Tourniquet use for civilian extremity hemorrhage: systematic review of the literature.

INTRODUCTION: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. METHODS: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. RESULTS: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. CONCLUSIONS: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature / Uso de torniquete nas hemorragias de extremidades na população civil: revisão sistemática da literatura

ABSTRACT Introduction: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. Methods: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. Results: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. Conclusions: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

RESUMO Introdução: o uso de torniquete em extremidades (TQ) aumentou no ambiente civil; os resultados benéficos observados nas forças armadas influenciaram a aceitação por equipes de pré-hospitalar (PH) assim como pela população leiga. Esta revisão teve como objetivo analisar os tipos de TQ de extremidades usados em ambiente civil, local da lesão, indicações e complicações. Métodos: revisão sistemática foi conduzida com base em artigos originais publicados no PubMed, Embase e Cochrane seguindo as diretrizes do PRISMA de 2010 a 2019. Extração de dados focada no uso de TQ de extremidade para controle de hemorragia em ambiente civil, dados demográficos, tipo de estudo e duração, mecanismo de lesão, indicações de uso, local da lesão, tipo de TQ, tempo de TQ e complicações. Resultados: dos 1.384 artigos identificados, 14 foram selecionados para revisão com total de 3.912 vítimas civis com hemorragia nas extremidades e 3.522 colocações de extremidades TQ analisadas. A maioria foi aplicado em pacientes do sexo masculino (79%), com trauma contuso ou penetrante. Entre as indicações estavam choque hemorrágico, suspeita de lesões vasculares, sangramento contínuo e amputações traumáticas parciais ou completas. A aplicação na extremidade superior foi o local de aplicação mais comum (56%), quase todos aplicados a uma única extremidade (99%), e apenas 0,6% requereram aplicações nas extremidades superior e inferior. 80% dos TQs aplicados eram dispositivos comerciais e 20% improvisados. Conclusões: o uso de TQ em ambientes civis está associado a traumas. Os TQs comerciais são mais utilizados, com tempo menor que uma hora de uso e poucas complicações.

The safety and efficacy of improvised tourniquets in life-threatening hemorrhage: a systematic review.

OBJECTIVE: The increased incidence of mass casualty incident (MCI) with penetrating injuries in the civilian setting creates a call for implementing devices, such as a tourniquet (TQ), in civilian first aid. Bystanders could act as immediate responders after an MCI in order to prevent a victim from exsanguination using direct pressure or commercial tourniquets (C-TQ). Reports have shown that immediate access to C-TQs was not available and bystanders used objects available at the trauma scene to make an improvised tourniquet (I-TQ). The aim of this systematic review of literature was to summarize the existing literature on designs, efficacy and safety of I-TQs. METHODS: A systematic review of the literature was performed. Bibliographic databases PubMed, EMBASE.com and Cochrane Library were searched. All types of original studies about I-TQ's were included. Review studies, exempts from textbooks or studies with TQs applied during elective surgeries were excluded. RESULTS: Twenty studies were included. In both simulated experiments and real-life situations, I-TQs outperformed commercial TQs (C-TQ) regarding success rate. Of the I-TQs, the band and windlass design performed most consistently. Although lacking any statistical analysis, there was no reported difference in adverse events between I-TQs and C-TQs. CONCLUSION: The use of- and training in I-TQ by civilian immediate responders is not recommended because of limited efficacy and safety concerns; direct pressure is a viable alternative. However, I-TQs may save lives when applied correctly with proper objects; therefore, future studies regarding the best design and training in application of effective and safe I-TQs should be encouraged.

