Selective Prehospital Advanced Resuscitative Care – Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage

Abstract

Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.

Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study

“…Operationalizing ARC into civilian care will be rich with challenges, many of which have been previously discussed. 9,13,32 For example, execution of REBOA requires arterial access, which is outside of the scope of practice of paramedics and could potentially require an overhaul of the current prehospital system by dispatching physicians to the scene of injury. In addition, it is important in a discussion of prehospital procedures to remember that there is no one-size-fits-all approach, but rather the solutions must be tailored appropriately, depending on factors, such as injury type, proximity to the nearest trauma center, and availability of resources.…”

“…Operationalizing ARC into civilian care will be rich with challenges, many of which have been previously discussed 9,13,32 . For example, execution of REBOA requires arterial access, which is outside of the scope of practice of paramedics and could potentially require an overhaul of the current prehospital system by dispatching physicians to the scene of injury.…”

“…Numerous previous studies have examined potentially preventable prehospital and early in-hospital deaths in attempts to determine who might benefit from advanced resuscitative techniques. 32 A retrospective cohort study reviewed 198 autopsy reports for NCTH patients who presented to a large Level I trauma center with cardiac arrest and found that more than 10% could have benefitted from prehospital REBOA. 33 Another recent retrospective review of 316 prehospital and early in-hospital deaths identified 12% as potentially preventable and that might have been amenable to ARC interventions.…”

Percutaneous delivery of self-propelling thrombin-containing powder increases survival from noncompressible truncal hemorrhage in a swine model of coagulopathy and hypothermia

“…However, in severe NCTH, the benefits of attempting lifesaving hemorrhage control often outweigh the risks associated with these procedures. 4,47 This study was limited by the small sample size used, although smaller sample sizes are common in swine studies. 25,26 Female pigs have increased survival during hemorrhage, 48 which may have impacted outcomes in all groups.…”

“…2 Most deaths due to hemorrhage occur prehospital, highlighting the importance of obtaining rapid hemorrhage control during early phases of care. [2][3][4][5] Noncompressible truncal hemorrhage (NCTH) is particularly challenging, accounting for 67% of all deaths due to hemorrhage, 2,6 and can currently only be definitively managed by surgery. 7,8 Strategies used to improve survival from hemorrhage include hemostatic dressings and tourniquets, administering intravenous tranexamic acid (TXA) within 3 hours of injury, far-forward whole blood transfusion, and resuscitative endovascular balloon occlusion of the aorta (REBOA).…”