They’re Bleeding, Stop It

Shaun FordDivision Chief North Country EMS

I am not a doctor Follow your protocols I am staying at Oxford Suites not the

Holiday Inn Express

Disclaimers

CDC 2013, Final Death TablesAll injury deaths Number of deaths: 192,945 Deaths per 100,000 population: 60.2Motor vehicle traffic deaths Number of deaths: 33,804 Deaths per 100,000 population: 10.7All firearm deaths Number of deaths: 33,636 (11,208 assault) Deaths per 100,000 population: 10.6

Fatality Causes

Non-transport accidents: 92,619 Falls: 30,208 Accidental discharge of fire arm: 505 Accidental drowning: 3,391 Accidental poisoning: 38,851Intentional self-harm: 41,149 Complications of medical and surgical procedures: 2,768Alcohol: 29,001

Fatality Causes

Assess your agencies call types Assess your prevention programs Become great at your usual call Be ready for it all

Causation

Today we are going to discuss “bleed·ing”

ˈblēdiNG/Adjective/BRITISH/informalused for emphasis or to express annoyance.

What does blood do? transport oxygen and nutrients to the lungs

and tissues form blood clots to prevent excess blood

loss carrying cells and antibodies that fight

infection bring waste products to the kidneys and

liver, which filter and clean the blood regulate body temperature

Hemorrhaging

We will discuss just two things

1) How to stop bleeding

2) How to best treat damage from blood loss

Tourniquets Pressure Dressings Wound Packing/Hemostatic Agents Clamps Fluid Resuscitation TXA

Control Bleeding

Indications Life threatening limb hemorrhage not

controlled by simple methods, such as mangled with multiple bleeding points.

Point of hemorrhage is not accessible due to patient entrapment or access issues.

MCI’s where personnel are not available to maintain other means of bleeding control

Tourniquets

As distal as possible, but at least 5cm proximal to the injury

Avoid joints as much as possible Directly onto bare skin Effectiveness based on cessation of the

bleeding and not be presence or absence of distal pulse

Tourniquet Placement

If the tourniquet application is ineffective, attempt to re-position or tighten.

If still ineffective consider the placement of a second tourniquet.

Oozing may continue after successful placement due to medullary blood flow.

Emerg Med J. 2007 Aug; 24(8): 584–587

Tourniquet Placement

Based on 13 studies reporting mortality data for casualties treated with tourniquets, prehospital tourniquets are an effective treatment method for the prevention of death due to exsanguination. The reported survival rates for casualties treated with prehospital tourniquets ranged from 87% to 100%. Snyder D, Tsou A, Schoelles K. Efficacy of Prehospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage.DOT HS 811 999b. Washington, DC: National Highway Traffic Safety Administration. May 2014. Available at: www.ems.gov.

Tourniquet Choice

NO

Improvised devices are not reliable Many commercial options Do your research and chose one that works

for your application Practice frequently Review often Store it in a readily accessible location

Tourniquet Choice

Emergency Bandage Israeli Bandage Trauma Wound Dressing Hemorrhage Control Bandage ACE

Pressure Dressings

Bleeding controlled by direct pressure Needs constant pressure

Pressure Dressing Indications

Many Sizes Available

20-30 mmHg

Can’t or shouldn’t use tourniquet What do we do when pressure dressings

don’t control bleeding ALS level>Wound Packing?

Junctional/Trunk Wounds

Identify need for wound packinga. Junctional wounds b. Large wound cavity 

Prepare EquipmentOpen “Z” fold gauze & hold in support hand 

Locate Bleeding Vessela. Visulize inside of wound or place fingers of gloved hand into wound to find bleeding vesselb. Tamponade vessel with fingers against wall of wound     

Clark County WA Wound Packing Protocol

Inserting Gauzea. Begin inserting gauze into wound, placing in space between fingers & bleeding vessel.b. Pack gauze into wound tightly until entire wound cavity is packedc. If arterial, hold steady, tight pressure over wound with remaining gauze for three minutesd. Wrap compression bandage over wounde. Reassess

Clark County WA Wound Packing Protocol

Wound Packing

Clear out pooled blood to find wound Make a ball in the end of the gauze and

place that on vessel wound Pile the gauze above the level of the skin Pressure dressing/bandage over the top of

wound

Wound Packing

Gauze

WOUND

Pile above the skin!