Titrate to equilibrate and not exsanguinate! Characterization and validation of a novel partial resuscitative endovascular balloon occlusion of the aorta catheter in normal and hemorrhagic shock conditions.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a significant advancement in the control of noncompressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. METHODS: Twenty-five swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1 (N = 5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N = 10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and rebleeding from injuries. Experiment 3 (N = 10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2 hours followed by complete deflation for 30 minutes. RESULTS: Balloon volume at minimum flow (mean, 0.09 L/min) was 3.5 mL to 6.0 mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. Partial REBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45 L/min to 0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3 L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3, respectively. There was a trend toward hyperkalemia and hypocalcemia in nonsurvivors. CONCLUSION: The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5 L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest.

Pilot Study of a Novel Swine Model for Controlling Junctional Hemorrhage Using the iTClamp in Conjunction With Hemostatic Agents.

Exsanguinating hemorrhage is a primary cause of battlefield death. The iTClamp is a relatively new device (FDA approval in 2013) that takes a different approach to hemorrhage control by applying mechanism wound closure. However, no previous studies have explored the feasibility of utilizing the iTClamp in conjunction with hemostatic packing. To fill this important gap in the literature, a novel swine model was developed, and a total of 12 trials were performed using QuikClot Combat Gauze or XSTAT sponges in conjunction with the iTClamp to treat arterial injuries through 5 cm or 10 cm skin incisions in the groin, axilla, or neck. First-attempt application success rate, application time, and blood loss were recorded. Hemostasis was achieved on all wounds, though reapplication was required in one Combat Gauze and three XSTAT applications. Application averaged ~50% slower for Combat Gauze (M = 41 seconds, 95%CI: 22-32 seconds) than for XSTAT (M = 27 seconds, 95%CI: 35-47 seconds). XSTAT application was faster than Combat Gauze for each wound location and size. The 10 cm wounds took ~10 seconds (36%) longer to close (M = 27 seconds, 95%CI: 35-47 seconds) than the 5 cm wounds (M = 27 seconds, 95%CI: 35-47 seconds). Blood loss was similar for Combat Gauze (M = 51 mL, 95%CI: 25-76 mL) and XSTAT (M = 60 mL, 95%CI: 30-90 mL). Blood loss was roughly twice as great for 10 cm wounds (M = 73 mL, 95%CI: 47-100 mL) than for 5 cm wounds (M = 38 mL, 95%CI: 18-57 mL). This pilot study supports the feasibility of a novel model for testing the iTClamp in conjunction with hemostatic packing towards controlling junctional hemorrhage.

Utilización del torniquete en la asistencia extrahospitalaria: revisión sistemática / Tourniquet use in out-of-hospital emergency care: a systematic review

Objetivo: La hemorragia no controlada producida por un traumatismo grave sigue siendo una de las principales causas de muerte evitable en el entorno extrahospitalario. En estas situaciones, los torniquetes podrían ser una herramienta rápida y útil para detener el sangrado exanguinante, aunque existe evidencia limitada en cuanto a su utilización y efectividad en el entorno civil. Analizar la efectividad del torniquete para detener las hemorragias en situaciones de urgencia extrahospitalaria y los factores relacionados. Método: Revisión sistemática de la bibliografía en español e inglés. Se elaboraron protocolos de búsqueda para localizar estudios que valoraran la utilización de los distintos dispositivos y la efectividad en la detención del flujo arterial. Se incluyeron estudios publicados entre 2011 y 2016, con utilización del torniquete en hemorragias exanguinantes. Resultados: Se analizaron 17 artículos. En todos los estudios se observó que el torniquete fue efectivo en la detención de la hemorragia, siendo el dolor el efecto adverso más frecuentemente descrito (35,7% de los casos). El retraso en su aplicación es un factor determinante que afecta negativamente a la efectividad. Conclusiones: Los torniquetes son efectivos deteniendo la hemorragia exanguinante. Sus complicaciones son escasas y la mayoría son atribuibles al estado crítico de los pacientes y no a su colocación. A nivel extrahospitalario, el torniquete debería utilizarse en pacientes con traumatismo mayor si la presión directa no es suficiente para controlar una hemorragia exanguinante que amenace la vida

