Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting

Abstract

IntroductionExsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed.MethodsMedline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research.ResultsIdentified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available.ConclusionOptions to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

Prehospital haemostatic dressings for trauma: a systematic review

“…It is notable that although haemostatic agents have been recommended for use in areas where tourniquets cannot be used (such as junctional zones and the trunk),2 we found that there were a large number of applications to the extremities. This is likely due to the predominance of extremity trauma in recent conflicts,1 and the presence of coagulopathy that might hinder the cessation of bleeding.…”

Nano- and micro-materials in the treatment of internal bleeding and uncontrolled hemorrhage

“…Current standard procedure for the treatment of catastrophic abdominal haemorrhage is to immediately evacuate to allow rapid surgical intervention [45]. Massive transfusion protocol is sometimes used, but often achieving this sort of haemorrhage control early on is difficult due to circumstances such as on-going gunfire, remoteness, and skill level of care providers [46]. After referring to current protocol for the treatment of internal bleeding and haemorrhage in pre-hospital and clinical phases, it is evident that alternative treatment methods are necessary.…”

Ambulance management of patients with penetrating truncal trauma and hypotension in Melbourne, Australia

“…fluid was restricted . Instead, the emphasis should be on timely transport to an appropriate hospital for surgical intervention …”

“…fluid to elevate blood pressure in these patients runs the risk of increased bleeding, hypothermia, anaemia and coagulopathy. [6][7][8] Data from one large, randomised, controlled trial suggested improved outcomes in penetrating truncal trauma if i.v. fluid was restricted.…”

“…9 Instead, the emphasis should be on timely transport to an appropriate hospital for surgical intervention. 4,8 In Melbourne, Australia, patients with penetrating truncal trauma and hypotension are transported to one of two adult major trauma services (MTSs) that are both near the centre of the city. There may be prolonged transport times for patients in outer metropolitan areas and recommendations for maintenance of hypotension in these patients may be associated with prolonged shock and potentially poorer outcomes.…”