Stop the Bleed Consensus

INTRODUCTION

Although there have been dramatic advances in trauma care over the last two decades, there are still a significant number of patients each year who succumb to death from hemorrhagic shock. Hemorrhage due to trauma is the leading preventable cause of death in the military setting, accounting for up to 90% of potentially preventable deaths;¹ in the civilian setting, hemorrhage is second only to neurologic injuries as a cause of death due to trauma.²

In April 2013, the American College of Surgeons released the Hartford Consensus, with recommendations to enhance survivability from mass casualty incidents and active shooter scenarios. One of the four reports recommended an improvement in the implementation of bleeding control to prevent death from hemorrhage in patients with traumatic injuries.³

Advances in hemostatic resuscitation, antifibrinolytic medications, and more rapid transport times have all decreased mortality from hemorrhage.⁴ There has also been better bystander training through the more recent “Stop the Bleed” campaign, with its emphasis on early extremity hemorrhage control, including tourniquet use in the field. While previous studies have shown a decreased mortality in patients who were transported to the hospital quicker, decreasing the time to hemorrhage control remains one of the greatest barriers to improving patient mortality.⁵

In this consensus, the methods of hemorrhage control are discussed for use in the prehospital setting and the emergency department. Additionally, surgical procedures are described that may enhance hemostatic control in the operating room and lead to better outcomes during and after damage control surgeries.

PREHOSPITAL OPPORTUNITIES

A majority of civilian and combat-related deaths caused by traumatic bleeding occur before reaching hospital care.⁶ Life-compromising bleeding without appropriate and timely control may lead either to death or, in case of initial survival and subsequent massive transfusion, to possible sepsis and/or multiorgan failure.⁷ Therefore, prehospital interventions aiming for hemorrhage control have now awakened great interest as a survival improvement opportunity. For that goal, several interventions have been developed or are currently being assayed experimentally. Table 1 shows the current available treatment option to stop the bleeding in the prehospital setting.⁸

The main issue to consider in implementing any set of interventions to control hemorrhage in the prehospital arena is the training level of the ambulance crew. In developing a system of prehospital care, it is essential to proactively establish the knowledge and skills that will be required of providers working at different levels in the system. National efforts to implement prehospital trauma care must not be hindered or sidetracked by well-intentioned but ill-advised schemes to emulate emergency care systems in developed countries. The implementation of costly advanced life support interventions may be counterproductive if it siphons scarce resources away from the core elements of prehospital care.⁹ Another aspect to consider regarding paramedic training and skills is communication with receiving hospitals. During the prehospital phase, it is crucial to identify those patients at risk of severe hemorrhage to quickly activate a specific intrahospital standardized hemorrhage control response, connecting the multispecialty trauma team, blood bank, transfusion protocols, interventional radiology, and surgical team.¹⁰ Prehospital medical doctors are also an option when the local context allows timely arrival of the emergency vehicle to the spot.

The prehospital setting remains an important window of opportunity to achieve a reduction in global trauma mortality. Currently, successful strategies used in the military setting must continue to be translated to the civilian prehospital setting. The extreme variability in training and material resources among prehospital trauma care providers remains as an obstacle in most of the low- and middle-income countries as well as in the rural zones of the high-income countries for the implementation of new interventions for acute bleeding; therefore, improvement strategies are mandatory. Data collection remains a priority as the prehospital setting in low- and middle-income countries remains poorly characterized.

NOVEL TECHNIQUES IN ABDOMINAL HEMORRHAGE CONTROL

Noncompressible torso hemorrhage remains an area where control of bleeding has proven to be difficult to improve outside of the confines of a major trauma center. Newer hemostatic agents and technologies are starting to move out of the laboratory and proof-of-concept phases and into the clinical setting. As the research landscape is continually changing, it remains to be seen which solutions will be the most effective; however, we will address some of the newer topical hemostatic agents and discuss other possible techniques for hemorrhage control in this section.