Elastic Bandage

DEPARTMENT OF COMBAT MEDIC TRAININGC168W003

Wound Packing Q: After packing a wound, how will you know

if the bleeding has NOT been controlled?

You may not know and should not assume, always consider bleeding may still continue internally.

A: Blood visible and spreading on bandaging/dressing

Signs your casualty is entering or progressing further into hemorrhagic shock.

DEPARTMENT OF COMBAT MEDIC TRAININGC168W003

Principles of Wound Packing Wound depth may affect how it is treated. Moderate and deep wounds may require

hemostatic agents and gauze packing. For superficial wounds, pressure bandages

may be all that is necessary.

DEPARTMENT OF COMBAT MEDIC TRAININGC168W003

Impregnated polyester gauze Active agents are Kaolin or Chitin When kaolin contacts blood it immediately initiates

the clotting process by transforming Factor XII to it’s activated form XIIa.

Chitosan functions by adhering to tissue and sealing wounds, it also possesses antimicrobial properties

Comparison of novel hemostatic dressings with QuickClot combat gauze in a standardized swine model of uncontrolled hemorrhageJournal of Trauma and Acute Surgery Care, August 2013, V75, Issue 2

Hemostatic Gauze Agents

Product Evaluation Swine models only Small study sizes High risk of bias Some tests not EMS relative, 30-45 second

bleeding time In the 3+ minute bleeding tests

◦ 0-17% survival rate with no treatment◦ 33% with RDH lived◦ 50-67% with standard gauze lived◦ 75% with Hemcon Lived◦ 90% of Quickclot granules lived◦ 67% of TraumaDex lived

Product AgentCelox ChitosanHemCon,Chitoflex, Chito Guaze, Guardacare

Chitosan

Quick Relief, PRO QR, StatSeal, WoundSeal, TraumaSeal, BioSeal

hydrophilic, or water- loving, polymer and potassium ferrate

Quikclot Combat Gauze, QuickClot ACS

Kaolin

RDH, MRDH pGlcNAc fibers

Trauma Dex, Bleed-X, Hemaderm microporous polysaccharide hemospheres

UltraClot, BallistiClot a proprietary hemostatic agent is dissolved into the wound from the UltraClot pouch

XSTAT

Based on what you see, does it appear bleeding has been controlled? Why or why not?

DEPARTMENT OF COMBAT MEDIC TRAININGC168W003

CLAMP!!!

http://www.innovativetraumacare.com/images/iTC-Case-Studies.pdf

Filips, D., Logsetty, S., Tan, J., Atkinson, I., & Mottet, K. (2013). The iTClamp Controls Junctional Bleeding in a Lethal Swine Exsanguination Model. Prehospital Emergency Care, 17(4), 526-532.Proof of concept study for iTClamp Hemorrhage Control Device. Lethal hemorrhagic injury to 20 swine found 100% of swine treated with iTClamp survived whether the clamp was placed immediately or placement was delayed. 60% treated with packing with standard gauze survived v. 0% survival if the wound was left untreated. The iTClamp was superior in terms of overall survival (p <0.009), total blood loss (p=0.008) and survival time (p=0.003) to standardgauze and the control. iTClamp is an effective temporary wound closure device.Mottet, K., Filips, D., Logsetty, S., & Atkinson, I. (2014). Evaluation of the iTClamp 50 in a human cadaver model of severe compressible bleeding. J Trauma Acute Care Surg, 76(3), 791-797.Laboratory cadaveric study testing effectiveness of iTClamp to control external fluid loss from injuries to compressible areas, maintain this control despite movement, as well as maintain distal perfusion. Wounds made to thigh, groin,neck, and arm and sterile water was pumped through the arteries. iTClamp was found to effectively stop fluid loss to all of these areas, the fluid used had no clotting factors, movement had no effect on the hematoma formation ormaintenance and distal flow remained intact.

