New Approaches to the Trauma Patient with Life-Threatening ...
New Approaches to the Patient With Life-Threatening Bleeding Richard N. Bradley, MD, EMT-P, FACEP International Trauma Conference Qubec City, Qubec, Canada November 4, 2017
Potential Conflicts of Interest Dr. Bradley is employed by the McGovern Medical School and is in the US Air Force Air National Guard. The American Red Cross (ARC) provides him with reimbursement for travel expenses as the Resuscitation Sub-Council Chairman of the ARC Scientific Advisory Council and as a board member of
the Citizen CPR Foundation. He is a member of the American College of Emergency Physicians. He has no other potential conflicts with this material. Objectives Upon completion of the session, participants
will be able to: describe the incident and pathophysiology of death due to traumatic hemorrhage and be able to describe the lethal triad, and discuss the pros and cons of pre-hospital and inhospital therapy for traumatic hemorrhage. Bleeding Kills
Hemorrhage is the second-leading cause of early deaths among injured.1 Kauvar, D. S., Lefering, R., & Wade, C. E. (2006). Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. The Journal of Trauma, Injury, Infection, and Critical Care, 60(6), S3-S11. doi:10.1097/01.ta.0000199961.02677.19 1
75,000 trauma patients at the two level one trauma centers in Houston from August 1994 to December 1999. 0.2 per thousand trauma patients at a level one trauma center die of isolated penetrating extremity injuries. Population incidence was 0.1 per 100,000 persons per year Average age was 31 years. 50% of fatal isolated extremity injuries were from gunshot wounds.
71% of the injuries were in the lower extremity. Average scene time was 10 minutes and transport time was 14 minutes. 86% has signs of life in the field but none had a pulse at hospital arrival. 29% had no documented hemorrhage control.
Lethal Triad Trauma Triad of Death, by Cburnett. CC BY 3.0 Gunshot Wound: Does This Person Need Bleeding Control?
GSW to thigh, by Richard N. Bradley 2017 Boston Marathon Bombing "KRON 4 Coverage of the Boston Marathon Bombings" by A Name Like Shields Can Make You Defensive is licensed under CC BY 2.0 Tourniquet use at the Boston Marathon
bombing: Lost in translation King, David; Larentzakis, Andreas; Ramly, Elie. Journal of Trauma and Acute Care Surgery. 78(3):594-599, March 2015. DOI: 10.1097/TA.0000000000000561 Figure 6 . Typical EMS improvised tourniquet. 2015 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2
Improvised Tourniquet Triangular bandage, by ZigZag. Image used under the provisions of the US Fair Use Act. Tourniquets
Combat Application Tourniquet (CAT), by INDNAM. CC BY-SA 3.0 The Combat Application Tourniquet is a registered trademark of CAT Resources, LLC, Rock Hill (SC). SWAT-T Stretch-Wrap-And Tuck Tourniquet, by LA Police Gear. 2001 - 2016 LA Police Gear, Inc. Image used under the provisions of the US Fair Use Act. The SWAT-T is a trademark of H&H Medical Corporation, Williamsburg (VA).
Survival With Emergency Tourniquet Use to Stop Bleeding in Major Limb Trauma Kragh, John; Jr MC, USA; Walters, Thomas; Baer, David; Fox, Charles; MC, USA; Wade, Charles; Salinas, Jose; Holcomb, John; MC, USA. Annals of Surgery. 249(1):1-7, January 2009. DOI: 10.1097/SLA.0b013e31818842ba FIGURE 3. Increase in survival rate by tourniquet use. By breaking down, the tourniquet use by whether the patient was prehospital or ED, whether there was shock present or
absent at the time of application, and whether tourniquets were used or not, a comparison of raw differences in survival rates indicates that the survival benefit to tourniquet use is more strongly related to tourniquet use before the patient has progressed to shock than to prehospital use. 2009 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2 Whats Wrong With This Picture?
CAT on thigh, by Richard N. Bradley. 2017 Topical Hemostatic Agents QuikClot Combat Gauze, by Jng46. CC-BY-SA-4.0 QuikClot is a registered trademark of Z-Medica, Wallingford (CT).
