Randomised controlled trial of tourniquet associated pain generated in lower limb after exsanguination by Esmarch bandage versus limb elevation.

BACKGROUND: Tourniquets are common adjuncts in the operating theatre but can be associated with post-operative pain. This study was designed to compare what effect pre-tourniquet Esmarch bandage exsanguination has on pain, compared to pre-tourniquet exsanguination by elevation alone. METHODS: 52 volunteers (104 lower limbs) were included in this study with each volunteer acting as their own matched control. The primary outcome was patient reported pain, measured in both legs simultaneously using area under curve. Secondary outcomes were pain score during inflation and deflation, cumulative pain score, duration of recovery and blood pressure during testing. RESULTS: Pain after Esmarch was superior to elevation as measured by area under pain curve (68.9 SD 26.1 vs 77.2 SD 27.3, p = 0.0010), independent of leg dominance. Cumulative pain scores demonstrated the same superiority after inflation (50.7 SD 17.1 vs 52.9 SD 17.0, p = 0.026) but not after deflation (p = 0.59). Blood pressure was not significantly different. Time to full recovery of the lower limb was the same for both groups-7.6 min (SD 2.1 min, p = 0.80). CONCLUSION: Previous studies describe a positive effect on pain when Esmarch bandage was used prior to tourniquet inflation for upper limb. Our findings suggest the same benefit from Esmarch when it was used on lower limbs-particularly during inflation of tourniquet. In addition to pain profiles, surgeon preference and patient factors need to be considered when deciding between elevation and Esmarch bandage.

Management of Pelvic Trauma.

Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.

Effective approaches to address noncompressible torso hemorrhage.

PURPOSE OF REVIEW: Noncompressible torso hemorrhage (NCTH) is now considered as the major cause of preventable death after both severe military and civilian trauma. Around 20% of all trauma patients still die from uncontrolled exsanguination along with rapidly evolving hemostatic failure. This review highlights the most recent advances in the field and provides an outline for future research directions. RECENT FINDINGS: The updated definition of NCTH includes a combination of high-grade anatomical torso injury, hemodynamic instability, urgent need for hemorrhage control and aggressive hemostatic resuscitation. Therapeutic concepts consider the following three aspects: control the bleeding source (close the tap), resuscitate to maintain organ perfusion and restore hemostasis (fill the tank), and increase the body's resistance against ischemia (upgrade the armor). SUMMARY: The concepts for the early management of NCTH have substantially evolved over the last decade. The development of new devices and techniques combined with early intervention of hemostatic failure have contributed to more successful resuscitations. Future research needs to refine and validate their potential clinical application.

Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) could prevent lethal exsanguination and support cardiopulmonary resuscitation. In prehospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. The aim of this study was to establish consensus on the use and implementation of REBOA in civilian prehospital settings for noncompressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings. METHODS: A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA experts with different medical specialties, backgrounds, and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject. RESULTS: Panel members reached consensus on potential (contra)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and prehospital REBOA. CONCLUSION: The international expert panel agreed that REBOA can be used in civilian prehospital settings for temporary control of noncompressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For prehospital REBOA and early femoral artery access, consensus was reached on (contra)indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of prehospital REBOA for noncompressible truncal hemorrhage. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Evaluation of hemostatic devices in a randomized porcine model of junctional hemorrhage and 72-hour prolonged field care.