Objective: Uncontrolled bleeding from serious injuries continues to be one of the main causes of preventable deaths outside hospitals. Tourniquets could be useful for quickly stemming blood flow and prevent exsanguination, although evidence supporting their use and effectiveness in civilian accidents is limited. To analyze the effectiveness of tourniquets for stopping bleeding in out-of-hospital emergencies and to explore factors associated with effectiveness. Methods: We undertook a systematic review of the literature in Spanish and English. Search protocols to identify studies that evaluated the use of various devices and their effectiveness in stemming arterial blood flow. We included studies published between 2011 and 2016 in which tourniquets were used to prevent massive blood loss. Results: We included 17 articles. Tourniquets were effective in stopping massive bleeding in all studies. Pain, the most frequently described adverse effect, was observed in 420 patients (35.7%). Delayed application of a tourniquet was associated with more negative outcomes. Conclusions: Tourniquets are effective for stopping massive blood loss. There are few complications, most of which are attributable to the critical state of patients rather than to application of the tourniquet. A tourniquet should be applied in major trauma cases in civilian settings if massive, life-threatening bleeding cannot be stopped with direct pressure

Tourniquet use in out-of-hospital emergency care: a systematic review. / Utilización del torniquete en la asistencia extrahospitalaria: revisión sistemática.

OBJECTIVES: Uncontrolled bleeding from serious injuries continues to be one of the main causes of preventable deaths outside hospitals. Tourniquets could be useful for quickly stemming blood flow and prevent exsanguination, although evidence supporting their use and effectiveness in civilian accidents is limited. To analyze the effectiveness of tourniquets for stopping bleeding in out-of-hospital emergencies and to explore factors associated with effectiveness. MATERIAL AND METHODS: We undertook a systematic review of the literature in Spanish and English. Search protocols to identify studies that evaluated the use of various devices and their effectiveness in stemming arterial blood flow. We included studies published between 2011 and 2016 in which tourniquets were used to prevent massive blood loss. RESULTS: We included 17 articles. Tourniquets were effective in stopping massive bleeding in all studies. Pain, the most frequently described adverse effect, was observed in 420 patients (35.7%). Delayed application of a tourniquet was associated with more negative outcomes. CONCLUSION: Tourniquets are effective for stopping massive blood loss. There are few complications, most of which are attributable to the critical state of patients rather than to application of the tourniquet. A tourniquet should be applied in major trauma cases in civilian settings if massive, life-threatening bleeding cannot be stopped with direct pressure.

OBJETIVO: La hemorragia no controlada producida por un traumatismo grave sigue siendo una de las principales causas de muerte evitable en el entorno extrahospitalario. En estas situaciones, los torniquetes podrían ser una herramienta rápida y útil para detener el sangrado exanguinante, aunque existe evidencia limitada en cuanto a su utilización y efectividad en el entorno civil. Analizar la efectividad del torniquete para detener las hemorragias en situaciones de urgencia extrahospitalaria y los factores relacionados. METODO: Revisión sistemática de la bibliografía en español e inglés. Se elaboraron protocolos de búsqueda para localizar estudios que valoraran la utilización de los distintos dispositivos y la efectividad en la detención del flujo arterial. Se incluyeron estudios publicados entre 2011 y 2016, con utilización del torniquete en hemorragias exanguinantes. RESULTADOS: Se analizaron 17 artículos. En todos los estudios se observó que el torniquete fue efectivo en la detención de la hemorragia, siendo el dolor el efecto adverso más frecuentemente descrito (35,7% de los casos). El retraso en su aplicación es un factor determinante que afecta negativamente a la efectividad. CONCLUSIONES: Los torniquetes son efectivos deteniendo la hemorragia exanguinante. Sus complicaciones son escasas y la mayoría son atribuibles al estado crítico de los pacientes y no a su colocación. A nivel extrahospitalario, el torniquete debería utilizarse en pacientes con traumatismo mayor si la presión directa no es suficiente para controlar una hemorragia exanguinante que amenace la vida.

Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center.

PURPOSE: Despite using a multidisciplinary treatment approach, the mortality rate of patients with hemodynamic instability from severe pelvic fractures is still 40-60%. We evaluated the improvement of outcomes in this patient population after the establishment of a regional trauma center in Korea. METHODS: We retrospectively reviewed the medical charts of 50 patients with hemodynamic instability due to pelvic fractures between March 2011 and November 2016. Patients were divided into two groups: the pre-trauma center (PTC) group (n = 23) and trauma center (TC) group (n = 27). RESULTS: Sixteen (32.0%) patients died of exsanguination. Patients in the TC group had shorter trauma resuscitation room stay (101 vs 273 min, p < 0.001) and underwent preperitoneal pelvic packing (PPP) more frequently (88.9 vs 8.7%, p < 0.001) than those in the PTC group. During the TC period, emergent procedures such as PPP and pelvic angiography were performed more frequently (92.6 vs 39.1%, p < 0.001). Although there was no statistical difference in the overall mortality rate between groups, patients in the TC group had less mortality due to hemorrhage (18.5 vs 47.8%, p = 0.027). Logistic regression analysis demonstrated that initial systolic blood pressure and establishment of trauma center were independent protective factors of mortality from hemorrhage [odds ratio (OR) 0.957, 95% confidence interval (CI) 0.926-0.988, p = 0.007; OR 0.134, 95% CI 0.028-0.633, p = 0.011]. CONCLUSIONS: Since the regional trauma center was established, emergent procedures such as pelvic angiography and PPP were performed more frequently, and mortality due to exsanguination was significantly decreased.

Impact of a prehospital discrimination between trauma patients with or without early acute coagulopathy of trauma and the need for damage control resuscitation: rationale and design of a multicenter randomized phase II trial.

BACKGROUND: The evidence of the Trauma Induced Coagulopathy Clinical Score (TICCS) accuracy has been evaluated in several studies but the potential effect of its use on patient outcomes needs to be evaluated. The primary objective of this study is to evaluate the impact on mortality of a prehospital discrimination between trauma patients with or without a potential need for damage control resuscitation. METHODS: The trial will be designed as randomized phase II clinical trial with comparison of the experimental protocol against the standard of care. The TICCS will be calculated on the site of injury for the patients of the intervention group and treatment will be guided by the TICCS value. Seven days mortality, 30 days mortality, global use of blood products and global hospital length-of-stay will be compared. DISCUSSION: Many data suggest that a very early flagging of trauma patients in need for DCR would be beneficial but this need to be proved. Do we improve our quality of care by an earlier diagnosis? Does a prehospital discrimination between trauma patients with or without a potential need for DCR has a positive impact?

Clinical Update: Concepts of Prehospital Traumatic Hemorrhage Control in the Operational K9.

Major trauma often involves varying degrees of hemorrhage. Left unattended, any amount of trauma-induced hemorrhage may rapidly become life threatening. Similar to humans, Operational canines (OpK9s) can suffer penetrating trauma and blunt trauma that lead to compressible and noncompressible hemorrhage. Preserving organ function and saving the life of a massively bleeding OpK9 require the implementation of immediate and effective hemostatic measures. Effective hemorrhage control interventions for the exsanguinating OpK9 are similar to those for humans: direct pressure, wound packing, hemostatic agents and devices, pressure bandage, and, possibly, tourniquet application. Although tourniquet application is a life-saving intervention in humans experiencing extremity hemorrhage, it is not considered a necessary, immediate-action life-saving intervention for canines with extremity injuries. This article provides a brief description of the basic methods for identifying life-threatening hemorrhage and achieving immediate hemostasis in the bleeding OpK9 during the prehospital period.

Patterns of vasopressor utilization during the resuscitation of massively transfused trauma patients.

