Non-compressible torso haemorrhage: the new holy grail for further improvement in trauma survival

Barnard, Edward; Smith, Jennifer

doi:10.1136/jrnms-104-107

Cited by 4 publications

(3 citation statements)

References 51 publications

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“…One of these subgroups comprises of patients with penetrating trauma to the torso. These patients pose a significant challenge to pre-hospital care providers, as bleeding from underlying vascular structures is non-compressible [ 9 ]. In the main, these patients benefit from expeditious transport to a specialist trauma centre [ 3 , 10 ].…”

Section: Introductionmentioning

confidence: 99%

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

Gavrilovski

Griggs

Avest

et al. 2021

Scand J Trauma Resusc Emerg Med

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Background Although the merit of pre-hospital critical care teams such as Helicopter Emergency Medical Services (HEMS) has been universally recognized for patients with penetrating torso injuries who present with unstable physiology, the potential merit in patients initially presenting with stable physiology is largely undetermined. The ability to predict the required pre-hospital interventions patients may have important implications for HEMS tasking, especially when transport times to definitive care are prolonged. Methods We performed a retrospective cohort study of patients who sustained a penetrating torso injury and were attended by the Air Ambulance Kent Surrey Sussex (AAKSS) over a 6-year period. Primary outcome was defined as the percentage of patients with penetrating torso injuries requiring HEMS-specific interventions anytime between HEMS arrival and arrival at hospital. Secondary outcomes were the association of individual patient- and injury characteristics with the requirement for HEMS interventions. Results During the study period 363 patients met inclusion criteria. 90% of patients were male with a median age of 30 years. 99% of penetrating trauma incident occurred more than 10-min drive from a Major Trauma Centre (MTC). Presenting GCS was > 13 in 83% of patients. Significant hemodynamic- or ventilatory compromise was present in more than 25% of the patients. Traumatic cardiac arrest was present in 34 patients (9.4%), profound hypotension with SBP < 80 mmHg in 30 (8.3%) and oxygen saturations < 92% in 30 (8.3%). A total of 121 HEMS-specific interventions were performed. Although HEMS-specific interventions were associated with presenting physiology (TCA OR 1.75 [1.41–2.16], SBP < 80 mmHg (OR 1.40 [1.18–1.67] and SpO2 < 92% (OR 1.39 [1.17–1.65], a minority of the patients presented initially with stable physiology but deteriorated on route to hospital and required HEMS interventions (n = 9, 3.3%). Conclusion HEMS teams provide potentially important contribution to the pre-hospital treatment of patients with penetrating torso injuries in rural and semi-rural areas, especially when they present with unstable physiology. A certain degree of over-triage is inevitable in these patients, as it is hard to predict which patients will deteriorate on route to hospital and will need HEMS interventions. The results of this study showing a potentially predictable geographical dispersion of penetrating trauma could inform multi-agency knife crime prevention strategy.

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Section: Introductionmentioning

confidence: 99%

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

Gavrilovski

Griggs

Avest

et al. 2021

Scand J Trauma Resusc Emerg Med

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“…Military medical services should be continuously striving to improve patient outcomes. It is known that ‘non-compressible’ haemorrhage is a leading cause of preventable battlefield death1–4 and often requires surgical or radiological intervention 5. The treatment of such injuries in the pre-hospital environment remains a challenge, particularly in junctional areas that are not amenable to conventional tourniquet application.…”

Section: Introductionmentioning

confidence: 99%

“…The treatment of such injuries in the pre-hospital environment remains a challenge, particularly in junctional areas that are not amenable to conventional tourniquet application. One in five cases of potentially survivable ‘non-compressible’ haemorrhage are junctional1–4—39% neck and the remaining 61% not differentiated between pelvic or axillary. There is no device readily available for Combat Medical Technicians (CMTs) to use for junctional or pelvic injury 6.…”