BACKGROUND: Hemorrhage control in prolonged field care (PFC) presents unique challenges that drive the need for enhanced point of injury treatment capabilities to maintain patient stability beyond the Golden Hour. To address this, two hemostatic agents, Combat Gauze (CG) and XSTAT, were evaluated in a porcine model of uncontrolled junctional hemorrhage for speed of deployment and hemostatic efficacy over 72 hours. METHODS: The left subclavian artery and subscapular vein were isolated in anesthetized male Yorkshire swine (70-85 kg) and injured via 50% transection, followed by 30 seconds of hemorrhage. Combat Gauze (n = 6) or XSTAT (n = 6) was administered until bleeding stopped and remained within subjects for observation over 72 hours. Physiologic monitoring, hemostatic efficacy, and hematological parameters were measured throughout the protocol. Gross necropsy and histology were performed following humane euthanasia. RESULTS: Both CG and XSTAT maintained hemostasis throughout the full duration of the protocol. There were no significant differences between groups in hemorrhage volume (CG: 1021.0 ± 183.7 mL vs. XSTAT: 968.2 ± 243.3 mL), total blood loss (CG: 20.8 ± 2.7% vs. XSTAT: 20.1 ± 5.1%), or devices used (CG: 3.8 ± 1.2 vs. XSTAT: 5.3 ± 1.4). XSTAT absorbed significantly more blood than CG (CG: 199.5 ± 50.3 mL vs. XSTAT: 327.6 ± 71.4 mL) and was significantly faster to administer (CG: 3.4 ± 1.6 minutes vs. XSTAT: 1.4 ± 0.5 minutes). There were no significant changes in activated clot time, prothrombin time, or international normalized ratio between groups or compared with baseline throughout the 72-hour protocol. Histopathology revealed no evidence of microthromboemboli or disseminated coagulopathies across evaluated tissues in either group. CONCLUSION: Combat Gauze and XSTAT demonstrated equivalent hemostatic ability through 72 hours, with no overt evidence of coagulopathies from prolonged indwelling. In addition, XSTAT offered significantly faster administration and the ability to absorb more blood. Taken together, XSTAT offers logistical and efficiency advantages over CG for immediate control of junctional noncompressible hemorrhage, particularly in a tactical environment. In addition, extension of indicated timelines to 72 hours allows translation to PFC.

Testing and Evaluation of a Novel Hemostatic Matrix in a Swine Junctional Hemorrhage Model.

INTRODUCTION: In an ongoing effort to improve survival and reduce blood loss from hemorrhagic injuries on the battlefield, new hemostatic dressings continue to be developed. This study aimed to determine the efficacy of a novel silicon dioxide-based hemostatic matrix (HM) and compare it with the current military standard Quikclot Combat Gauze (QCG) utilizing a lethal femoral artery injury model. MATERIALS AND METHODS: The femoral arteries of 20 anesthetized swine were isolated, and an arteriotomy was performed. After a 45 s free bleed, the wound was treated with either HM or QCG (n = 10 per group). Following a 60-min observation period, ipsilateral leg manipulations and angiography were performed. Animal survival, hemostasis, blood loss, exothermic reaction, and femoral artery patency were analyzed. RESULTS: Despite a volumetric size discrepancy between the two products tested, the survival rate was similar between the two groups (80% HM, 90% QCG, n = 10, P = 0.588). Immediate hemostasis was obtained in 50% of HM animals and 40% of QCG animals. There was no difference in total blood loss recorded between the two groups (P = 0.472). Femoral artery patency rates following ipsilateral leg manipulations were similar between the two groups (50% HM, 33% QCG, P = 0.637), with no contrast extravasation in HM-treated wounds (0% HM, 33% QCG, P = 0.206). There was no significant difference in either pretreatment or posttreatment laboratory values, and there were no exothermic reactions in either group. CONCLUSIONS: The SiOxMed HM demonstrated comparable hemostatic efficacy to QCG. The tested form of HM may be appropriate for surgical or topical hemostasis applications, and with further product development, it could be used for battlefield trauma implementation.

Advances in trauma care to save lives from traumatic injury: A narrative review.

ABSTRACT: Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment.As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.

Trauma Hybrid Operating Room (THOR) shortened procedure time in abdominopelvic trauma patients requiring surgery and interventional radiology procedures.

