Consensus guidance on prehospital haemorrhage control in trauma patients: Collaborative statement by leading medical organizations
USA: A recent article published in the Annals of Emergency Medicine reports consensus-based guidance on prehospital haemorrhage control and hemostatic resuscitation.
The guidance was a joint position statement by the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians. The statement addresses exsanguination, the leading cause of preventable death among trauma victims, with nearly half of these patients dying in the prehospital setting.
It is intended for emergency medical services (EMS) clinicians, emergency physicians, EMS medical directors, trauma surgeons, and nurses in treating acute trauma patients with severe, life-threatening external bleeding.
The following are the main points of the consensus:
- Identifying and Assessing Life-Threatening Bleeding
Identify the source of bleeding and determine if it is life-threatening. Prompt assessment is essential to identify the bleeding site and assess the severity of haemorrhage.
- Wound Packing: Increasing Direct Pressure
If direct pressure alone is insufficient, additional measures can be employed. Wound packing with gauze or hemostatic-impregnated dressings is recommended. Wound packing increases the direct pressure on the bleeding vessels. It involves pressing a clean cloth, gauze, or hemostatic-impregnated dressing deeply and firmly into the wound until it is completely filled. After packing the wound, it should be covered with a dressing, and significant pressure should be applied and maintained until initial hemostasis is achieved.
- Tourniquets: Controlling Arterial Bleeding in Extremities
For compressible arterial bleeding in the extremities, tourniquets can be used. Tourniquets should be applied at least 2 to 3 inches proximal to the wound. The "high and tight" method of placing the tourniquet as proximal and as tight as possible should be limited to situations where determining the exact source of bleeding is impossible or unsafe. Tourniquets should be placed on bare skin whenever possible and not over joints. The tourniquet should be tightened until bleeding stops and the distal pulse is eliminated. The time of tourniquet application should be noted for reference.
- Regular Reassessment: Ensuring Continued Hemostasis
Regular reassessment of the wound and tourniquet is necessary to ensure continued adequate hemostasis. If hemostasis is not achieved, a second tourniquet can be added above the original one without removing the original tourniquet. Tourniquets should not be loosened once applied, except during tourniquet conversion performed by trained medical professionals.
- Junctional Wounds: Special Considerations for Control
Junctional wounds, such as those in the neck, shoulder/axilla, and groin, can be controlled by direct pressure, wound packing, and/or the use of junctional tourniquets. Junctional tourniquets are external compression devices that occlude blood flow from the aorta, axillary artery, or iliac artery. However, their routine use in civilian trauma is not widely recommended due to limited clinical experience and data.
- Prehospital Blood Product Resuscitation: Early Administration for Improved Outcomes
Prehospital blood product resuscitation has shown promising results in severely injured patients. The early administration of blood products, such as packed red blood cells (PRBC) and plasma, has been associated with reduced mortality rates. A 1:1 ratio of PRBC and plasma is recommended, starting with plasma if both are available. Prehospital blood transfusion protocols should be established, and the availability and storage of blood products should be ensured.
- Additional Considerations: Calcium Gluconate, Tranexamic Acid, and Normothermia
Other considerations in prehospital haemorrhage control include the administration of calcium gluconate for resuscitation-induced hypocalcemia, using tranexamic acid (TXA) within 3 hours of injury, and maintaining normothermia to avoid hypothermia.
- Advanced Intervention: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is used in select cases where direct bleeding control is not feasible. It involves the placement of a balloon catheter in the aorta to occlude blood flow and control haemorrhage. REBOA is an advanced intervention that requires specialized training and resources and is not routinely performed in the prehospital setting.
The document states, "It is important to note that the management of life-threatening external haemorrhage should be performed by trained medical professionals following established protocols and guidelines. Regular training and education are crucial for healthcare providers caring for trauma patients."
Reference;
Prehospital hemorrhage control and treatment by clinicians: A joint position statement. (2023). Annals of Emergency Medicine, 82(1), e1–e8. https://doi.org/10.1016/j.annemergmed.2023.03.017