St John, A. E., Wang, X., Lim, E. B., Chien, D., Stern, S. A., & White, N. J. (2015). Effects of rapid wound sealing on survival and blood loss in a swine model of lethal junctional arterial hemorrhage. J Trauma Acute Care Surg,79(2), 256-262.

Laboratory study performed on 50 swine, 5-mm diameter femoral arteriotomy was performed and 1 of 7 interventions was randomized and applied after 30 seconds of free bleeding: control, iTClamp, standard gauze packing, iTClampwith standard gauze packing, compression, standard gauze packing with compression and hemostatic gauze packing with compression. At 3:30 minutes post arteriotomy all animals received one dose of Hextend (15mL/kg over15 mins). Animals were monitored for 3 hours or until death. Survival rates were as follows: control and compression 0%, standard gauze packing 12.5%, iTClamp 62.5%, hemostatic gauze packing with compression 62.5%, standardgauze packing with compression 87.5% and iTClamp with standard gauze packing 100%. Proper wound packing was a key factor in this study and the iTClamp is seen as a viable option for junctional hemorrhage.

You stopped the bleeding, now what?

How much Metrics What fluid

Fluid Resuscitation

We base it on Mean Arterial Pressure (M.A.P.)

How Much Fluid?

MAP = SBP + 2 (DBP)/3BP= 83/50MAP = 83 +2 (50)/3 MAP = 83 +100/3 MAP = 183/3 MAP = 61 mm HG

“Resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy”.

50 is really lowExamples; BP 70/40 is a MAP of 50 mmHg

90/60 is a MAP of 70 mmHg

Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial.Morrison CA1, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, Liscum KR, Wall MJ Jr, Mattox KL.

In non-TBI patients we aim for a systolic of 90Approximate MAP of 65

In TBI patients we aim for a systolic of 110Approximate MAP of 90

Based on a Cerebral Perfusion Pressure of 50-70CPP= MAP-ICP

Optimal ICP <20

Journal of Trauma and Acute Care Surgery:April 2015 - Volume 78 - Issue 4 - p 687–697A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: Results of a prospective randomized pilot trial

Schreiber, Martin A. MD; Meier, Eric N. MS; Tisherman, Samuel A. MD; Kerby, Jeffrey D. MD, PhD; Newgard, Craig D. MD, MPH; Brasel, Karen MD; Egan, Debra MSc, MPH; Witham, William MD; Williams, Carolyn RN; Daya, Mohamud MD; Beeson, Jeff DO; McCully, Belinda H. PhD; Wheeler, Stephen MD; Kannas, Delores RN, MS, MHA; May, Susanne PhD; McKnight, Barbara PhD; Hoyt, David B. MD; the ROC Investigators

192 Randomized Patients from 19 EMS Systems in the Resuscitation Outcomes Consortium (97 CR, 95 SR) Controlled Resuscitation (CR) patients received 250 mL of fluid if they had no radial pulse or an SBP lower than 70 mm Hg and additional 250-mL boluses to maintain a radial pulse or an SBP of 70 mm Hg or greater.The Standard Resuscitation (SR) group patients received 2 L initially and additional fluid as needed to maintain an SBP of 110 mm Hg or greater. The crystalloid protocol was maintained until hemorrhage control or 2 hours after hospital arrival.

Mean volume given in CR group was 1.0LMean volume given in the SR group was 2.0LIntensive care unit–free days, ventilator-free days, renal injury, and renal failure did not differ between the groups.At 24 hours after admission, there were 5 deaths (5%) in the CR group and 14 (15%) in the SR groupAmong patients with blunt trauma, 24-hour mortality was 3% (CR) and 18% (SR)

There was no difference among patients with penetrating trauma 9% each

“Prehospital Volume Therapy as an Independent Risk Factor after Trauma”

