Pre-Hospital Hemorrhage Control: A Review of the Literature
Prehospital hemorrhage control remains a critical and evolving area in trauma care…
introduction
Prehospital hemorrhage control remains a critical and evolving area in trauma care, with ongoing advancements in best practices and educational interventions. Uncontrolled bleeding continues to be the primary contributor to trauma-related mortality and morbidity globally. [4] Trauma is the leading cause of death in individuals under 45 worldwide and the fourth leading cause of death across all age groups according to American Association for the Surgery of Trauma. Upwards of 35% of trauma-related deaths are directly attributed to uncontrolled hemorrhage. In the US, approximately 150,000 civilians die annually from trauma, with around 3 million sustaining non-fatal injuries. This burden, coupled with the rise in active shooter incidents (400-700 per year), underscores the importance of layperson education and intervention initiatives to mitigate preventable deaths.
Studies focusing on mass shooting events reveal that most deaths occur within minutes of the incident, well before EMS arrival or surgical care is possible. [12,13] Autopsy reports suggest that up to 32% of victims had survivable hemorrhagic wounds, with 60% of injuries involving junctional areas not amenable to tourniquets. [12,13] These findings highlight the necessity of robust public education, emphasizing not only tourniquet use but also direct pressure and wound packing. Additionally, increased funding to expand Stop the Bleed (STB) initiatives and ensure the availability of hemorrhage control kits is imperative.
Historical Context and Military Contributions
Significant advancements in hemorrhage control stem from military research. During prolonged US military engagements in Afghanistan and Iraq, evolving injury patterns prompted the Joint Trauma System (JTS) to prioritize robust prehospital education and interventions. This led to the development of Tactical Combat Casualty Care (TCCC) in 2004, pioneered by special forces and later adopted broadly across the military. [1] TCCC's focus on hemorrhage control, airway management, and rapid evacuation increased combat survival by 44%.
TCCC's MARCH algorithm (Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia) replaced the traditional ABCs of resuscitation, emphasizing immediate hemorrhage control through aggressive tourniquet application and hemostatic dressings. The TCCC model has since been adapted for civilian use through Tactical Emergency Casualty Care (TECC), bridging the gap between military and civilian trauma care. TECC, developed in collaboration with the Hartford Consensus and the National Association of Emergency Medical Technicians, addresses the specific needs of non-military providers in the prehospital setting.
Current Challenges and Civilian Application
Despite widespread national support, there is no unified civilian approach to implementing, researching, or educating the public on prehospital hemorrhage control. The military's iterative, experience-driven model lacks comprehensive civilian data, often relying on empirical evidence. This review aims to synthesize emerging research and techniques, drawing parallels between military and EMS practices.
discussion
Hemorrhagic injuries are classified as compressible (amenable to tourniquets) or non-compressible (requiring direct pressure or advanced techniques). Non-compressible injuries, including junctional and torso hemorrhages, account for approximately 67% of prehospital trauma fatalities.
Advanced Interventions
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and Resuscitative Thoracotomy with Aortic Cross-Clamping (RTACC) are advanced techniques for managing non-compressible hemorrhage. REBOA, though relatively new, temporarily arrests distal bleeding by inflating a balloon within the aorta, maintaining cerebral and myocardial perfusion. [4] RTACC, a more established technique, involves thoracic incision and direct aortic clamping. Prognostic factors influencing RTACC success include mechanism of injury (MOI), location of injury (LOMI), and signs of life (SOL). Survival rates for penetrating injuries are higher (8.8%) than for blunt trauma (1.4%), with thoracic injuries demonstrating the greatest survival (10.7%). [9]
Layperson and Provider Interventions
For most prehospital providers, direct pressure and wound packing remain the cornerstone of hemorrhage control. Direct pressure, despite its simplicity, remains under-researched. The Hartford Consensus endorses direct pressure as the first-line intervention regardless of injury location. Provider fatigue, optimal pressure duration, and PSI requirements warrant further investigation.
Wound packing, often supplemented with hemostatic agents like QuikClot Combat Gauze (QCG), is vital for junctional injuries. Hemostatic dressings, impregnated with agents like kaolin or chitosan, promote clotting through absorptive and bioactive mechanisms. A case series by the Israel Defense Forces demonstrated an 88.6% success rate for junctional hemorrhage and 91.9% for extremity hemorrhage when using hemostatic dressings. [11]
Tourniquets: The Gold Standard
Tourniquets, both traditional and junctional, are crucial for managing compressible hemorrhage. Modern windlass tourniquets have proven effective, with studies showing a 4.5-fold increase in mortality from hemorrhagic shock when tourniquets are not applied. [10] Junctional tourniquets, FDA-approved since 2010, address non-extremity hemorrhage and demonstrate 75-100% efficacy, with application times averaging two minutes. [14]
Tourniquet safety, long a concern, has been reevaluated. Current data suggests minimal risk for up to two hours, with significant complications arising only after four to six hours of continuous application. Given the average EMS response time of 10-20 minutes, tourniquet use in the prehospital setting remains a safe and life-saving intervention.
conclusion
Prehospital hemorrhage control continues to evolve, driven by military advancements and adapted for civilian use. While techniques like direct pressure, wound packing, and tourniquet application remain foundational, new technologies and educational initiatives aim to enhance survivability. However, significant gaps persist in civilian data, epidemiology, and educational efficacy. Future research must focus on validating current practices, developing standardized training, and exploring innovative solutions for non-compressible hemorrhage2. By addressing these gaps, the medical community can further reduce preventable deaths and improve trauma care outcomes.
AUTHOR: Brian Drury, MD, MEd, is a current fourth-year resident at Brown Emergency Medicine Residency.
FACULTY REVIEWER: Elizabeth Kadow, MD, is an assistant professor and clinician educator at Brown Emergency Medicine.
references
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