and shock index may be important because prolonged occlusion is associated with a poorer outcome.
Un garrot, dont l'intérêt apparaît être d'une part sur sa largeur et d'autre part sur sa boucle de serrage innovante.
Clic sur l'image pour accéder à une vidéo
La pose d'un garrot est essentiel à la survie d'un blessé présentant une hémorragie sévère des membres. Encore faut-il qu'il soit de bonne qualité. Les autorités sanitaires américaines insistent sur l'importance de ne se fournir qu'auprès de distributeurs connues distribuant des garrots éprouvés plutôt que de céder aux sirènes de la copie chinoise de basse qualité. En effet même ces garrots voient leur efficacité réduite après exposition aux conditions de combat. C'est ce que met une fois de plus en évidence ce travail.
The purpose of the present study was to mechanically assess models of emergency tourniquet after 18 months of environmental exposure to weather to better understand risk of component damage.
MATERIALS AND METHODS:
An experiment was designed to test tourniquet performance on a manikin thigh. Three tourniquet models were assessed: Special Operations Forces Tactical Tourniquet Wide, Ratcheting Medical Tourniquet, and Combat Application Tourniquet. Unexposed tourniquets formed a control group stored in a laboratory; exposed tourniquets were placed outdoors on a metal roof for 18 months in San Antonio, Texas. Two users, a military cadet and a scientist, made 300 assessments in total. Assessment included major damage (yes-no), effectiveness (hemorrhage control, yes-no), casualty survival (alive-dead), time to stop bleeding, pressure, and blood loss. Time, pressure, and blood loss were reported in tests with effectiveness.
Exposed devices had worse results than unexposed devices for major damage (3% [4/150] versus 0% [0/150]; ρ = .018), effectiveness (89% versus 99%; ρ = .002), and survival of casualties (89% versus 100%; ρ < .001). In tests for effectiveness, exposed devices had worse results than unexposed devices for time to stop bleeding (29 seconds versus 26 seconds; ρ = .01) and pressure (200mmHg versus 204mmHg; ρ = .03, respectively), but blood loss volume did not differ significantly.
Compared with unexposed control devices, environmentally exposed tourniquets had worse results in tests of component damage, effectiveness, and casualty survival.
Un nouveau venu qui fait aussi bien que la référence US, à savoir le CAT, sans apporter plus (1). Ne pas confondre ce garrot dont le distributeur est connu et dont la fabrication parfaitement tracée. Sans aucune comparaison avec nombre de copies qui ne bénéficie pas des mêmes contrôle de qualité distribués à moins de 10 Euros et qui peuvent faire illusion.
Les événements récents ont mis en avant l'importance de l'application précoce de garrot. L'approvisionnement en garrot est un véritable challenge et un marché où la guerre commerciale fait maintenant rage. Si le nombre de fabricants historiques de garrot était relativement restreint (CAT, SOFT-T, TK4, RATS, MAT, SWAT), on voit fleurir nombre de copies essentiellement chinoises dont il est relativement aisé de se procurer des exemplaires, notamment sur le marché de l'AIRSOFT. Deux fabricants sont particulièrement la cible de ces contrefacteurs CAT ressources et TACMED solutions, car ce sont les deux garrots validés par les US dans le cadre du TCCC. Ces deux fabricants diffusent leurs produits pour une 20aines d'euros. Le garrot en service dans l'armée française depuis une dizaine d'année est le SOFT-T de la société TACMED, garrot dont il existe une version adaptée pour l'enfant. Les contrefacteurs chinois affichent des tarifs parfois 10 fois moindres. Les produits proposés par ces sociétés ne peuvent pas disposer des qualités techniques de même niveau que ceux détenus par les originaux. Un aspect important des garrots est leur résistance au vieillissement, aux intempéries, au froid, aux UV. Il a été démontré que ces caractéristiques sont très importantes en terme d'efficacité après quelques mois de port du garrot en ambiance opérationnelle vraie. Il serait étonnant que ces copies de garrot, dont les matières premières et les circuits de fabrication sont pour le moins opaques offrent les mêmes garanties de sécurité que ceux de fabricants historiques maîtrisant tous les process de fabrication de leur production.