INTRODUCTION: Abdominopelvic injuries are common, and bleeding occurring in both cavities requires various bleeding control techniques i.e., laparotomy, angiographic embolization (AE), and orthopedic fixation. Hence, the use of Trauma Hybrid Operating Room (THOR) in abdominopelvic injuries has theoretical advantages including rapid bleeding control and minimizing patient transportation. The objective of the present study is to evaluate the impact of THOR in abdominopelvic injuries. METHOD: A pre-post intervention study of abdominopelvic injury patients requiring both surgery and interventional radiology (IR) procedures for bleeding control from January 2015 to May 2020 was conducted. The patients were divided into 2 groups, pre-THOR group (received surgery in OR and scheduled for IR procedures in a separate IR suite, before December 2017) and THOR group (received all procedures in THOR, after December 2017). The primary outcomes were procedure time (including transit time in the pre-THOR group) and mortality. RESULTS: Ninety-one abdominopelvic trauma patients were identified during the study period, 56 patients in pre-THOR group and 35 patients in THOR group. Distribution of injuries was similar in both groups (59 abdominal injuries, 25 pelvic fractures, and 7 combined injuries). The bleeding-control interventions in both groups were 79 laparotomies, 10 preperitoneal pelvic packings, 12 pelvic fixations, 45 liver AEs, and 21 pelvic AEs. THOR group underwent significantly less thoracotomy (1 vs. 11, p = 0.036), more resuscitative endovascular balloon occlusion of the aorta (REBOA, 0 vs. 5, p = 0.014), and more pelvic AE (13 vs. 9, p = 0.043). The procedure time was significantly shorter in THOR group (153 min vs. 238 min, p = 0.030). Excluding the transit time in the pre-THOR group, procedure time was not significantly different (153 vs. 154 min, p = 0.872). Both groups had similar mortality rates of 34%, but the mortality due to exsanguination was significantly lower in THOR group (11% vs. 34%, p = 0.026). CONCLUSIONS: THOR eliminated transit time, resulting in shorter procedure time in abdominopelvic trauma patients requiring bleeding-control intervention. Although overall mortality reduction could not be demonstrated, the mortality due to exsanguination was reduced in THOR group.

The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial).

BACKGROUND: Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury. METHODS: Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective. DISCUSSION: This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice. TRIAL REGISTRATION: ISRCTN16184981.

A comparison of efficacy, efficiency, and durability in novel tourniquet designs.

BACKGROUND: Exsanguination due to extremity hemorrhage is a major cause of preventable traumatic deaths. Extremity tourniquet use has been shown to be safe and improve survival. The purpose of this study was to compare the efficacy, efficiency, and durability of the Generation 7 Combat Application Tourniquet (CAT; North American Rescue, Greer, SC), the Tactical Mechanical Tourniquet (TMT; Combat Medical Systems, Harrisburg, NC), and the SOF Tactical Tourniquet-Wide (SOFTT-W; Tactical Medical Solutions, Anderson, SC). METHODS: This study was a three-phase randomized, cross-over trial. In successive trials, subjects were timed during the application of each tourniquet to the upper and lower extremity. Following successful lower extremity application, subjects low crawled 25 ft and then were dragged 25 ft, after which effectiveness was reassessed, as defined by the cessation of distal pulses by Doppler ultrasound. RESULTS: In arm application, both the CAT and TMT had significantly less failure rates than the SOFTT-W (5.56%, 19.44%, 58.33%), with the CAT being the fastest tourniquet when compared with TMT and SOFTT-W (37.8 seconds, 65.01 seconds, 63.07 seconds). In leg application, the CAT had significantly less rates of failure when compared with the SOFTT-W, but there was no other significant difference between the tourniquets (27.78%, 44.44%, 61.11%). In addition, the CAT was significantly faster than both the TMT and SOFTT-W when applied to the leg (8.33 seconds, 40.96 seconds, 34.5 seconds). There was no significant difference in tourniquet failure rates between the three tourniquets after subject maneuvers in phase 3 (34.29%, 42.86%, 45.45%). DISCUSSION: The CAT is as effective as the TMT and significantly more effective than the SOFTT-W. In addition, the CAT demonstrated shorter application times than either the TMT or SOFTT-W. However, there was no significant difference between the three tourniquets in their ability to maintain pulselessness after subject maneuvers. LEVEL OF EVIDENCE: Care management, level II.

Therapeutic cardiac arrest as an adjunct to resuscitative endovascular balloon occlusion of the aorta: Bridging the gap from fatal hemorrhage to definitive surgical control in swine.

