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John Mohler, RN, BSN, CFRN, CCRN

REACH Air – Elko, NV

Hemorrhage Control

Hemorrhage Control

The Evolving Paradigmof Hemorrhage Control

in the Prehospital Setting

A special thanks toJeffrey P. Salomone, MD, NREMT-P and

And Mike McElvoy, PhD, RN for theircontributions to this presentation

Blood Everywhere:How to Stop a Gusher

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An Overview

Tourniquets

Hemostatic agents or adjuncts

Other hemorrhage control devices

Permissive hypotenstion

Hypotensive resuscitation

Tranexamic Acid (TXA)

Freeze dried plasma

Resuscitation

Hemorrhage

Number ONE causeof preventabledeaths on thebattlefield

Old surgeon’s adage:

All bleeding stops. . .

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MARCH

Massive hemorrhage control

Airway

Respirations

Circulation

Hypothermia

Triage Life-Savers

1. Stop bleeding

2. Decompress tension pneumothorax

3. Insert nasopharyngeal airway

Every RBC Counts!

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Shock: 4 Kinds

Despite what you might read or hear, there areONLY four shock states:

1. Hypovolemic

2. Obstructive

3. Distributive

4. Cardiogenic

Normal Adult Blood Volume5 Liters

5 Liters Blood Volume

1 literby

volume

1 literby

volume

1 literby

volume

1 literby

volume

1 literby

volume

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ACS Classification of Acute Hemorrhage

Class % BloodLoss

Clinical Signs

I Up to 750ml (15%)

Slight increase in HR; no change inBP or respirations

II 750-1500ml (15-30%)

Increased HR and respirations;restlessness (anxiety, fright orhostility); [increased diastolic BP]

III 1500-2000ml (30-40%)

Increased HR and respirations; falling

systolic BP; significant AMS

IV >2000(>40%)

Severe tachycardia; severe BP;cold, pale skin; decreased LOC

2500 ml Blood Loss

2.5 Liters Blood Volume Left

2500 ml Blood Loss Mental State: Unconscious

Radial Pulse: Absent

Heart Rate: 140+

Systolic Blood pressure: Markedlydecreased

Respiratory Rate: Over 35

Is the patient going to die from this?

Probably

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So What’s the Problem?

Military

9% fatal bleeds are preventable

Civilian

10 million ED visits annually in US for externalhemorrhage

Definite advances have been made/are beingmade in hemorrhage control (both externaland internal)

CAUSES OF DEATH ON THE MODERNBATTLEFIELD: 2001-2005

COL John B. Holcomb, MAJ Lisa A. Pearse, CDR Jim Caruso, MimiLawnick RN, Charles E. Wade, Howard R. Champion

USAISR, AFMES, USUHS

Battlefield Deaths

Explosion57%

Aviation11%

GSW27%

MVC2%

Multi2%

Unk1%

n=413

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Potentially Preventable Deaths

n = 413

32% Compressible68% Non-compressible

Other2%

Causes of Preventable Deaths

Causes of Combat Wounds

(WWI, WWII, Korea, Vietnam, Middle East)

Fragments62%

Bullets23%

Burns6%

Blast3%

Other6%

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Compare to Civilian Deaths

MVC68%

Falls4%

GSW8%

Stab6%

Burns5%

Unk9%

Evans J, et al. Epidemiology of Traumatic Deaths: Comprehensive Population-Based Assessment. World J Surg. 2010;34:158-163

Civilian – All Causes Deaths

CNS33%

Hemorrhage33%

CNS+Hem17%

Airway8%

MOF3%

Other6%

Evans J, et al. Epidemiology of Traumatic Deaths: Comprehensive Population-Based Assessment.World J Surg. 2010; 34:158-163

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Potentially Preventable MilitaryHemorrhagic Deaths

n = 72

Bleeding45%

CNS injury41%

Organ failure10%

Other4%

Bleeding Kills about ½ of our Trauma Patients

Civilian Hemorrhage Deaths

Aortic Trauma23%

Chest(heart/hilum)

23%

Pelvic23%

Abdomen14%

Extrem7%

Combo10%

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Beyond Statistics

7 Caveats When ApplyingMilitary Literature

Different weapons Less pre-existing dehydration Shorter pre-hospital time Different surgical intervention More resources Better monitoring Less threatening environment

Hemorrhage control steps

Direct pressure

Elevation of extremity

Pressure points

Tourniquet as last resort

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Tourniquets should onlybe used as a last resortwhen all other methodsof hemorrhage control

fail.