TOPICAL HEMOSTATIC AGENTS

ABDOMINAL INTERVENTIONS

RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA

There are several life-saving procedures in trauma and vascular surgery, such as tourniquets for extremity bleeding, which have reduced prehospital mortality to 10%. However, for truncal and junctional regions, prehospital mortality remains around 90%. The implementation of massive transfusion protocol and damage control surgery has reduced the mortality associated with trauma, but truncal and junctional hemorrhage still remains challenging for trauma surgeons.

Some critical maneuvers used in hemorrhage control, such as descending aorta occlusion through anterolateral thoracotomy, are associated with poor results. With advances in endovascular procedures and the new endovascular catheter, the use of an endovascular balloon to occlude the aorta is an option for catastrophic, uncontrolled hemorrhage of trunk and junctional regions. It is thought that obstruction of the distal aorta increases cardiac afterload, and the additional pressure in the proximal aorta enhances myocardial and cerebral prefusion. The use of endovascular aorta occlusion is not a new idea, with the first instance in 1954 by Hughes during the Korean War.²⁴ However, this initial method was abandoned because of the high incidence of complications. It was only renewed in the early 2000s with new models of catheters and enhancements of resuscitation techniques.

Below, we outline the major steps involved in deploying REBOA. The steps to insertion of the endovascular aorta balloon are as follows:

• Step 1: arterial access—dissection of femoral artery using a 12-Fr catheter or a Seldinger puncture techniques using a 7-Fr catheter.
• Step 2: balloon position in the aorta: zone 1—between left subclavian artery and celiac trunk, zone 2—between celiac trunk and superior mesenteric artery, and zone 3—below superior mesenteric artery. Please note that it is important to confirm the position of the catheter by radiographic imaging.
• Step 3: balloon insufflation—occlusion of the distal aortic flow while avoiding over-dilatation of aorta.
• Step 4: management—during balloon occlusion, stabilize the catheter to avoid balloon dislocation.
• Step 5: balloon deflation—monitor the hemodynamic and metabolic parameters to avoid reperfusion problems—the duration of the aorta occlusion must be the least possible amount of time required to control the hemorrhage (usually at zone 1, 30 minutes maximum; and zone 3: 60 minutes, avoid the use in zone 2).
• Step 6: catheter removal and post-resuscitation care—sometimes the femoral artery must be repaired and clots must be removed.

Most of the potential complications of aortic balloon occlusion are associated with the steps of the catheter insertion.²⁵ There is currently much discussion concerning where and when to insert the catheter. Some are exploring the possibility of insertion in the prehospital setting, while others are questioning whether catheter insertion should occur in the emergency room or the operating room. Typically, aseptic technique is used to insert the catheter in the hospital; however, a 7-Fr catheter can be inserted without a guide wire in the prehospital setting or in the emergency department.

Endovascular balloon occlusion of the aorta has been used in trauma patients, and ruptured aortic aneurysm patients have been associated with improvements of hemodynamic parameters and outcomes for several decades. There are currently a series of case studies, a prospective study, and some meta-analysis studies on the use of REBOA. In 2018, Borger van der Burg performed a meta-analysis of the use of REBOA in the management of major exsanguination (ruptured aortic aneurism and trauma), which included 1,436 patients in hemodynamic shock with an overall mortality of 49.2%. This study found that the use of the balloon increased systolic mean pressure almost 50 mm Hg.²⁶ A formal, prospective study is warranted to clarify the role of this technique in all hemodynamically unstable patients. In a 2017 meta-analysis study, Nunez et al. compared aortic cross-clamping with aortic endovascular balloon occlusion for bleeding control in trauma patients. Of the 1,276 patients in the study, the 873 patients who received REBOA had lower odds of mortality compared with the 403 patients who received aortic cross-clamping. Overall, this study suggests a positive effect of REBOA on mortality among noncompressible torso hemorrhage patients.²⁷ However, these results warrant further investigation.

OPERATIVE TECHNIQUES FOR DAMAGE CONTROL SURGERY

After traumatic injury, more than 80% of deaths in the operating room are due to exsanguination or coagulopathy.²⁸ Thus, it is extremely important to understand the many available surgical techniques for emergent hemostatic control. The following operative techniques will be categorized by thorax or abdomen, depending on the region where the technique is most commonly applicable.