BACKGROUND: Uncontrolled hemorrhage is the leading cause of potentially survivable combat casualty mortality, with 86.5% of cases resulting from noncompressible torso hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive technique used to stabilize patients with noncompressible torso hemorrhage; however, its application can take an average of 8 minutes to place. One therapeutic capable of bridging this gap is adenosine-lidocaine-magnesium (ALM), which at high doses induces a reversible cardioplegia. We hypothesize by using ALM as an adjunct to REBOA, the ALM-induced cardiac arrest will temporarily halt exsanguination and reduce blood loss, allowing for REBOA placement and control of bleeding. METHODS: Male Yorkshire swine (60-80 kg) were randomly assigned to REBOA only or ALM-REBOA (n = 8/group). At baseline, uncontrolled hemorrhage was induced via a 1.5-cm right femoral arteriotomy, and hemorrhaged blood was quantified. One minute after injury (S1), ALM was administered, and 7 minutes later (T0), zone 1 REBOA inflation occurred. If cardiac arrest ensued, cardiac function either recovered spontaneously or advanced life support was initiated. At T30, surgical hemostasis was obtained, and REBOA was deflated. Animals were resuscitated until they were humanely euthanized at T90. RESULTS: During field care phase, heart rate and end-tidal CO2 of the ALM-REBOA group were significantly lower than the REBOA only group. While mean arterial pressure significantly decreased from baseline, no significant differences between groups were observed throughout the field care phase. There was no significant difference in survival between the two groups (ALM-REBOA = 89% vs. REBOA only = 100%). Total blood loss was significantly decreased in the ALM-REBOA group (REBOA only = 24.32 ± 1.89 mL/kg vs. ALM-REBOA = 17.75 ± 2.04 mL/kg, p = 0.0499). CONCLUSION: Adenosine-lidocaine-magnesium is a novel therapeutic, which, when used with REBOA, can significantly decrease the amount of blood loss at initial presentation, without compromising survival. This study provides proof of concept for ALM and its ability to bridge the gap between patient presentation and REBOA placement.

Massive Transfusion Protocol and Subsequent Development of Venous Thromboembolism: Statewide Analysis.

BACKGROUND: Massive transfusion protocols (MTP) are a routine component of any major trauma center's armamentarium in the management of exsanguinating hemorrhages. Little is known about the potential complications of those that survive a MTP. We sought to determine the incidence of venous thromboembolism (VTE) following MTP. We hypothesized that MTP would be associated with a higher risk of VTE when compared with a risk-adjusted control population without MTP. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2015 to 2018 for trauma patients who developed VTE and survived until discharge at accredited trauma centers in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in VTE development between MTP and non-MTP patients. A multivariate logistic regression model assessed the adjusted impact of MTP on VTE development. RESULTS: 176 010 patients survived until discharge, meeting inclusion criteria. Of those, 1667 developed a VTE (pulmonary embolism [PE]: 662 [0.4%]; deep vein thrombosis [DVT]: 1142 [0.6%]; PE and DVT: 137 [0.1%]). 1268 patients (0.7%) received MTP and, of this subset of patients, 171 (13.5%) developed a VTE during admission. In adjusted analysis, patients who had a MTP and survived until discharge had a higher odds of developing a VTE (adjusted odds ratio: 2.62; 95% CI: 2.13-3.24; P < .001). DISCUSSION: MTP is a harbinger for higher risk of VTE in those patients who survive. This may, in part, be related to the overcorrection of coagulation deficits encountered in the hemorrhagic event. A high index of suspicion for the development of VTE as well as aggressive VTE prophylaxis is warranted in those patients who survive MTP.

Thermoreversible Reverse-Phase-Shift Foam for Treatment of Noncompressible Torso Hemorrhage.

BACKGROUND: Noncompressible torso hemorrhage (NCTH) is a leading cause of traumatic exsanguination, requiring emergent damage control surgery performed by a highly trained surgeon in a sterile operating environment. A self-expanding, intraabdominally deployed, thermoreversible foam is one proposed method to potentially task shift temporizing hemostasis to earlier providers and additional settings. The purpose of this study was to assess the feasibility of using Fast Onset Abdominal Management (FOAM) in a lethal swine model of NCTH. METHODS: This was a proof-of-concept study comparing FOAM intervention in large Yorkshire swine to historical control animals in the established Ross-Burns model of NCTH. After animal preparation, a Grade IV liver laceration was surgically induced, followed by a free bleed period of 10 min. FOAM was then deployed to a goal intraabdominal pressure of 60 mm Hg for 5 min, followed by a total 60-min observation period following injury. RESULTS: At the end of the experiment, the FOAM agent was found to be distributed throughout the peritoneal cavity in all animals, without signs of iatrogenic injury. The FOAM group demonstrated a significantly higher mean arterial pressure compared with historical controls and a trend toward improved survival: 82% (9/11) compared with 50% for controls (7/14; P = 0.082). CONCLUSIONS: This is the first study to describe the use of a thermoresponsive foam to manage NCTH and successfully demonstrated proof-of-concept feasibility of FOAM deployment. These results provide strong support for future, higher-powered studies to confirm improved survival with this novel intervention.