Les autorités américaines ne sont saisies de ce problème et rappellent l'importance de ne s'approvisionner que chez les forunisseurs des garrots validés dans le T3C, à savoir les garrots produits apr CAT ressources et TacMed Solutions en excluant toute autre production au prétexte de tarifs à première vue (tro) alléchants. Lire le rapport de la FDA
Je vous propose dans le lien suivant quelques exemples concernant le garrot SOFT-T
Certains modèles de tourniquet s'inspirent très fortement de ces produits et en particulier du SOF-T (notamment le wide) mais avec une démarche d' innovation réelle. Aussi ces tourniquets sont ils différents de simples copies et très probablement de bonne qualité. Ils ne sont pas produits en chine mais dans des pays de l'Est européen, voire en Russie (a,b). On manque néanmoins de recul d'expertise technique de ces derniers.
Dans l'état actuel des choses, à moins de s'équiper pour de l'airsoft, la prudence est de rester à l'écart des ces garrots et de continuer à utiliser les produits distribués par les fournisseurs reconnus des fabricants historiques (4, 5,6)
La gamme quikclot s'agrandit avec toute une proposition de pansement adapté à l'usage hospitalier, que ce soit peropératoire ou en soins critiques.
Nous ne sommes pas les seuls à avoir à faire face au contexte d'isolement. Il est particulièrement intéressant de regarder comment ces problèmes sont abordés par les pays en voie de construction. L'exemple rwandais devrait nous interpeller. Le recours à des drones de livraison en contexte militaire n'est pas une utopie car ce mode de ravitaillement a été utilisé en afghanistan.
Battlefield Tourniquets: Lessons Learned in Moving Current Care Toward Best Care in an Army Medical Department at War
Un point d'étape qui insiste sans surprise sur l'apport d'une pose précoce d'un garrot. Précoce mais aussi rapide: 25 secondes sont nécessaires aux plus entraînés mais c'est 20 secondes de trop. Plus on s'entraîne et plus vite ET mieux on pose ce garrot.
Bleeding prevention and control by tourniquet use by out-of-hospital caregivers is a major breakthrough in military medicine of current wars. The present review documents developments in tourniquet practices since 2001 among the US military services for aid in improving doctrine, policy, and especially care in wars to come. Tourniquets are an adjunct for resuscitation in self-care and buddy aid and today are issued to all military service persons who deploy into a combat zone. In the US Army, virtually every Soldier is trained in first aid tourniquet use; since 2009 they are instructed early and often to use them early and often. Despite substantial knowledge gains among the services in tourniquet use and resulting improvements in casualty survival, current evidence shows persistent diffi culties in achieving best care with tourniquet use for individual trauma patients. Nevertheless, contemporary tourniquet use incorporates key lessons learned over the last 14 years of war that include: (1) tourniquet use reliably stops bleeding from limb wounds and prevents mortality in prehospital settings; and (2) brief tourniquet use appears to be safe. These 2 lessons have become so evident that civilian emergency medical systems have begun using them, albeit unevenly. Collection and interpretation of data of casualties with tourniquet use have showed that such intervention has lifesaving benefit through 2 mechanisms: control of both ongoing hemorrhage and shock severity. The next generation of interventions in bleeding control involves developing the skill sets, education, and standards of tourniquet users which may improve hemorrhage control in wars to come
Controlling intraoperative hemorrhage during burn surgery: A prospective, randomized trial comparing NuStat® hemostatic dressing to the historic standard of care.
One of the primary intraoperative challenges during burn surgery is to adequately excise the burn while avoiding massive hemorrhage. This has become increasingly important, as we see more burn patients that are older and with more medical comorbidities. While adequate excision down to healthy tissues for deep burns is essential for skin graft to take, it also leads to active bleeding that can be a challenge to control. Good hemostasis is imperative as a hematoma is the most common cause of graft loss. Several new products have become available to help control intraoperative hemorrhage. A new hemostatic dressing, NuStat®, is available and approved by FDA in United States.