DirectPressure

Hemorrhage related to transmural pressure

Difference between intraluminal and extraluminal(atmospheric) pressures

Direct pressure controls bleeding by:

Increases extraluminal pressure = decreasestransmural pressure

Decreases cross sectional area of opening

Direct Pressure

Controls MOSTbleeding

Size of vessels

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Pressure Dressing

Pressure dressingif limited manpower

Gauze sponges,roller bandage

Elastic bandage

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Israeli Trauma Dressing

ITS

ITD

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When direct pressure fails. . .

Elevation

Elevation may aggravatea fractured extremity

No published evidencedemonstrates thatelevation slowshemorrhage or that itdoesn’t

Pressure points?

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Pressure points

Requires manpower

Difficult in moving vehicle

No published studies tosupport or refute

What not to do

Tourniquet

Major Blackwood, aBritish field surgeon inWWI called them…..

“instruments of the Devil”

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Tourniquet

Tourniquets fell out offavor in the 60’s becauseof potential complications:

Inappropriate civilian use

Damage to nerves andblood vessels

Loss of the limb

Yet, used in ORs. . .

Safely used in surgery for hours (< 8)

Tourniquets

In military, evidencesuggests they mayprevent 7 out of 100combat deaths

Life over limb!

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Tourniquets- Devices

Spanish windlass created with cravat

Avoid narrow, bandlike material

Wider tourniquets more effective atcontrolling bleeding Inverse relationship between width and

pressure necessary to stop bleeding

Spanish Windlass

BP Cuff

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Tourniquets

Military study concluded only 3devices effective at occluding distalblood flow:

C-A-T

EMT

SOFTT

CAT

Emergency & Military Tourniquet

Delfi MedicalInnovations

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SOFT-T

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TourniquetsDirect pressure

Tourniquet

ITLS & PHTLS are advocates

Placement

Just proximal to wound

Allows more limb perfusion; less ischemictissue

Tourniquets: Principles

Place directly on skin

Place just proximal to bleeding wound

Tighten until distal pulse disappears

Mark time applied on tourniquet

Leave tourniquet uncovered

Don’t release except in exceptionalcircumstances

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Placement- Multiple wounds

Just proximal tomost proximalwound

Pitfalls- Inadequate control

Place second tourniquet more proximal

Pitfalls- Inadequate control

Ratchet tourniquet

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Pitfalls- Placement

Place directly on skin

Pitfalls- Placement

Pitfalls- Placement

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Break?

EMS Bleeding ControlOld

1. Direct Pressure

2. Elevation

3. Additional dressings

4. Pressure Point

5. Pressure dressing

6. Tourniquet

New

1. Direct Pressure

2. Tourniquet

OK, What About Non-tourniquetable Wounds?

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Non- tourniquet-ableHemorrhage

Groin / axilla

Torso

Neck

Face

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Hemostatic Agents/Dressings The latest & greatest surgical advance

Continually evolving

Included in ITLS, PHTLS, ATLS, EMR, EMT

Available OTC

Hemostatic Dressing

Elevation helpful

Pressure points technically near impossible toproperly apply

Pressure dressings beneficial

Hemostatic dressings VERY helpful

Topical Hemostatic Agents

Military has extensively studied a number ofagents

Hemostatic dressing pad (Alltracel) Oxidized cellulose; physical effect (expansion)

ARC dressing (Am Red Cross) Human fibrinogen, thrombin, Factor XIII and

Ca

Hemostatin bandage (Anal. Contr. Systs) Propyl gallate (procoagulant)

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Topical Hemostatic Agents

Hemarrest dressing (Clarion Pharma.) Epsilon aminocaproic acid (antifibrinolytic) and

thrombin

Sorbstance microcaps (Hemostace LLC) Aluminum sulfate (astringent)

RDH (Marine Polymer Tech) Poly-N-acetyl glucosamine dressing (amino sugar

normally found in the body)

Military Experience

QuikClot®

Early versions very exothermic – up to 147°F(discontinued in 2008)

Difficult to debride

New Advanced Clotting Sponge (ACS)

Gauze sack – easily removed from wound

Prehydrated (reduces exothermic reaction)

Controls bleeding in 3 – 5 minutes

Can remain in place for up to 24 hours

Hemostatic Agents/Dsgs Compared

Military studies: Army (USAISR) & Navy (NMRC)

