Objective: The purpose of this study was to determine if emergency tourniquet use saved lives. Summary Background Data: Tourniquets have been proposed as lifesaving devices in the current war and are now issued to all soldiers. Few studies, however, describe their actual use in combat casualties. Methods: A prospective survey of injured who required tourniquets was performed over 7 months in 2006 (NCT00517166 at ClinicalTrials.gov). Follow-up averaged 28 days. The study was at a combat support hospital in Baghdad. Among 2838 injured and admitted civilian and military casualties with major limb trauma, 232 (8%) had 428 tourniquets applied on 309 injured limbs. We looked at emergency tourniquet use, and casualties were evaluated for shock (weak or absent radial pulse) and prehospital versus emergency department (ED) tourniquet use. We also looked at those casualties indicated for tourniquets but had none used. We assessed survival rates and limb outcome. Results: There were 31 deaths (13%). Tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; P Ͻ 0.001). Prehospital tourniquets were applied in 194 patients of which 22 died (11% mortality), whereas 38 patients had ED application of which 9 died (24% mortality; P ϭ 0.05). The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used (P Ͻ 0.001). H emorrhage from injured extremities continues to be one of the leading sources of preventable death on the battlefield. 1-4 Data from recent conflicts involving US military personnel confirmed the continued importance of improving prehospital hemorrhage control. 3,[5][6][7] In response, the US Army implemented a design, testing, training, and fielding program for battlefield tourniquets, 8 -11 resulting in policy that all military personnel in theater carry tourniquets. As a result of this effort, tourniquets are now common on the battlefields of Iraq and Afghanistan, both in the hands of medical and nonmedical personnel.With the Tactical Combat Casualty Care initiative, the US military is not alone in establishing procedures and equipment for use of tourniquets in the prehospital environment by both medical and nonmedical personnel. 12,13 However, this renewed emphasis on tourniquets for prehospital hemorrhage control of extremity injuries is not agreed upon by all authors 14 -16 with some authors discouraging prehospital use of tourniquets altogether. [17][18][19][20] showed that tourniquet use is indicated in civilian trauma, albeit in a very small percentage of patients. However, the lifesaving capability of tourniquets has been unproven. Most of the controversy regarding the capacity of tourniquets to save lives versus tissue damage has been based more on speculation rather than actual data, as research in the human use of emergency tourniquets is limited. Clearly, the discussion would be better informed with actual data regarding these critical concerns. In 2003, we initiated data collection regarding e...

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Background A 2015 AAST trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality. Methods In 2004 we initiated a PPP protocol for pelvic fracture hemorrhage. Results During the 11-year study, 2293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age 44 ± 2 years and ISS 48 ± 1.2). The lowest emergency department SBP was 74 mmHg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions prior to SICU admission compared to the 24 postoperative hours were 8 versus 3 units (p<0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush. Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the OR at 89 and 100 minutes after arrival while 1 died 9 hours after arrival. Conclusions PPP results in a shorter time to intervention and lower mortality compared to modern series utilizing AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be employed for pelvic fracture related bleeding in the patient who remains unstable despite initial transfusion.

This interim report represents the largest analysis of US military vascular injuries in more than 30 years. Wounding patterns reflect past experience with a high percentage of extremity injuries. Management of arterial repair with autologous vein graft remains the treatment of choice. Repairs in contaminated wound beds should be avoided. An increase in injuries from improvised explosive devices in modern conflict warrants the more liberal application of contrast arteriography. Endovascular techniques have advanced the contemporary management and proved valuable in the treatment of select wartime vascular injuries.

Therapeutic study, level II.

Despite technological advancements, REBOA is associated with significant risks due to complications of vascular access and ischemia-reperfusion. The inherent morbidity and mortality of REBOA is often compounded by coexisting injury and hemorrhagic shock. Additionally, the potential for REBOA-related injuries is exaggerated due to the growing number of interventions being performed by providers who have limited experience in endovascular techniques, inadequate resources, minimal training in the technique, and who are performing this maneuver in emergency situations. In an effort to ultimately improve outcomes with REBOA, we sought to compile a list of complications that may be encountered during REBOA usage. To address the current knowledge gap, we assembled a list of anecdotal complications from high-volume REBOA users internationally. More importantly, through a consensus model, we identify contributory factors that may lead to complications and deliberate on how to recognize, mitigate, and manage such events. An understanding of the pitfalls of REBOA and strategies to mitigate their occurrence is of vital importance to optimize patient outcomes.

The management of patients with exsanguinating torso hemorrhage is challenging. Emergency surgery, with the occasional use of resuscitative thoracotomy for patient in extremis, is the current standard. Recent reports of REBOA (resuscitative endovascular balloon occlusion of the aorta) have led to discussions about changing paradigms in the management of patients in both civilian and military are nas. We submit that broad and liberal application of this technique is premature given the current data and in light of historical experience. We propose an algorithm for the management of patients with exsanguinating torso hemorrhage, as well as a set of research questions that we feel can help clarify the role of REBOA in modern trauma care in a variety of trauma settings.

Pseudoaneurysms are a common finding in patients with high-velocity gunshot wounds or blast injuries to the head and neck. Most involve branches of the external carotid artery and can be treated by embolization. CTA should be performed on all patients with high-velocity gunshot wounds or in cases of blast trauma with fragmentation injuries of the head and neck.