A single institution prospective randomized control trial was completed at Regional Burn Center of the University of South Alabama comparing NuStat® with the institutional historic standard of care. Twenty such patients were included in our study. A cost analysis was also completed as part of the study retrospectively.
For dressings used to treat the burn site, blood loss on the side treated with NuStat® was on average less (27g/100cm2) than the side treated with our historic standard of care (31g/100cm2), though it was not statistically significant (p=0.81). Similarly, on the donor site, blood loss on the side treated with NuStat® was on average less (14g/100cm2) than the side treated with our historic standard of care (15g/100cm2), but it was also not statistically significant (p=0.92). Average total blood loss from both excision and donor sites was also less with NuStat®(10g/100cm2) compared to the historic standard of care (12g/100cm2), but it was also not significant (p=0.77). There was no difference in the number of cycles required to achieve hemostasis for either the burn (1.15 NuStat® vs. 1.1 for historic standard of care, p=0.70) or the donor site (1 vs. 1, p=1.0). When comparing the cost of NuStat® versus the historic standard of care, the actual costs incurred for the wounds was less for the portion treated with NuStat® ($148.43) when compared to the historic standard of care ($186.45) (p<0.001).
Based on these findings, NuStat® hemostatic action should be comparable to the historic standard of care, and these newerhemostatic agents evaluated further in burn surgery and bleeding during other procedures such as trauma surgery.
Does practice make perfect? Prospectively comparing effects of 2 amounts of practice on tourniquet use performance
L'entretien des compétences et en particulier des gestes apparaît fondamentale et nécessite un suivi chiffré pour garantir un niveau suffisant d'expertise pour une projection opérationnelle. Ceci est parfaitement mis en avant dans le travail de schaeur et Al. (1) qui porte sur des gestes de réanimation préhospitalière. Le document proposé à votre lecture porte sur un geste essentiel: La pose du garrot. Une pratique plus régulière limite le désapprentissage.
Although a lifesaving skill, currently, there is no consensus for the required amount of practice in tourniquet use. We compared the effect of 2 amounts of practice on performance of tourniquet use by nonmedical personnel.
Israeli military recruits without previous medical training underwent their standard tactical first aid course, and their initial performance in use of the Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC) was assessed. The educational intervention was to allocate the participants into a monthly tourniquet practice program: either a single-application practice (SAP) group or a triple-application practice (TAP) group. Each group practiced according to its program. After 3 months, the participants' tourniquet use performance was reassessed. Assessments were conducted using the HapMed Leg Tourniquet Trainer (CHI Systems, Fort Washington, PA), a mannequin which measures time and pressure.
A total of 151 participants dropped out, leaving 87 in the TAP group and 69 in the SAP group. On initial assessment, the TAP group and the SAP group performed similarly. Both groups improved their performance from the initial to the final assessment. The TAP group improved more than the SAP group in mean application time (faster by 18 vs 8 seconds, respectively; P = .023) and in reducing the proportion of participants who were unable to apply any pressure to the mannequin (less by 18% vs 8%, respectively; P = .009).
Three applications per monthly practice session were superior to one. This is the first prospective validation of a tourniquet practice program based on objective measurements.
Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges: TCCC Guidelines Change 15-03.
Le recours à de petites éponges comprzsées et recouvertes de chitosan apparaît fortement séduisant à tel point que l'XStat fait partie du TCCC. Cependant les bases scientifiques qui pourraient permettre de recommander ce produit paraissent très faibles. La lecture attentive du document proposé permet de s'en rendre compte. D'une part une application sur un cochon dans des conditions de laboratoire par un expert ne reproduit pas les conditions de combat. Ce produit apparaît ne pass être adapté pour un emploi intra-thoracique, abdominal ou cervical et il est prévu pour une durée d'application de 04h, ce qui ne permet pas de couvrir un certain nombre de missions vraiment spéciales ou certaine régions comme le cou (1). On comprend bien dès lors toute la prudence à avoir avec ces produits que l'industrie nous présente comme "magique". Ils le sont peut être, et ceci concerne tous les pansements hémostatiques (2), mais il faut le prouver et ne pas céder aux sirènes effrénées du marketing des laboratoires. En la matière bien réaliser un packing de plaie, ne serait qu'avec une gaze standard doit rester un objectif fondamental, le reste étant un plus mais pas le fondamental.