Resuscitative endovascular balloon occlusion of the aorta for thoracic trauma in the setting of platelet dysfunction: A translational swine study.

BACKGROUND: In patients with noncompressible torso hemorrhage, antiplatelet medications may lead to worse outcomes. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may potentially stabilize these patients, but currently, major thoracic bleeding is a contraindication. The goal of this study was to determine if REBOA use for shock with major thoracic bleeding has worse outcomes in the setting of platelet dysfunction (PD). METHODS: Forty-one male Yorkshire swine (60-80 kg) underwent a 30% hemorrhage and then were randomized to three thoracic injuries, with and without zone 1 REBOA occlusion: pulmonary parenchymal injury (PI), thoracic venous injury (VI), or subclavian artery injury (AI). All animals were given aspirin to produce PD. Following hemorrhage, thoracic injuries were induced (T0) and allowed to bleed freely. Resuscitative endovascular balloon occlusion of the aorta groups had zone 1 occlusion, with deflation at T30. All groups received whole blood resuscitation at T30 and were euthanized at T90. Survival, total blood loss, hemodynamics, and arterial blood gas parameters were analyzed. RESULTS: The PD-VI-REBOA group had 87.5% survival where PD-VI survival was 28.6%. No difference in survival was seen in the PI or AI groups. The PD-VI-REBOA group had total blood loss of 575.0 ± 339.1 mL, which was less than the PD-VI group (1,086.0 ± 532.1 mL). There was no difference in total thoracic blood loss in the PI and AI groups with the addition of REBOA. All groups showed an equivalent decrease in HCO3 and base excess and increase in lactate at the end of the 30-minute prehospital phase. CONCLUSION: In this study, zone 1 REBOA improved survival and decreased blood loss with major VI, where no differences were seen in parenchymal and subclavian artery injuries. For thoracic bleeding without surgical capability, outcomes may be improved with REBOA, and these findings challenge current guidelines stating the contraindication of REBOA use in this setting.

Outcomes following resuscitative thoracotomy for abdominal exsanguination, a systematic review.

BACKGROUND: Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however Its role in resuscitation of patients with abdominal exsanguination is uncertain. OBJECTIVE: The primary objective of this systematic review was to estimate mortality based on survival to discharge in patients with exsanguinating haemorrhage from abdominal trauma in cardiac arrest or a peri arrest clinical condition following a resuscitative thoracotomy. METHODS: A systematic literature search was performed to identify original research that reported outcomes in resuscitative thoracotomy either in the emergency department or pre-hospital environment in patients suffering or suspected of suffering from intra-abdominal injuries. The primary outcome was to assess survival to discharge. The secondary outcomes assessed were neurological function post procedure and the role of timing of intervention on survival. RESULTS: Seventeen retrospective case series were reviewed by a single author which described 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries. Isolated abdominal trauma survival to discharge ranged from 0 to 18% with polytrauma survival of 0-9.7% with the majority below 1%. Survival following a thoracotomy for abdominal trauma varied between studies and with no comparison non-intervention group no definitive conclusions could be drawn. Timing of thoracotomy was important with improved mortality in patients not in cardiac arrest or having the procedure performed just after a loss of signs of life. Normal neurological function at discharge ranged from 100 to 28.5% with the presence of a head injury having a negative impact on both survival and long-term morbidity. CONCLUSIONS: Pre-theatre thoracotomy may have a role in peri-arrest or arrested patient with abdominal trauma. The best outcomes are achieved with patients not in cardiac arrest or who have recently arrested and with no head injury present. The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy. More high-quality evidence is required to demonstrate a definitive mortality benefit for patients.

