For debate: advanced bleeding control potentially saves lives in armed forces and should be considered

Abstract

IntroductionAdvanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel.MethodsThe trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control.ResultsThere were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61).ConclusionRetrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.

Advanced bleeding control in combat casualty care: An international, expert-based Delphi consensus

“…There was a consensus among the expert panel that REBOA should be available at all levels of care, including the prehospital arena. This statement is supported by recent gap analyses and case series on REBOA in austere environments 34–38 . Modern REBOA devices are specifically developed for trauma cases and carry features that make them suitable for application in austere, resource-limited environments 39 .…”

“…This statement is supported by recent gap analyses and case series on REBOA in austere environments. [34][35][36][37][38] Modern REBOA devices are specifically developed for trauma cases and carry features that make them suitable for application in austere, resource-limited environments. 39 However, techniques for lengthening balloon occlusion time have to be explored given the increasing shift to prolonged field care or for cases where the number of casualties exceeds the surgical capacity.…”

Prehospital care according to the principles of Damage Control Resuscitation in the conditions of modern warfare (literature review)

“…Ретроспективный анализ боевых потерь нидерландского контингента в Афганистане вы явил потенциальные показания к РЭБОА у 42 % пострадавших с тяжестью повреждений по шкале Abbreviated Injury Scale (AIS) ≥ 4 бал лов. Анализ показал, что РЭБОА потенциально могла снизить летальность у 29 раненых [5].…”