Exsanguination from wounds in the so-called junctional regions of the body (i.e., the neck, the axilla, and the groin) was responsible for 19% of the combat fatalities who died from potentially survivable wounds sustained in Afghanistan or Iraq during 2001 to 2011. The development of improved techniques and technology to manage junctional hemorrhage has been identified in the past as a high-priority item by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Army Surgeon General's Dismounted Complex Blast Injury (DCBI) Task Force. Additionally, prehospital care providers have had limited options with which to manage hemorrhage resulting from deep, narrow-track, penetrating trauma. XStat™ is a new product recently approved by the US Food and Drug Administration as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat has now been recommended by the CoTCCC as another tool for the combat medical provider to use in the management of junctional hemorrhage. The evidence that supports adding XStat to the TCCC Guidelines for the treatment of external hemorrhage is summarized in this paper.
Different Width and Tightening System: Emergency Tourniquets on Distal Limb Segments
Tourniquets are used on distal limb segments. We examined calf and forearm use of four thigh-effective, commercial tourniquetswith different widths and tightening systems: 3.8 cm windlass Combat Application Tourniquet® (CAT, combattourrniquet.com) and Special Operations Forces® Tactical Tourniquet-Wide (SOFTTW, www.tacmedsolutions.com), 3.8 cm ratchet Ratcheting Medical Tourniquet - Pediatric (RMT-P, www.ratchetingbuckles. com), and 10.4 cm elastic Stretch-Wrap-And-Tuck Tourniquet® (SWATT, www.swattourniquet.com).
From Doppler-indicated occlusion, windlass completion was the next securing opportunity; ratchet completion was one additional tooth advance; elastic completion was end tucked under a wrap.
All applications on the 16 recipients achieved occlusion. Circumferences were calf 38.1±2.5 cm and forearm 25.1±3.0 cm (p<.0001, t-test, mean±SD). Pressures at Occlusion, Completion, and 120-seconds after Completion differed within each design (p<.05, one-way ANOVA; calf: CAT 382±100, 510±108, 424±92 mmHg; SOFTT-W 381±81, 457±103, 407±88 mmHg; RMT-P 295±35, 350±38, 301±30 mmHg; SWATT 212±46, 294±59, 287±57 mmHg; forearm: CAT 301±100, 352±112, 310±98 mmHg; SOFTT-W 321±70, 397±102, 346±91 mmHg; RMT-P 237±48, 284±60, 256±51 mmHg; SWATT 181±34, 308±70, 302±70 mmHg). Comparing designs, pressures at each event differed (p<.05, one-way ANOVA), and the elastic design had the least pressure decrease over time (p<.05, one-way ANOVA). Occlusion losses differed among designs on the calf (p<.05, χ²; calf: CAT 1, SOFTT-W 5, RMT-P 1, SWATT 0; forearm: CAT 0, SOFTT-W 1, RMT-P 2, SWATT 0).
All four designs can be effective on distal limb segments, the SWATT doing so with the lowest pressures and least pressure losses over time. The pressure change from Occlusion to Completion varies by tourniquet tightening system and can involve a pressure decrease with the windlass tightening systems. Pressure losses occur in as little as 120 seconds following Completion and so can loss of Occlusion. This is especially true for nonelastic strap tourniquet designs.
Pressures Under 3.8cm, 5.1cm, and Side-by-Side 3.8cm-Wide Tourniquets
Plus un garrot est large et plus efficace il est. parmi les garrots en dotation le Garrot Delfi est le plus performant en terme d'occlusion. Néanmoins son emploi en première intention et hors un vecteur d'évacuation est difficilement envisageable. Aussi l'association de deux garrots apparaît elle très pertinente surtout si ces derniers sont posés côte à côte. Ce n'est pas pour autant une sécurité car en permettant l'obtention d'une pression d'occlusion plus basse, cette méthode expose à une occlusion insuffisante . Cette publication a par ailleurs comme intérêt de montrer que la pression d'occlusion baisse avec le temps et ce dès les premières minutes. Il est fondamental d'apprécier TRES régulièrement l'efficacité du garrot. Donc plutôt un garrot large d'emblée mais si l'on doit compléter poser le second à côté du premier. A noter que le garrot utilisé n'est pas en dotation dans l'armées US mais qu'il s'agit d'un des meilleurs garrots de dernière génération.