Prehospital External Aortic Compression for Temporizing Exsanguinating Sub-Diaphragmatic Hemorrhage - A Promising Technique, but with Challenges: Four Illustrative Cases, Including Two Survivors.

External aortic compression (EAC) has long been used to control exsanguinating post-partum hemorrhage, but it has only recently been described in the prehospital trauma setting. This paper reports four cases where manual EAC was used during transport to manage life-threatening bleeding, twice from stab wounds, once from ruptured ectopic pregnancy, and once from severe lower-limb trauma. It showed that EAC has life-saving potential in the prehospital setting, but that safety and efficacy during transport requires the use of a hands-free compression device, such as an aortic tourniquet.

Systematic reviews of scores and predictors to trigger activation of massive transfusion protocols.

BACKGROUND: The use of massive transfusion protocols (MTPs) in the resuscitation of hemorrhaging trauma patients ensures rapid delivery of blood products to improve outcomes, where the decision to trigger MTPs early is important. Scores and tools to predict the need for MTP activation have been developed for use to aid with clinical judgment. We performed a systematic review to assess (1) the scores and tools available to predict MTP in trauma patients, (2) their clinical value and diagnostic accuracies, and (3) additional predictors of MTP. METHODS: MEDLINE, EMBASE, and CENTRAL were searched from inception to June 2017. All studies that utilized scores or predictors of MTP activation in adult (age, ≥18 years) trauma patients were included. Data collection for scores and tools included reported sensitivities and specificities and accuracy as defined by the area under the curve of the receiver operating characteristic. RESULTS: Forty-five articles were eligible for analysis, with 11 validated and four unvalidated scores and tools assessed. Of four scores using clinical assessment, laboratory values, and ultrasound assessment the modified Traumatic Bleeding Severity Score had the best performance. Of those scores, the Trauma Associated Severe Hemorrhage score is most well validated and has higher area under the curve of the receiver operating characteristic than the Assessment of Blood Consumption and Prince of Wales scores. Without laboratory results, the Assessment of Blood Consumption score balances accuracy with ease of use. Without ultrasound use, the Vandromme and Schreiber scores have the highest accuracy and sensitivity respectively. The Shock Index uses clinical assessment only with fair performance. Other clinical variables, laboratory values, and use of point-of-care testing results were identified predictors of MTP activation. CONCLUSION: The use of scores or tools to predict MTP need to be individualized to hospital resources and skill set to aid clinical judgment. Future studies for triggering nontrauma MTP activations are needed. LEVEL OF EVIDENCE: Systematic review, level III.

Selective aortic arch perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of noncompressible torso hemorrhage.

BACKGROUND: Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC) after HiTCA, compared with resuscitative endovascular balloon occlusion of the aorta and cardiopulmonary resuscitation (CPR). Hemoglobin-based oxygen carriers, such as hemoglobin-based oxygen carrier (HBOC)-201, may alleviate the logistical constraints of using FWB in a prehospital setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB, whether conversion from SAAP to extracorporeal life support (ECLS) is feasible, and whether physiologic derangement post-SAAP therapy is reversible. METHODS: Twenty-six swine (79 ± 4 kg) were anesthetized and underwent HiTCA which was induced via liver injury and controlled hemorrhage. Following arrest, swine were randomly allocated to resuscitation using SAAP with FWB (n = 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a 20-minute prehospital period prior to a 40-minute damage control surgery and resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included rate of ROSC, survival, conversion to ECLS, and correction of physiology. RESULTS: Baseline physiologic measurements were similar between groups. ROSC was achieved in 100% of the FWB animals and 86% of the HBOC-201 animals (p = 0.483). Survival (t = 320 minutes) was 92% (11/12) in the FWB group and 67% (8/12) in the HBOC-201 group (p = 0.120). Conversion to ECLS was successful in 100% of both groups. Lactate peaked at 80 minutes in both groups, and significantly improved by the end of the experiment in the HBOC-201 group (p = 0.001) but not in the FWB group (p = 0.104). There was no significant difference in peak or end lactate between groups. CONCLUSION: Selective aortic arch perfusion is effective in eliciting ROSC after HiTCA in a swine model, using either FWB or HBOC-201. Transition from SAAP to ECLS after definitive hemorrhage control is feasible, resulting in high overall survival and improvement in lactic acidosis over the study period.