Group 0-500ml

501-1L 1-1.5L 1.5-2L >2L Total

Pre-Hosp. BPMean,SD

133.8 34.5

12234.7

115.432.9

109.732.3

100.334.4

117.635.6

BP at admissionMean, SD

130.329.7

124.229.8

117.830.2

116.429.5

110.621.2

120.730.8

Age 52.6 46.3 43.4 40.1 39.9 45

“Prehospital Volume Therapy as an Independent Risk Factor after Trauma”

Group 0-500 501-1L 1001-1500

1501-2000

>2000

Days of Intubation

6.6 10.8

7.811.7

9.313.3

10.212.7

1113.1

Days in ICU 10.913

12.113.5

13.715.5

14.714.2

15.315

Days in Hospital

21.920.1

25.623.4

27.825.7

28.525.9

29.727.2

Sepsis % 8.6 8.9 10.8 13.7 14.6

Organ Failure %

46.5 49.4 56.1 58.1 61.3

Multiorgan failure %

29.4 31.5 37.3 40.9 43.3

Death % 18.3 16.8 16.9 18.7 24

Death within 24H %

7.2 7.7 8.9 10.7 13.4

Bjoern Hussmann, Matthias Heuer, Rolf Lefering, et al., “Prehospital Volume Therapy as an Independent Risk Factor after Trauma,” BioMed Research International, vol. 2015, Article ID 354367, 9 pages, 2015. doi:10.1155/2015/354367

Patients seen between 2002 and 2010 were selected for this study according to the following criteria:(1) Primary admission to the hospital (no transfers).(2) Injury Severity Score (ISS) ≥16.(3) Age ≥16 years.(4) Data available for prehospital and hospital volumetherapy and packed red blood cell administration,Glasgow Coma Scale (GCS), hemoglobin concentration,base excess, one coagulation parameter (e.g.,prothrombin time), blood pressure at the accidentsite, blunt trauma, therapeutic measures (resuscitation,intubation, insertion of chest tube), and prehospitaltime.

Conclusions: Prehospital volume therapy in patients without severe TBI represents an independent risk factor for mortality. In such cases, respiratory and circulatory conditions should be stabilized during permissive hypotension, and patient transfer should not be delayed.

AlbuminDextran 40Dextran 705% Dextrose (D5W)Hydroxyethyl starch (HES)Lactated Ringer’s (LR)0.9% NaCl (NS)3% NaClBlood productsHBOC (PolyHeme)

We know how much now, what flavor do we choose?

Investigators in Australia and New Zealand conducted the Saline versus Albumin Fluid Evaluation (SAFE) study

Colloid Flavors

The study showed no significant difference between albumin and saline with respect to the rate of death

Hypertonic FlavorsAmong injured patients with hypovolemic shock, initial resuscitation fluid treatment with either HS or HSD compared with NS, did not result in superior 28-day survival.

**TBIOut-of-hospital Hypertonic Resuscitation After Traumatic Hypovolemic Shock A Randomized, Placebo Controlled TrialEileen M. Bulger, MD,* Susanne May, PhD,* Jeffery D. Kerby, MD, PhD,† Scott Emerson, MD, PhD,* Ian G. Stiell, MD,‡ Martin A. Schreiber, MD,§ Karen J. Brasel, MD, MPH,‖ Samuel A. Tisherman, MD,¶ Raul Coimbra, MD, PhD,# Sandro Rizoli, MD, PhD,** Joseph P. Minei, MD,†† J. Steven Hata, MD,‡‡ George Sopko, MD, MPH,§§ David C. Evans, MD,‖‖ and David B. Hoyt, MD¶¶, for the ROC investigators

FlavorsHuman Polymerized Hemoglobin for the Treatment of Hemorrhagic Shock when Blood Is Unavailable: The USA Multicenter Trial Abstract presented at the American College of Surgeons 93rd Annual Clinical Congress, New Orleans, LA, October 2007.