BACKGROUND: The use of vasopressors (VP) in the resuscitation of massively transfused trauma patients might be considered a marker of inadequate resuscitation. We sought to characterize the utilization of VP in patients receiving massive transfusion and examine the association of their use with mortality. METHODS: Trauma patients admitted from January 2011 to October 2016 receiving massive transfusion, defined as 3 units of pRBC within the first hour from admission, were selected for analysis. Demographics, admission vital signs and labs, use of VP, surgical interventions and outcomes were collected. Standard statistical tools were utilized. RESULTS: Over the 5-year study period, 120 trauma patients met inclusion criteria. The median age was 39 years with 77% being male and 41% sustaining a penetrating injury. Patients who received VP [VP (+)] were more likely to have a lower admission GCS (median 4.5 vs. 14.0, p <0.01) and less likely to have a penetrating injury (31% vs. 54%, p=0.02). The overall mortality was 49% and significantly higher in the VP (+) cohort (60% vs. 34%, AHR: 9.9, adjusted p=0.03). Mortality increased in a stepwise fashion with increasing number of VP utilized, starting at 34% for no VP, to 78% for 3 VP, and 100% for 5 or more. The majority of deaths in the VP (-) group (88%) occurred within one day from admission. For the VP (+) group, 57% of deaths occurred within one day, with the remaining 43% occurring at a later time. CONCLUSION: In the era of massive transfusion protocols, vasopressors are commonly utilized in exsanguinating trauma patients and their use is associated with a higher mortality risk. Deaths in patients receiving vasopressors are more likely to occur later compared to those in patients who do not receive vasopressors. Further research to characterize the role of these agents in the resuscitation of trauma patients is required.

Acute Management of the Traumatically Injured Pelvis.

Severe pelvic trauma is a challenging condition. The pelvis can create multifocal hemorrhage that is not easily compressible nor managed by traditional surgical methods such as tying off a blood vessel or removing an organ. Its treatment often requires reapproximation of bony structures, damage control resuscitation, assessment for associated injuries, and triage of investigations, as well as multimodality hemorrhage control (external fixation, preperitoneal packing, angioembolization, REBOA [resuscitative endovascular balloon occlusion of the aorta]) by multidisciplinary trauma specialists (general surgeons, orthopedic surgeons, endovascular surgeons/interventional radiologists). This article explores this complex clinical problem and provides a practical approach to its management.

The Damage Control Surgery in Austere Environments Research Group (DCSAERG): A dynamic program to facilitate real-time telementoring/telediagnosis to address exsanguination in extreme and austere environments.

Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.

Intra-Arterial Perimortem Resuscitation Using a Micellar Colloid.

OBJECTIVE: The following were studied in a perimortem mouse model of rapid blood loss: (a) efficacy of a prototypical micellar colloid, Intralipid 20%, (IL20), compared to albumin (b) comparison of intra-arterial and intravenous resuscitation, (c) efficacy of IL20 at a volume 2 × the volume of blood removed, and (d) efficacy of oxygenated IL20 after clinical death (CD). METHODS: CD, the absence of breathing and zero blood pressure (BP), was produced by removing 55% of the blood volume within 3 minutes. After CD, the chest was opened to observe ventricular contraction. IL20, Ringer's lactate (RL), or albumin was infused perimortem. RESULTS: Without resuscitation CD occurred in 2.85 ± 0.40 minutes. Ventricular contraction persisted 20.50 ± 1.11 minutes after CD. RL infused immediately after CD restored breathing if given intra-arterially but not intravenously. IL20 was superior to the prototypical colloid, albumin in maintaining the BP. Increasing the volume of IL20 further increased BP. Delayed RL infusion after CD failed to restore breathing. Delayed resuscitation after CD with oxygenated IL20 restored breathing and BP. CONCLUSIONS: Micellar colloid is superior to the prototypical colloid albumin and can possibly be of use when signs of life are no longer present. In extremis, intra-arterial infusion is superior to intravenous infusion.