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Quik Clot

Combat Gauze

Gauze impregnated withKaolin clay Edible mineral used as

anti-caking agent inproducts

Rapidly effective

No heat generation

Moldable to wound

Now 1st Line per TCCC(because of preferencefor gauze like agent)

3-inch x 4-yard roll ofsterile gauze impregnatedwith kaolin. Activatesclotting factors andplatelets, absorbs water(increasing concentrationof platelets and clottingfactors at bleeding site)

REQUIRES TRAINING

Combat Gauze™

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Combat Gauze Directions (2)Pack Wound Completely

Military Choices

Committee on Tactical Combat Casualty Care(CoTCCC) QuikClot Combat gauze

HemCon

Marine Corps / Navy QuikClot

Combat Ready Clamp (CRoC)

SAM junctional Tourniquet

iTClamp

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Hemostatics- Summary

Experimental models don’t correlate well withinjuries encountered in civilian prehospitaltrauma care

Little civilian prehospital experience with anyagent

Cost effective +/-

Still require direct pressure to work-NOT A MAGIC BULLET!

Hemostatics- Summary

No evidence these agents aresuperior to direct pressure, apressure dressing or a tourniquet!!

Consider for non-tourniquetablehemorrhage

Hemorrhage Control Summary

Apply direct pressure with/without elevation

Elevation is potentially helpful to wounds of lowerleg and forearm

Consider hemostatic agents

Early for the subset of patients that bleeding can’t becompletely controlled with direct pressure andelevation

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Rapidly apply a tourniquet

Massive bleeding that isn’t controlled by DP &elevation

MCIs or tactical situations

To stop bleeding until triage is complete or it’s safe toevaluate the actual need for the tourniquet

Break?

Resuscitation

Permissive Hypotension

TXA

Damage Control Surgery

Other stuff

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Resuscitate

IV fluids in hypovolemic shock:

No survival, some mortality

Theories on IVF in trauma:

1. BP dislodges clots

2. BP = bleeding

3. IVF hemodilutes clotting factors

EMS/ED: Permissive HypotensionDuchesne JC et al. Damage Control Resuscitation: From Emergency Department to theOperating Room. The Amer Surgeon. 2011; 77: 201-206.

ResuscitatePermissive hypotension – allow SBP 90 (MAP

50 – 60 mmHg):

1. Bleeding controlled, no shock = no IVF

2. Bleeding controlled, shock 500 ml IVF(may repeat X 1)

3. Bleeding uncontrolled = no IVF

Ideal permissive hypotension < 90 min.

Severe damage when > 120 min.

Li T, et al. Ideal Permissive Hypotension to Resuscitate Uncontrolled Hemorrhagic Shock and theTolerance Time in Rats. Anesthesiology. 2011; 114 (1): 111-119.

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In bleeding trauma patients:

Coagulation occurs rapidly at the site of injury.

Fibrinolysis begins immediately to break downblood clots.

In patients with serious bleeding fibrinolysiscan be detrimental and occasionally pathologicin “hyperfibrinolysis”

Coagulation and Fibrinolysis

TXA is a lysine analogue (similarto aminocaproic acid, but about8 times more potent)

TXA binds to plasminogen’sLysine receptor site - blockingthe conversion of plasminogento Plasmin

The amount of Plasmin is thenreduced, so less Fibrin (clot)breakdown occurs

TXA Inhibits Fibrinolysis: Stabilizing Developing Clots

Bleeding45%

CNS injury41%

Organ failure10%

Other4%

Bleeding Kills about ½ of our Trauma Patients

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Patient enrolment

20,211 patients

in 40 countries

from 274 hospitals

CRASH2 Randomised Many Trauma Patients

Cause of death TXA Placebo Risk of death P value10,060 10,067

Bleeding 489 574 0.85 (0.76–0.96) 0.0077

Thrombosis 33 48 0.69 (0.44–1.07) 0.096

Organ failure 209 233 0.90 (0.75–1.08) 0.25

Head injury 603 621 0.97 (0.87–1.08) 0.60

Other 129 137 0.94 (0.74–1.20) 0.63

Any death 1463 1613 0.91 (0.85–0·97) 0·0035

Results

TXA worseTXA better

0.8 0.9 1.0 1.1

RR (95% CI)TXA (n= 10,060)

489 (4.9%)

Placebo (n= 10,067)

574 (5.7%)

Risk = 0.85 (0.76–0.96)2P=0.0077

Most of the Benefit is for Bleeding Deaths

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1.7 .8 .9 1.1 1.2 1.3 1.4 1.5

RR (99% CI) p=0.000008

≤1 hour 0.68 (0.54–0.86)

>1 to ≤ 3 hours 0.79 (0.60–1.04)

>3 hours 1.44 (1.04–1.99)

0.85 (0.76–0.96) P=.0077

For Bleeding Deaths – Early Treatment is Better

All Bleeding Patients

After the CRASH-2 trial, tranexamic acid was added to theWHO List of Essential Medicines (March 2011)

TXA is Now Being Used

The military are using tranexamic acid to treat combatcasualties:--they consider TXA a class 1a drug – to be given before fluids!

