Use of an improvised clamp to manage bleeding tongue injuries,

Chen M.W.J. et Al. Am J Emergency Medicine (2020), https://doi.org/10.1016/j.ajem.2020.06.051

Compresses éventuellement hémostatiques, deux abaisses langues, du sparadrap. Et voilà la langue est comprimée.

SAignement Langue.jpg

Intravenous Hydroxocobalamin Versus Hextend Versus Control for Class III Hemorrhage Resuscitation in a Prehospital Swine Model.

Bebarta VS et Al 2018 Nov 5;183(11-12):e721-e729.

Background:

Hydroxyethyl starch (Hextend) has been used for hemorrhagic shock resuscitation, however, hydroxyethyl starch may be associated with adverse outcomes.

Objective:

To compare systolic blood pressure (sBP) in animals that had 30% of their blood volume removed and treated with intravenous hydroxocobalamin, hydroxyethyl starch, or no fluid.

Methods:

Twenty-eight swine (45-55 kg) were anesthetized and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged 20 mL/kg over 20 minutes and then administered 150 mg/kg IV hydroxocobalamin in 180 mL saline, 500 mL hydroxyethyl starch, or no fluid and monitored for 60 minutes. Data were modeled using repeated measures multivariate analysis of variance.

Results:

There were no significant differences before treatment. At 20 minutes after hemorrhage, there was no significant difference in mean sBP between treated groups, however, control animals displayed significantly lower mean sBP (p < 0.001). Mean arterial pressure and heart rate improved in the treated groups but not in the control group (p < 0.02). Prothrombin time was longer and platelet counts were lower in the Hextend group (p < 0.05). Moreover, thromboelastography analysis showed longer clotting (K) times (p < 0.05) for the hydroxyethyl starch-treated group.

Conclusion:

Hydroxocobalamin restored blood pressure more effectively than no treatment and as effectively as hydroxyethyl starch but did not adversely affect coagulation.

External Soft-Tissue Hemostatic Clamp Compared to a Compression Tourniquet as Primary Hemorrhage Control Device in Pilot Flow Model Study.

Paquette R et Al. 2019 Apr;34(2):175-181.

INTRODUCTION:

Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet.

HYPOTHESIS:

The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet.

METHODS:

Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD).

RESULTS:

Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P <.001) and in the thigh (103.1mL versus 5.2mL; P <.001).

CONCLUSION:

In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.

Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers.

Douma MJ, et Al.Prehosp Emerg Care. 2018 Nov 2:1-5

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Il existe un grand engouement pour la mise en place de REBOA en préhospitalier. Il s'agit d'une technique d'occlusion bien relativement ancienne mais qui s'est simplifiée avec l'apparition de kits spécifique. Il s'agit néanmoins d'une technique qui nécessite une formation préalable et qui s'intègre dans une stratégie globale. Cela ne doit pas occulter le fait qu'il est possible de comprimer par voie externe l'aorte abdominale (1). C'est ce que permettent l'abdominal tourniquet et la compression abdominale bimanuelle. Cet article met en avant la simplicité de sa mise en oeuvre et son efficacité, par ailleurs difficile à maintenir dans le temps. Ils proposent d'intégrer cette manoeuvre en attendant l'équipe permettant la mise en place d'un REBOA (2).

images?q=tbn:ANd9GcT8tHmScdAvTH_blK2dFxJarVXlzEw_aeKrtZ4UlPNa6bBGGlb2sA

Il s'agit cependant d'une technique difficile à maintenir dans le temps. Les mêmes auteurs préconisent de réaliser ce geste avec le genou (3, 4).

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INTRODUCTION:

Following life-threatening junctional trauma, the goal is to limit blood loss while expediting transfer to operative rescue. Unfortunately, life-threatening abdominal-pelvic or junctional hemorrhage is often not amenable to direct compression and few temporizing strategies are available beyond hemostatic dressings, hypotensive resuscitation, and balanced transfusion.

OBJECTIVES:

In this study, we evaluated proximal external aortic compression to arrest blood flow in healthy adult men.

METHODS:

This was a simulation trial of proximal external aortic compression, for life-threatening abdominal-pelvic and junctional hemorrhage, in a convenience sample of healthy adult male volunteers. The primary end points were cessation of femoral blood flow as assessed by pulse wave Doppler ultrasound at the right femoral artery, caudal to the inguinal ligament. Secondary end points were discomfort and negative sequelae.