Ernest E. Moore, MD, FACSa, , Frederick A. Moore, MD, FACSb, Timothy C. Fabian, MD, FACSc, Andrew C. Bernard, MD, FACSd, Gerard J. Fulda, MD, FACSe, David B. Hoyt, MD, FACSf, Therese M. Duane, MD, FACSg, Leonard J. Weireter Jr, MD, FACSh, Gerardo A. Gomez, MD, FACSi, Mark D. Cipolle, MD, FACSj, George H. Rodman Jr, MD, FACSk, Mark A. Malangoni, MD, FACSl, George A. Hides, BAm, Laurel A. Omert, MDn, Steven A. Gould, MD, FACSn, o, PolyHeme Study Group

PolyHemePatients resuscitated with PolyHeme, without stored blood for up to 6 U in 12 hours postinjury, had outcomes comparable with those for the standard of care. Although there were more adverse events in the PolyHeme group, the benefit-to-risk ratio of PolyHeme is favorable when blood is needed but not available.

PolyhemeFDA has not approved any Hemoglobin Based Oxygen Carriers for use in the United States, and the regulatory agencies of most other countries also have not approved HBOCs.

pH of 6.5 compared to 5.0 of NS Less acidity dose not cause vasodilatation Base excess is recovered by LR not NS Electrolyte content is most closely related to

blood serum

Lactated Ringers

A hypercoagulable state can result when Lactated Ringers is given to resuscitate patients experiencing shock; this state may prove to be a positive protective symptom but could result in thrombolytic complication

Isotonic fluid Cheap Readily available Small doses equals small harm

NS Anyone?

Tranexamic acid (TXA) was originally developed for the treatment of hemophilia and to reduce bleeding in patients undergoing oral surgery

TXA

TXA is a synthetic amino acid (lysine) that blocks plasminogen from being converted to the enzyme plasmin.

Plasmin works to break down already-formed blood clots in the human body by attacking and breaking down fibrin, destroying clots in a process known as fibrinolysis

TXA is widely used by hospitals in Europe and other countries for severely injured trauma patients

TXA Pharmacokinetics

CRASH-2 study, undertaken in 274 hospitals in 40 countries and published in 2010

TXA, when administered within one hour of significant trauma, greatly reduced patient mortality (over 30%) when used in conjunction with blood transfusions.

When TXA was used alone, patient mortality was reduced by over 20%

TXA CRASH-2 Study

MATTERs was a retrospective observational study of 893 consecutive admissions of combat-injured persons in a role 3 surgical hospital (equivalent to a U.S. level 2 trauma center) in southern Afghanistan.

Authors measured patient mortality at 24 hours, 48 hours and 30 days, as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications.

TXA MATTERs Study

MATTERs studies showed a decrease in the unadjusted mortality of patients who received TXA (vs. placebo) within the first three hours of injury (17.4% vs. 23.9%)

Patients who received TXA (vs. placebo) with associated blood transfusion within one hour of injury had an even greater decrease in mortality (14.4% vs. 28.1%).

TXA administered more than three hours after injury, however, appears to increase the risk of death due to bleeding, to 4.4% compared with 3.1% for the placebo group

MATTER’s

TXA may not be beneficial if it greatly delays scene time to prepare and initiate the initial 1-gram dose and establish an IV.

TXA would be ideal for situations including prolonged extrication, extended transport times due to heavy traffic or other conditions, and mass-casualty incidents.

If TXA is administered after three hours, mortality rates have shown to increase.

TXA Indications

In the United States the cost is approximately $10 per gram

Cost/Benefit

The recommended procedure for administering TXA is 1 gram in 100 mL of 0.9% normal saline or Ringer’s lactate given by IV infusion over 10 minutes, followed by 1 gram in 500 mL of 0.9% NS or LR infused over eight hours

Dosage

It is recommended that TXA not be mixed with colloid fluid, (e.g., Hextend or Hespan, plasma or any other blood components), nor with solutions containing penicillin, and/or piggybacked into any IV line delivering blood.

TXA Administration

Still new Higher incidents of DVT’s in MATTER’s study Patients is MATTER’s also had worse injuries

TXA Cautions

Get the right tools Practice with the tools Make educated decisions before additions

s.ford@northcountryems.orghttps://www.youtube.com/user/NCEMStraining

Wrap Up