Tranexamic acid is being used in hospitals around the world

Tranexamic acid is being given in most UK ambulances as ofsummer (2011)

Tranexamic acid is being given in Oklahoma City, New YorkCity, the catchment area of Mayo Clinic, and in California AirAmbulance Patients (CALSTAR) as well as Care Flight

Tranexamic acid is safe and reduces mortality and bleeding insurgical patients

Millions of trauma patients die from bleeding every year

Millions of trauma patients require surgery

TXA for Trauma Patients?? CRASH - 2

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Aeromedical Use of TXA

PREHOSPITAL use of tranexamic acid for hemorrhagic shock in primary and secondaryaeromedical evacuationAuthors: E.N. Vu, R.S. Schlamp, R.T. Wand, G. Kleine-Deters, S.J. Wheeler, J.M. Tallon;Introduction:Major hemorrhage remains a leading cause of death in both military and civilian trauma. Wereport the use of a tranexamic acid (TXA) as part of a trauma exsanguination/massive transfusionprotocol in the management of hemorrhagic shock in a civilian primary and secondaryaeromedical evacuation (AME) helicopter EMS program.Methods:TXA was introduced into our critical care flight paramedic program in June of 2011. Indications for use includeage > 16 years, major trauma (defined a priori, based on mechanism of injury or findings on primary survey),and HR > 110 bpm or SBP < 90 mm Hg. Our protocol includes 24-hour online medical oversight, rapid initiationof transport, permissive hypotension in select patients, early use of blood products (secondary AME only), andinfusion of TXA while en route to a major trauma centre.

Results:Over a 4-month period, our CCP flight crews used TXA a total of 13 times. Patients had an average HR of 111bpm (95% CI 90. 71–131. 90), SBP of 91 mm Hg (95% CI 64. 48–118. 60), and GCS of 7 (95% CI 4. 65–9. 96). Forprimary AME, average response time was 33 minutes (95% CI 19. 03–47. 72), scene time was 22 minutes(95% CI 20. 23–24. 27), and time to TXA administration was 32 minutes (95% CI 25. 76–38. 99) from firstpatient contact. There were no reported complications with the administration of TXA in any patient.

Conclusions:We report the first successful integration of TXA into a primary and secondary aeromedical evacuation programin the setting of major trauma with confirmed or suspected hemorrhagic shock. Further studies are needed toassess the effect of such a protocol in this patient population on outcomes.

Resuscitate Is time important?

“Golden Hour”conceived by MarylandShock Trauma Center

No evidence basis inrepeated studies

Newgard CD, et al. Emergency Medical Services Intervalsand Survival in Trauma: Assessment of the “GoldenHour” in a North American Prospective Cohort. AnnEmer Med. 2010; 55(3): 235-260

Resuscitate Are there time critical trauma patients?

First rule of hemorrhage control =

Find the leak (you cannot control what youcannot see)

Shock without evidentbleeding requires

“Cold hard steel”

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Damage Control Surgery Central tenet: Avoid the “Deadly Triad”:

Hypothermia

Coagulopathy

Metabolic acidosis

Each condition worsens the others

Stop the bleeding

Remove major contaminants

Left open (avoid compartment syndrome)

“Pack ‘em and wrap ‘em”

Transfer to ICU

ICU Resuscitation1. Normalize blood pressure

2. Normalize body temperature

3. Normalize coagulation factors

4. Return to OR 12-18 hours for definitivesurgery

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Hippocrates

Above all, do nofurther harm

The Future?

Freeze dried Plasma

Whole blood transfusions

PCC’s (Prothrombin Complex Concentrate) likeKcentra

REBOA

Balloon tamponade of the aorta

Arsenal’s foam abdominal packing

EPR (Emergency Preservation andResuscitation) with 10* C hypothermia

Questions orThoughts?