RESULTS:

Aortic blood flow was arrested in 12 volunteers. Median time to blood flow cessation was 12.5 seconds. Median reported discomfort was 5 out of 10. No complications or negative sequelae were reported.

CONCLUSION:

This trial suggests that it may be reasonable to attempt temporization of major abdominal-pelvic and junctional hemorrhage using bimanual proximal external aortic compression. In the absence of immediate alternatives for this dangerous and vexing injury pattern, there appear to be few downsides to prehospital proximal external aortic compression while concomitantly expediting definite care.

Tournquet choice.jpg

Source: CoTCCC_Meeting_Minutes_2019_02.pdf

Pas nouveau mais instructif dans le contexte de bataille commerciale entre les industriels

Clic sur l'image pour accéder au rapport

External Soft-Tissue Hemostatic Clamp Compared to a Compression Tourniquet as Primary Hemorrhage Control Device in Pilot Flow Model Study.

Paquette R et Al. 2019 Apr;34(2):175-181.

INTRODUCTION:

Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet.

HYPOTHESIS:

The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet.

METHODS:

Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD).

RESULTS:

Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P <.001) and in the thigh (103.1mL versus 5.2mL; P <.001).

CONCLUSION:

In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.

High Tourniquet Failure Rates Among Non-Medical Personnel Do Not Improve with Tourniquet Training, Including Combat Stress Inoculation: A Randomized Controlled Trial.

Tsur AM, et Al 2019 Jun;34(3):282-287.

BACKGROUND:

The rate of failing to apply a tourniquet remains high.

HYPOTHESIS:

The study objective was to examine whether early advanced training under conditions that approximate combat conditions and provide stress inoculation improve competency, compared to the current educational program of non-medical personnel.

METHODS:

This was a randomized controlled trial. Male recruits of the armored corps were included in the study. During Combat Lifesaver training, recruits apply The Tourniquet 12 times. This educational program was used as the control group. The combat stress inoculation (CSI) group also included 12 tourniquet applications, albeit some of them in combat conditions such as low light and physical exertion. Three parameters defined success, and these parameters were measured by The Simulator: (1) applied pressure ≥ 200mmHg; (2) time to stop bleeding ≤ 60 seconds; and (3) placement up to 7.5cm above the amputation.

RESULTS:

Out of the participants, 138 were assigned to the control group and 167 were assigned to the CSI group. The overall failure rate was 80.33% (81.90% in the control group versus 79.00% in the CSI group; P value = .565; 95% confidence interval, 0.677 to 2.122). Differences in pressure, time to stop bleeding, or placement were not significant (95% confidence intervals, -17.283 to 23.404, -1.792 to 6.105, and 0.932 to 2.387, respectively).

Tourniquet failure.jpeg

Tourniquet placement was incorrect in most of the applications (62.30%).

CONCLUSIONS:

This study found high rates of failure in tourniquet application immediately after successful completion of tourniquet training. These rates did not improve with tourniquet training, including CSI. The results may indicate that better tourniquet training methods should be pursued.

Duration of extremity tourniquet application profoundly impacts soft-tissue antibiotic exposure in a rat model of ischemia-reperfusion injury

Mangum LC et al. Injury 10.1016/j.injury.2019.09.025

Introduction

Extremity tourniquet (TNK) application is an effective means of achieving compressible hemorrhage control in the emergency prehospital and clinical trauma setting. Modern United States military medical doctrine recommends TNK use to prevent lethal hemorrhage from extremity injury, followed by systemic prophylactic antibiotics to prevent wound infection. Because tissue pharmacokinetics of prophylactic antimicrobials during and after TNK-induced limb ischemia are largely unknown, this study was conducted to empirically determine the relationship between TNK application time and soft tissue antibiotic exposure in order to guide medical personnel in the management of extremity trauma.

Materials and Methods

Hind limbs of anesthetized male Sprague Dawley rats were exsanguinated, and ischemia maintained by a pneumatic cuff placed at the level of the mid femur on one limb; the non-ischemic contralateral limb served as comparison tissue. Systemic prophylactic antibiotics (cefazolin, moxifloxacin, or ertapenem) were administered intravenously before or after TNK release following 2 or 4 hours of ischemia with subsequent re-dosing every 12 hours for 3 days. Free antibiotic in the interstitial fluid (ISF) of the tibialis anterior muscle of both hind limbs was recovered via microdialysis during ischemia and over three periods during reperfusion: immediately following TNK release, at 24 hours post TNK release, and at 72 hours post TNK release. Plasma and ISF free drug concentrations were determined by high-performance liquid chromatography.