Applications of wider tourniquet are expected to occlude arterial flow at lower pressures. We examined pressures under 3.8cm-wide, 5.1cm-wide, and side-by-side-3.8cm-wide nonelastic strap-based tourniquets.
Ratcheting Medical Tourniquets (RMT) were applied mid-thigh and mid-arm for 120 seconds with Doppler-indicated occlusion. The RMTs were a Single Tactical RMT (3.8cm-wide), a Wide RMT (5.1cm-wide), and Paired Tactical RMTs (7.6cm-total width). Tightening completion was measured at one-tooth advance past arterial occlusion, and paired applications involved alternating tourniquet tightening.
All 96 applications on the 16 recipients reached occlusion. Paired tourniquets had the lowest occlusion pressures (ρ < .05). All pressures are given as median mmHg, minimum-maximum mmHg. Thigh application occlusion pressures were Single 256, 219-299; Wide 259, 203-287; Distal of Pair 222, 183-256; and Proximal of Pair 184, 160-236. Arm application occlusion pressures were Single 230, 189-294; Wide 212, 161-258; Distal of Pair 204, 193-254, and Proximal of Pair 168, 148-227. Pressure increases with the final tooth advance were greater for the 2 teeth/cm Wide than for the 2.5 teeth/cm Tacticals (ρ < .05). Thigh final tooth advance pressure increases were Single 40, 33-49; Wide 51, 37-65; Distal of Pair 13, 1-35; and Proximal of Pair 15, 0-30. Arm final tooth advance pressure increases were Single 49, 41-71; Wide 63, 48-77; Distal of Pair 3, 0-14; and Proximal of Pair 23, 2-35. Pressure decreases occurred under all tourniquets over 120 seconds. Thigh pressure decreases were Single 41, 32-75; Wide 43, 28-62; Distal of Pair 25, 16-37; and Proximal of Pair 22, 15-37. Arm pressure decreases were Single 28, 21-43; Wide 26, 16-36; Distal of Pair 16, 12-35; and Proximal of Pair 12, 5-24. Occlusion losses before 120 seconds occurred predominantly on the thigh and with paired applications (ρ < .05). Occlusion losses occurred in six Paired thigh applications, two Single thigh applications, and one Paired arm application.
Side-by-side tourniquets achieve occlusion at lower pressures than single tourniquets. Additionally, pressure decreases undertourniquets over time; so all tourniquet applications require reassessments for continued effectiveness.
Influences of limited resuscitation with plasma or plasma protein solutions on hemostasis and survival of rabbits with noncompressible hemorrhage
Dans ce travail et alors que l'albumine diluée n'est pas recommandée, les auteurs évoquent la possibilité que les effets favorables d'une réanimation basée sur l'apport de plasma serait lié à l'apport de protéine et en particulier d'albumine qui aurait un effet tampon élevé, réduisant l'acidose métabolique, un des facteurs de la triade létale.
Plasma infusion with or without red blood cells is the current military standard of care for prehospital resuscitation of combat casualties. We examined possible advantages of early and limited resuscitation with fresh plasma compared with a single plasma protein or crystalloid solutions in an uncontrolled hemorrhage model in rabbits.
Anesthetized spontaneously breathing rabbits (3.3 ± 0.1 kg) were instrumented and subjected to a splenic uncontrolled hemorrhage. Rabbits in shock were resuscitated at 15 minutes with Plasma-Lyte (PAL; 30 mL/kg), PAL + fibrinogen (PAL + F; 30 mL + 100 mg/kg), fresh rabbit plasma (15 mL/kg), or 25% albumin (ALB; 5 mL/kg) solution, all given in two bolus intravenous injections (15 minutes apart) to achieve a mean arterial pressure of 65 mm Hg, n = 8 to 9/group. Animals were monitored for 2 hours or until death, and blood loss was measured. Blood samples and tissues were collected and analyzed.