The iTClamp in the management of prehospital haemorrhage.

INTRODUCTION: Bleeding remains a leading cause of death in trauma patients. The iTClamp is a temporary wound closure device designed to control external bleeding within seconds of injury. We describe our experience using this device on 10 patients in the prehospital environment. METHODS: We have implemented the iTClamp for prehospital use through our physician-staffed helicopter emergency medical service (HEMS). Indications were massive bleeding that could not be controlled with an ordinary compressive bandage or a haemostatic bandage. RESULTS: Ten patients were treated with the iTClamp. Seven patients had a severe head injury due to various traumas, one patient had a neck injury from a disk cutter, one patient had an open chest wound and one patient had an open femur fracture. After applying the iTClamp, bleeding was controlled in 90% of these patients (n=9), with complete cessation reported in 60% (n=6), partial cessation with adequate control reported in 30% (n=3); in one patient, the bleeding could not be controlled with the iTClamp alone. It took an average of 10s to apply the iTClamp, and the average usage satisfaction score was 7.7. CONCLUSION: We conclude that the iTClamp is a safe, fast and useful tool for stopping or controlling external blood loss in our series of prehospital patients. Further studies of the iTClamp are needed to determine which patients might benefit from this device.

Damage-control resuscitation and emergency laparotomy: Findings from the PROPPR study.

BACKGROUND: The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial has demonstrated that damage-control resuscitation, 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. METHODS: 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 laparotomy as well as postsurgical survival at 24 hours and 30 days. RESULTS: 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). CONCLUSION: We found no evidence that resuscitation strategy affects whether a patient requires an emergency laparotomy, time to laparotomy, or subsequent survival. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Modulating the endotheliopathy of trauma: Factor concentrate versus fresh frozen plasma.

BACKGROUND: Transfusion of balanced ratios of plasma to platelets and red blood cells has been shown to reduce early death from exsanguination in trauma patients. Aside from hemostasis, recent work has shown that plasma reduces vascular endothelial permeability, inflammation, and organ edema after hemorrhagic shock (HS), all components of the endotheliopathy of trauma. We hypothesized that Kcentra could have protective effects on the endotheliopathy of trauma comparable with fresh frozen plasma (FFP). METHODS: In vitro, endothelial cell (EC) barrier function was assessed by measuring changes in transendothelial electrical resistance for Kcentra, FFP, and albumin. In vivo, a modified Miles assay was used on mice to study the effects of Kcentra, FFP, and albumin on vascular permeability induced by VEGF-A. The same groups were studied in a second in vivo model of pulmonary vascular leak induced by HS and laparotomy. The identification of proteins in Kcentra was assessed by liquid chromatography/mass spectrometry. RESULTS: We found that FFP and Kcentra inhibit EC permeability. We also found that Kcentra and FFP have equivalent capacity to restore EC adherens junction breakdown induced by VEGF-A. In vivo, we found that Kcentra and FFP, but not albumin, significantly inhibited vascular permeability induced by VEGF-A and HS-induced vascular permeability in mice. Investigation of the protein content of Kcentra by mass spectroscopy revealed that there are a number of proteins in Kcentra, derived from plasma that may have contributory roles in the noted effects of Kcentra on vascular leak. CONCLUSION: Taken together, we have demonstrated that FFP and Kcentra inhibit vascular permeability in vivo and in vitro. These beneficial effects of Kcentra may be due in part to the modulation of vascular function by soluble factors present in Kcentra aside from the known clotting factors II, VII, IX, and X. The clinical implications of these findings are unknown and warrant further investigation.

Remote Telementored Ultrasound-Directed Compression to Potentially Accelerate Hemostasis in Exsanguinating Junctional Vascular Injuries.

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; http://innovativetraumacare.com). This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.