Results

Tourniquet application prevented delivery of prophylactic antibiotics into distal soft tissue for the duration of ischemia, and caused a profound reduction in skeletal muscle drug exposure for up to 72 hours following TNK release. A progressive decline in tissue antibiotic exposure during reperfusion was observed as TNK times increased from 2 hours to 4 hours.

1-s2.0-S0020138319305431-gr4.jpg

The timing and severity of reduced drug distribution in post-ischemic skeletal muscle varied substantially among the three antibiotic classes evaluated.

Conclusions

Prolonged tourniquet application can significantly reduce distribution of prophylactic antibiotics into soft tissue during and after ischemia, potentially impairing prophylaxis of extremity wound infection. Our findings support the examination of alternative approaches to wound infection prophylaxis under conditions of delayed casualty evacuation when occlusive hemorrhage control measures are utilized.

Tactical tourniquet: Surgical management must be within 3 hours.

Caubère A et Al. 2019 Jul 3;22:100217. doi: 10.1016/j.tcr.2019.100217. eCollection 2019 Aug.

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L'usage précoce et libéral des garrot a prouvé son bien fondé. Encore faut il que ce que l'on appelle le garrot tactique soit bien on, mis en oeuvre. En effet ce garrot sauve la vie au prix de certaines complications dès lors que sa durée dépasse 02h00 (1). Cette stratégie libérale repose sur quelques éléments fondamentaux (une pose bien indiquée et réalisée interrompant le flux artériel ET une réévaluation précoce systématique visant à établir le besoin et la mise en oeuvre éventuelle d'alternatives. Ceci n'est pas toujours parfaitement fait. C'est ce que montre cette publication qui rappelle quelques fondamentaux. Curieusement certaines leçons du passé ont été oubliées notamment celles qui portent sur les alternatives au garrot quand les durées d'évacuations sont longues (2)

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Despite longstanding controversy, tourniquets are widely used in tactical combat casualty care, with undisputed benefits for recent conflicts in Iraq and Afghanistan. Increased time delays are a particular issue in large areas, such as the Sahel-Saharan band. Complications associated with tourniquet use are predominantly related to acute ischemia with risk of amputation and ischaemia-reperfusion injury, as shown in the first clinical case. Often stated but poorly described, misuse of tourniquet and subsequent failure to interrupt arterial blood flow is also a clinical scenario that should be recognized. In the case of misuse of the tourniquet, more significant blood loss may be expected because of venous compression (« venous tourniquet », second clinical case). Early medical re-evaluation of the tourniquet is an essential component in prolonged field care. This includes reassessment of the tourniquet's ability to achieve hemostasis, abolish the downstream pulse and the relevance of the tourniquet altogether. This combat tool requires training to be successful and complications are time dependent. Tourniquet use requires appropriate application, re-evaluation and triage of wounded personnel within 3 h towards more structured surgical management.

Systematic review of prehospital haemostatic dressings.

Welch M et Al. 2019 Feb 2. pii: jramc 2018-001066. doi: 10.1136/jramc-2018-001066.

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Une revue qui confirme l'analyse faite par Boulton et Al. (1), ce qui contraste avec les écrits pour le moins partiaux de Winstanley M et Al. (2)

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INTRODUCTION:

Haemorrhage is one of the leading causes of battlefield and prehospital death. Haemostatic dressings are an effective method of limiting the extent of bleeding and are used by military forces extensively. A systematic review was conducted with the aim of collating the evidence on current haemostatic products and to assess whether one product was more effective than others.

METHODS:

A systematic search and assessment of the literature was conducted using 13 health research databases including MEDLINE and CINAHL, and a grey literature search. Two assessors independently screened the studies for eligibility and quality. English language studies using current-generation haemostatic dressings were included. Surgical studies, studies that did not include survival, initial haemostasis or rebleeding and those investigating products without prehospital potential were excluded.

RESULTS:

232 studies were initially found and, after applying exclusion criteria, 42 were included in the review. These studies included 31 animal studies and 11 clinical studies. The outcomes assessed were subject survival, initial haemostasis and rebleeding. A number of products were shown to be effective in stopping haemorrhage, with Celox, QuikClot Combat Gauze and HemCon being the most commonly used, and with no demonstrable difference in effectiveness.