There were no differences among groups in baseline measures and their initial bleeding volume at 15 minutes. At 60 minutes after injury, mean arterial pressure was higher with ALB than with crystalloids (PAL or PAL + F), but shock indices were not different despite the large differences in resuscitation volumes. Fibrinogen addition to PAL only increased clot strength. Plasma resuscitation increased survival rate (75%) without significant improvement in coagulation measures. Albumin administration replenished total plasma protein and increased survival rate to 100% (p < .05 vs. crystalloids). No histological adverse events were identified in the vital organs.
Fibrinogen administration added to a compatible crystalloid did not improve hemostatic outcomes. Plasma resuscitation increased survival rate; however, its effects did not differ from those obtained with 25% ALB at one-third of the volume. The ALB advantage was consistent with our previous findings in which 5% ALB was used at a volume equal to plasma. The benefit of plasma for resuscitation may be mostly due to its ALB content rather than its coagulation proteins
Optimization of indirect pressure in order to temporize lifethreatening haemorrhage: a simulation study
Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, specifically external aortic compression (EAC). Indirect pressure has great potential for temporizing bleeds not amenable to direct tamponade i.e. abdominal-pelvic, junctional, and multi-site trauma. However, it is currently unclear how to optimize this technique.
We designed a model of central vessel compression using the Malbrain intraabdominal pressure monitor and digital weigh scale. Forty participants performed simulated external aortic compression on the ground, on a stretcher mattress, and with and without a backboard.
The greater the rescuer’s bodyweight the greater was their mean compression (Pearson’s correlation 0.93). Using one-hand, a mean of 28% participant bodyweight (95% CI, 26% - 30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased the percentage of rescuer bodyweight transmission 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p <0.001). Adding a backboard increased transmission of rescuer bodyweight 7%-15% (p < 0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4%-9% (p < 0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p < 0.001).
Efficacy is maximized with larger-weight rescuers who use both hands, position themselves atop victims, and compress on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). Our work quantifies methods to optimize indirect pressure as a temporizing measure following life-threatening haemorrhage not amenable to direct compression, and while expediting compression devices or definitive treatment.
The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition
Background: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.
Methods: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.
Results: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.
Conclusions: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally
Damage-control resuscitation and emergency laparotomy: Findings from the PROPPR study
The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial has demonstrated that damage-controlresuscitation, a massive transfusion strategy targeting a balanced delivery of plasma-platelet-red blood cell in a ratio of 1:1:1, results in improved survival at 3 hours and a reduction in deaths caused by exsanguination in the first 24 hours compared with a 1:1:2 ratio. In light of these findings, we hypothesized that patients receiving 1:1:1 ratio would have improved survival after emergency laparotomy.
Severely injured patients predicted to receive a massive transfusion admitted to 12 Level I North American trauma centers were randomized to 1:1:1 versus 1:1:2 as described in the PROPPR trial. From these patients, the subset that underwent an emergency laparotomy, defined previously in the literature as laparotomy within 90 minutes of arrival, were identified. We compared rates and timing of emergency laparotomyas well as postsurgical survival at 24 hours and 30 days.
Of the 680 enrolled patients, 613 underwent a surgical procedure, 397 underwent a laparotomy, and 346 underwent an emergency laparotomy. The percentages of patients undergoing emergency laparotomy were 51.5% (174 of 338) and 50.3% (172 of 342) for 1:1:1 and 1:1:2, respectively (p = 0.20). Median time to laparotomy was 28 minutes in both treatment groups. Among patients undergoing an emergency laparotomy, the proportions of patients surviving to 24 hours and 30 days were similar between treatment arms; 24-hour survival was 86.8% (151 of 174) for 1:1:1 and 83.1% (143 of 172) for 1:1:2 (p = 0.29), and 30-day survival was 79.3% (138 of 174) for 1:1:1 and 75.0% (129 of 172) for 1:1:2 (p = 0.30).
We found no evidence that resuscitation strategy affects whether a patient requires an emergency laparotomy, time to laparotomy, or subsequent survival.