Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

Abstract

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice. Graphical Abstract

Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service

“…For haemorrhaging patients in extremis to survive, they should have access to modern haemorrhage control treatments available in trauma hospitals as well as balanced blood transfusions [10,25]. Tailored treatment offering out of hospital whole blood to patients with lifethreatening noncompressible haemorrhage may offer a more targeted approach than traditional transfusion protocols [9,26].…”

“…The timing of intubation is crucial, and despite current European guidelines, ETI on-scene is not always done [35]. ETI should be restricted to those showing signs of increasing airway compromise or deteriorating level of consciousness [25]. Detrimental effects of advanced airway management strategies in exsanguinating patients have been reported [36].…”

“…The physiological effects of ETI and subsequent positive pressure ventilation on venous return may mimic the physiology of tension pneumothorax in hypovolemic patients, leading to a further decrease in cardiac output [37,38]. Therefore, in patients with noncompressible haemorrhage, reducing on-scene times and postponing ETI until haemorrhage control is achieved may increase survival [25]. Knowledge of whether, when and how to intubate these patients is important [39].…”

“…More studies are needed to clarify the role of whole blood in civilian out of hospital haemostatic resuscitation and whether early transfusions reduce the overall use of blood products in these patients, as well as aid in developing more objective transfusion protocols. The experience and research gained from the implementation of advanced interventions, such as whole blood transfusion programs in HEMS, may provide guidance on future resuscitation strategies for these patients [25].…”

Dynamic structures and emerging trends in the management of major trauma: A bibliometric analysis of publications between 2012 and 2021

“…Management of massive hemorrhage over the past decade has evolved to now deliver a package of hemostatic resuscitation including surgical or radiological control of bleeding; regular monitoring of hemostasis; advanced critical care support; and avoidance of the lethal triad of hypothermia, academia, and coagulopathy ( 53 ). Resuscitative endovascular balloon occlusion of the aorta (REBOA) is growingly utilized in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm ( 54 ), and is also available in a few pre-hospital critical care teams ( 55 ). Traumatic coagulopathy describes abnormal coagulation processes that are attributable to trauma.…”