Surgical and endovascular options to control hemorrhage of the thorax:

• Pulmonary tractotomy. This technique consists of opening the pulmonary parenchyma along the tract of injury or laceration and individually ligating each bleeding vessel.²⁹
• The pulmonary hilum twist is a technique used to rotate the entire lung after dissection of the inferior pulmonary ligament. This is done by placing one hand on the anterior aspect of the upper pulmonary lobe and the other on the posterior aspect of the lower lobe. The lower lobe is rotated anteriorly, and the upper lobe is rotated posteriorly 180°; thus the apex of the lung is moved adjacent to the diaphragm. The twisting of the hilum during this maneuver can help control bleeding from the lung.³⁰
• Thoracic endovascular aortic repair. A recent study by the American Association for the Surgery of Trauma demonstrated that the use of endovascular stent grafts in thoracic aorta injuries led to a decrease in mortality compared with standard operative repair.³¹
• Aortic cross-clamping. An aortic cross-clamp can be used to control hemorrhage from an aortic injury to a distal segment, or it can be used to restrict blood flow to distal regions to allow time for definitive surgical repair.
• Vascular shunt. A shunt can be placed inside the ends of a vessel, such as the aorta. This can be a chest tube or any tube with similar caliber. Similarly, a Foley catheter can be placed anywhere in the aorta to obtain control of that segment.
• Cardiac staples can be used to correct cardiac lacerations. Placing a Foley catheter in the lesion is another temporary way to obtain hemostatic control prior to definitive repair of a cardiac injury (Fig. 3). Prior to repairing any cardiac injury, a vascular clamp can be placed in the right atrium (Fig. 4).
• A vascular clamp can be stapled or placed at the hilum of the lung to control active bleeding prior to definition intervention to pulmonary injury (Fig. 5). Similarly, the hilum can be occluded by manual compression for short periods of time.
• Packing a bleeding chest. Even though it is not traditionally encouraged because of the increased thoracic pressure, restriction of cardiac filling, compromise of cardiac ejection fraction, and restriction of lung expansion, there are data showing that packing a nonsurgical bleeding chest is safe and that it has controlled bleeding in patients with life-threatening hemorrhage.³²

Surgical and endovascular options to control hemorrhage of the abdomen and pelvis:

• Pelvic packing and binders. Direct preperitoneal packing in conjunction with a pelvic binder can be used to control hemorrhage from pelvic ring disruptions and has been reported to be superior to transabdominal pelvic packing. This technique utilizes a midline suprapubic incision into the space of Retzius and allows for hemostatic control until definitive fixation of the pelvic ring is appropriate.³³
• Transcatheter arterial embolization. Endovascular interventions have been proven to be an extension of damage control surgery. It is most useful in patients with solid organ injuries with areas of extravasation or areas with high potential for bleeding. An appropriate catheter and embolization agent are then selected based on the location and severity of injury. This technique is generally used to control abdominal bleeding from the pelvis and abdominal organs, such as the liver, spleen, or kidneys. When deciding on appropriate use of embolization, care should be taken to only embolize non-vital vessels, as to reduce ischemic injury to extremities and end organs.³⁴
• Vessel ligation. Target blood vessels can be ligated using metal clips, plastic clips, or surgical ties. When vessel ligation is indicated, one should also consider primary surgical repair or endovascular options.³⁵
• Temporarily closing with a plastic equivalent to the Bogota bag and making the final skin closure when the patient returns for definitive surgery.
• In special situations, and under fluoroscope or direct palpation, REBOA could be placed in zone 1 or 3 proximal to the aortic lesion to control hemorrhage, as previously mentioned.

CONCLUSION

Hemorrhage remains as a significant cause of mortality in both military and civilian trauma patients. Currently, the therapies most likely to improve survival are injury prevention and decreasing transport times to major trauma centers with the surgical expertise to care for these patients.

With further investigation of hemostatic equipment and bleeding control techniques, we may be able to practically eliminate unnecessary death due to hemorrhage after trauma. This will require advances in prehospital structure and training, early hemostatic control in the hospital setting, and better surgical options for damage control. Likewise, injury prevention appears to be another feasible target for reducing deaths from hemorrhagic shock after trauma.

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