ChitoGauze. Amazon. Image used under the provision of the US Fair Use Act. ChitoGauze is a registered trademark of Tricol Biomedical, Inc., Portland (OR). Open-Book Pelvis Fracture Diastasis symphysis pubis 1300500, by Nevit Dilmen. CC BY-SA 3.0
Anatomy of the presacral venous plexus, by UpToDate. 2011 UpToDate. Image used under the provisions of the US Fair Use Act. Pelvic Circumferential Compression Devices PCCDs, by SP Knops, et al. Open-i. The Pelvicbinder is a registered trademark of PelvicBinder, Inc., Dallas. The SAM Pelvic Sling II is manufactured by SAM Medical, Wilsonville (OR). The TPOD Responder is manufactured by Pyng Medical.
Tactical Combat Casualty Care TCCC Pelvic Binder Guidelines A pelvic binder should be applied for severe blunt force or blast injury with: Pelvic pain
Any major lower limb amputation Physical exam findings suggestive of pelvic fx Unconsciousness Shock Pelvic Circumferential Compression Device
T-POD Responder, by Pyng Medical. 2014 Pyng Medical. Image used under the provisions of the US Fair Use Act. The T-POD Responder is manufactured by Pyng Medical. Tranexamic Acid Tranexamic acid Structural Formulae, by J. Public domain. Tranexamic acid (cropped), by Mark Oniffrey. CC BY-SA 4.0
The COAST Score Variable Value Score
Entrapment Yes 1
Systolic blood pressure < 90 mm Hg, < 100 mm Hg 2, 1 Temperature
< 32 C, < 35 C 2, 1 Major chest injury
Yes 1 Intraabdominal, pelvic injury Yes
1 TCCC Guidelines for TXA If significant blood transfusion is anticipated, Hemorrhagic shock Major amputation
Penetrating torso trauma Evidence of severe bleeding Administer 1 g of tranexamic acid in 100 ml 0.9% saline or Lactated Ringers ASAP, over 10 min., but not later than 3 hours after injury.
Fluid Resuscitation If not in shock, no fluids are immediately needed. If in shock, resuscitation fluids, in order of preference are: Whole blood Plasma, RBCs, and platelets in 1:1:1 ratio Plasma and RBCs in 1:1 ratio
Plasma or RBCs alone Hextend Lactated Ringers or Plasma-Lyte A Stop the bleed logo, by US Dept. of Homeland Security. USG image. Stop the bleed infographic, by US Dept. of Homeland Security. USG image.
American College of Surgeons Committee on Trauma Position Paper Protocol for prehospital external hemorrhage control, by Eileen M. Bulger, et al. Copyright 2017 Informa UK Limited. Image used under the provisions of the US Fair Use Act. Guidelines
NICE 2017 Bleeding Control Guidelines Simple dressings Tourniquets on limbs if direct pressure fails Pelvic binders in pre-hospital setting for
suspected active bleeding from pelvic fracture Use TXA ASAP in pre-hospital and hospital settings for patients with major trauma & suspected active bleeding ( 3 hrs after injury) NICE 2017 Bleeding Control Guidelines
Pre-hospital peripheral IV. IO if IV fails or consider 1st line in pts < 16 yrs if peripheral IV is anticipated to be difficult Restrictive approach to volume resuscitation until definitive early control of bleeding In pre-hospital setting, titrate volume resuscitation to a palpable carotid or femoral
pulse Bleeding Control Guidelines Pre-hospital: crystalloids if blood component not available REBOA: Resuscitative Endovascular Balloon
Occlusion of the Aorta ER-REBOATM Catheter. 2017 All Rights Reserved. Prytime Medical Devices, Inc The REBOA Company. Image used under provisions of the Fair Use Act. REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta
REBOA. Image: Pryor Medical Devices, Inc. Thinkstock. Image used under the provisions of the US Fair Use Act. REBOA Insertion Zones 2016 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. Blood Product Therapy
PRBCs, by Richard N. Bradley 2017 . Transfusion in the Field
Implementing Protocols to Administer Blood Products in the Prehospital Setting, by North Memorial Ambulance Service. Copyright 2017: PennWell Corporation, Tulsa, OK. Image used under provisions of the Fair Use Act. Blood Substitutes? FreshFrozenPlazma, by DiverDave. is licensed under CC BY-SA 3.0.
Junctional Tourniquets Junctional Tourniquet, U.S. Army photo by Ellen Crown. The SAM Junctional Tourniquet is manufactured by SAM Medical, Wilsonville (OR). Conclusion
Stop the bleed We dont do that as well as we should Tourniquets save lives Pelvic circumferential compression devices
may save lives Tranexamic acid may be beneficial Blood should be replaced by blood [email protected] +1-713-500-7878
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