CONCLUSIONS:

There was a lack of high-quality clinical evidence with the majority of studies being conducted using a swine haemorrhage model. Iterations of three haemostatic dressings, Celox, HemCon and QuikClot, dominated the studies, probably because of their use by international military forces and all were shown to be effective in the arrest of haemorrhage.

Bleeding control in combat fields with extreme transfer time

Ratnayake AS et Al 2019 Feb 6. pii: jramc-2018-001120. doi: 10.1136/jramc-2018-001120.

Cette lettre à l'éditeur émane d'une équipe srilankaise qui a l'expertise de prise en charge de plaies vasculaires avec des délais de prise en charge de près de 04heures (1) Ceci se rapproche des conditions dans lesquelles opèrent nos équipes. Les auteurs y rappellent tout l'intérêt lors de la révision du bien fondé de la pose d'un garrot du packing de plaies ET des compressions sélectives par des pansements adaptés dont un exemple est proposé ici.

Balloon tamponnade.jpeg

Rescue Bandage TQ Inflatable Tourniquet

Un garrot développé dans le cadre de la campagne STOP THE BLEED.

Can they stop the bleed? Evaluation of tourniquet application by individuals with varying levels of prior self-reported training.

McCarty et Al. Injury. 2019 Jan;50(1):10-15. doi: 10.1016/j.injury.2018.09.041.

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1 garrot sur 3 posé correctement malgré une formation ad-hoc.

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BACKGROUND:

Application of extremity tourniquets is a central tenet of multiple national initiatives to empower laypersons to provide hemorrhage control (HC). However, the efficacy of the general population who self-report prior first-aid (FA) or HC training on individual's ability to control bleeding with a tourniquet remains unknown. Therefore, the objective of this study was to assess the effectiveness of laypeople with self-reported prior FA or HC training to control bleeding with a tourniquet.

STUDY DESIGN:

Employees of a stadium were assessed via simulation in their ability to apply a Combat Application Tourniquet. As a subgroup analysis of a larger study, participants who self-reported: 1) No prior training, 2) FA training only or 2) FA + HC training were compared. Logistic regression adjusting for age, gender, education, willingness-to-assist, and comfort level in HC was performed.

RESULTS:

317 participants were included. Compared to participants with no prior training (14.4%,n = 16/111), those with FA training only (25.2%,n = 35/139) had a 2.12-higher odds (95%CI:1.07-4.18) of correct tourniquet application while those with FA + HC (35.8%,n = 24/67) had a 3.50-higher odds (95%CI:1.59-7.72) of correct application. Participants with prior FA + HC were more willing-to-assist and comfortable performing HC than those without prior training (p < 0.05).

However, reporting being very willing-to-assist [OR0.83,95%CI:0.43-1.60] or very comfortable [OR1.11,95%CI:0.55-2.25] was not associated with correct tourniquet application.

CONCLUSION:

Self-reported prior FA + HC training, while associated with increased likelihood to correctly apply a tourniquet, results in only 1/3 of individuals correctly performing the skill. As work continues in empowering and training laypeople to act as immediate responders, these findings highlight the importance of effective layperson education techniques.

Comparison of Two Tourniquets on a Mid-Thigh Model: The Israeli Silicone Stretch and Wrap Tourniquet vs. The Combat Application Tourniquet.

Glick CPTY et Al. 2018 Mar 1;183(suppl_1):157-161. doi: 10.1093/milmed/usx169.

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Le succès des garrots artériels tels que le SOFT-T et le CAT ne doit pas occulter l'intérêt des bandes de compression élastiques (Bande d'Esmach, SWAT-Tourniquet, IDF Silicone Tourniquet) préconisées en médecine rurale lors d'explosion de mines antipersonnelles (1). Ce travail met en avant leur efficacité.

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Introduction:

Experience from recent conflicts underlines the dramatic impact of effective tourniquet use on combat casualty mortality. Although the Combat Application Tourniquet (CAT) is replacing the silicone band tourniquets (IST; "Israeli Silicone Tourniquet") in the Israeli Defense Forces, no direct comparison was made between them. The purpose of this study is to compare the performance of the two tourniquets on a mid-thigh model.