Section: Introductionmentioning

confidence: 99%

Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) can be applied both successfully and rapidly by Combat Medical Technicians (CMTs)

Smith¹,

Beaven

Handford

et al. 2021

BMJ Mil Health

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Background‘Non-compressible’ haemorrhage is the leading cause of preventable battlefield death, often requiring surgical or radiological intervention, which is precluded in the pre-hospital environment. One-fifth of such bleeds are junctional and therefore potentially survivable. We examine the use of the Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) among UK Combat Medical Technicians (CMTs) as a device to control junctional haemorrhage with external compression of the abdominal aorta—compression of junctional haemorrhage previously considered ‘non-compressible.’ This follows animal studies showing that the AAJTS achieves control of haemorrhage and improves physiological parameters.MethodsCMTs were selected and applied the AAJTS to each other following a 1-hour training package. A consultant radiologist-operated hand-held ultrasound monitored flow changes in the subjects’ common femoral artery. CMTs were then surveyed for their opinions as to utility and function.Results21 CMTs were screened and 17 CMTs participated with 34 total applications (16 day and 18 low-light). 27/34 (79%) achieved a successful application. The median application time was 75 s in daylight and 57 s in low-light conditions. There was no significant difference in Body Mass Index (p=0.23), median systolic blood pressure (p=0.19), nor class of CMT (p=0.10) between successful and unsuccessful applications. Higher systolic blood pressure was associated with longer application times (p=0.03). Users deemed the device easy to use (median score 4.4 on a 5-point Likert scale).ConclusionCMTs can use AAJTS successfully after a 1-hour training session in the majority of applications. Application was successful in both daylight and low-light conditions. Self-reported usability ratings were high.

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The Efficacy of Whole Blood Resuscitation During Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Mitigate Post-occlusion Circulatory Collapse: A Translational Model in Large Swine

Newberry,

Paredes,

Barnard

et al. 2024

Military Medicine

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Introduction Uncontrolled torso hemorrhage is the primary cause of potentially survivable deaths on the battlefield. Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), in conjunction with damage control resuscitation, may be an effective management strategy for these patients in the prehospital or austere phase of their care. However, the effect of whole blood (WB) transfusion during REBOA on post-occlusion circulatory collapse is not fully understood. Materials and Methods Yorkshire male swine (n = 6 per group, 70–90 kg) underwent a 40% volume-controlled hemorrhage. After a 10-minute hemorrhagic shock period, a REBOA balloon was inflated in Zone 1. Fifteen minutes after inflation, 0, 1, or 3 units (450 mL/unit) of autologous WB was infused through the left jugular vein. Thirty minutes after initial balloon inflation, the balloon was deflated slowly over 3 minutes. Following deflation, normal saline was administered (up to 3,000 mL) and swine were observed for 2 hours. Survival (primary outcome), hemodynamics, and blood gas values were compared among groups. Statistical significance was determined by log-rank test, one-way ANOVA, and repeated measures ANOVA. Results Survival rates were comparable between groups (P = .345) with 66% of control, 33% of the one-unit animals, and 50% of the 3-unit animals survived until the end of the study. Following WB infusion, both the 1-unit and the 3-unit groups had significantly higher blood pressure (P < .01), pulmonary artery pressure (P < .01), and carotid artery flow (P < .01) compared to the control group. Conclusions WB transfusion during Zone 1 REBOA was not associated with increased short-term survival in this large animal model of severe hemorrhage. We observed no signal that WB transfusion may mitigate post-occlusion circulatory collapse. However, there was evidence of supra-normal blood pressures during WB transfusion.

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Non-compressible torso haemorrhage: the new holy grail for further improvement in trauma survival

Cited by 4 publications

References 51 publications

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) can be applied both successfully and rapidly by Combat Medical Technicians (CMTs)

The Efficacy of Whole Blood Resuscitation During Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Mitigate Post-occlusion Circulatory Collapse: A Translational Model in Large Swine

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