Aim: To discuss important interventions and techniques to control hemorrhage in trauma patients. Background: 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; in the civilian setting, hemorrhage is second only to neurologic injuries as a cause of death due to trauma. 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. Review results: Advances in hemostatic resuscitation, antifibrinolytic medications, and more rapid transport times have all decreased mortality from hemorrhage. 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. Conclusion: 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.
Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma 2011;71(1 Suppl):S4–S8. DOI: 10.1097/TA.0b013e318221147b.
Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma 2006;60(6 Suppl):S3–S11. DOI: 10.1097/01.ta.0000199961.02677.19.
Jacobs LM. The Hartford Consensus III: implementation of bleeding control. Conn Med 2015;79(7):431–435.
Ker K, Roberts I, Shakur H, et al. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev 2015;5:CD004896. DOI: 10.1002/14651858.CD004896.pub4.
Alarhayem AQ, Myers JG, Dent D, et al. Time is the enemy: Mortality in trauma patients with hemorrhage from torso injury occurs long before the “golden hour”. Am J Surg 2016;212(6):1101–1105. DOI: 10.1016/j.amjsurg.2016.08.018.
Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009;249(1):1–7. DOI: 10.1097/SLA.0b013e31818842ba.
Malone DL, Dunne J, Tracy JK, et al. Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma 2003;54(5):898–905. DOI: 10.1097/01.TA.0000060261.10597.5C.
van Oostendorp SE, Tan ECTH, Geeraedts Jr LMG. 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. Scand J Trauma Resusc Emerg Med 2016;24(1):110. DOI: 10.1186/s13049-016-0301-9.
Sasser S, Varghese M, Kellermann A, et al. Prehospital trauma care systems. Geneva: World Health Organization; 2005.
Hamada SR, Rosa A, Gauss T, et al. Development and validation of a pre-hospital “Red Flag” alert for activation of intra-hospital haemorrhage control response in blunt trauma. Crit Care 2018;22(1):113. DOI: 10.1186/s13054-018-2026-9.
Choron RL, Hazelton JP, Hunter K, et al. Intra-abdominal packing with laparotomy pads and QuikClot during damage control laparotomy: a safety analysis. Injury 2017;48(1):158–164. DOI: 10.1016/j.injury.2016.07.033.
Vilardo N, Feinberg J, Black J, et al. The use of QuikClot combat gauze in cervical and vaginal hemorrhage. Gynecol Oncol Rep 2017;21:114–116. DOI: 10.1016/j.gore.2017.07.012.
Shiu VF, Keller R. The use of QuikClot combat gauze during Mohs stages for intra-operative hemostasis. J Am Acad Dermatol 2018;80(5):e117–e118. DOI: 10.1016/j.jaad.2018.06.020.
Rago AP, Larentzakis A, Marini J, et al. Efficacy of a prehospital self-expanding polyurethane foam for noncompressible hemorrhage under extreme operational conditions. J Trauma Acute Care Surg 2015;78(2):324–329. DOI: 10.1097/TA.0000000000000507.
Rago A, Duggan MJ, Marini J, et al. Self-expanding foam improves survival following a lethal, exsanguinating iliac artery injury. J Trauma Acute Care Surg 2014;77(1):73–77. DOI: 10.1097/TA.0000000000000263.
Chang JC, Holloway BC, Zamisch M, et al. ResQFoam for the treatment of non-compressible hemorrhage on the front line. Mil Med 2015;180(9):932–933. DOI: 10.7205/MILMED-D-15-00049.
TRAUMAGEL™ Hemostatic Gel. (2019, April 15). Retrieved from https://cresilon.com/traumagel/.
Velmahos GC, Spaniolas K, Tabbara M, et al. Abdominal insufflation decreases blood loss without worsening the inflammatory response: implications for prehospital control of internal bleeding. Am Surg 2008;74(4):297–301.
Velmahos GC, Spaniolas K, Duggan M, et al. Abdominal insufflation for control of bleeding after severe splenic injury. J Trauma 2007;63(2): 285–288; discussion 288–290. DOI: 10.1097/TA.0b013e3180d0a6ea.
Zakaria el R, Garrison RN, Spain DA, et al. Intraperitoneal resuscitation improves intestinal blood flow following hemorrhagic shock. Ann Surg 2003;237(5):704–711; discussion 711–713. DOI: 10.1097/01.SLA.0000064660.10461.9D.
Garrison RN, Conn AA, Harris PD, et al. Direct peritoneal resuscitation as adjunct to conventional resuscitation from hemorrhagic shock: a better outcome. Surgery 2004;136(4):900–908. DOI: 10.1016/j.surg.2004.06.027.
Smith JW, Neal Garrison R, Matheson PJ, et al. Adjunctive treatment of abdominal catastrophes and sepsis with direct peritoneal resuscitation: indications for use in acute care surgery. J Trauma Acute Care Surg 2014;77(3):393–398; discussion 398–399. DOI: 10.1097/TA.0000000000000393.
Smith JW, Garrison RN, Matheson PJ, et al. Direct peritoneal resuscitation accelerates primary abdominal wall closure after damage control surgery. J Am Coll Surg 2010;210(5):658–664, 664–667. DOI: 10.1016/j.jamcollsurg.2010.01.014.
Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954;36(1):65–68.
Davidson AJ, Russo RM, Reva VA, et al. The pitfalls of resuscitative endovascular ballon occlusion of the aorta: risk facatores and mitigation strategies. J Trauma Acute Care Surg 2018;84(1):192–202. DOI: 10.1097/TA.0000000000001711.
Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg 2018;44(4):535–550. DOI: 10.1007/s00068-018-0959-y.
Nunez RM, Naranjo MP, Foianini E, et al. A meta-analyisis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients. World J Emerg Surg 2017;12:30. DOI: 10.1186/s13017-017-0142-5.
Hoyt D, Bulger EM, Knudson MM, et al. Death in the operating room: an analysis of a multi-center experience. J Trauma 1994;37(3):426–432. DOI: 10.1097/00005373-199409000-00016.
Wall Jr MJ, Villacencio RT, Miller 3rd CC, et al. Pulmonary tractotomy as an abbreviated thoracotomy technique. J Trauma 1998;45(6): 1015–1023. DOI: 10.1097/00005373-199812000-00008.
Wilson A, Wall Jr MJ, Maxson R, et al. The pulmonary hilum twist as a thoracic damage procedure. Am J Surg 2003;186(1):49–52. DOI: 10.1016/S0002-9610(03)00102-8.
Demetriades D, Velmahos GC, Scalea TM, et al. Blunt traumatic thoracic aortic injuries: early or delayed repair–results of an American Association for the Surgery of Trauma prospective study. J Trauma 2009;66(4):967–973. DOI: 10.1097/TA.0b013e31817dc483.
Phelan HA, Patterson SG, Hassan MO, et al. Thoracic damage control operation, principles, techniques and definitive repair. J Am Coll Surg 2006;203(6):933–941. DOI: 10.1016/j.jamcollsurg.2006.08.016.
Aseni P, Carlis L, Mazzola A, et al. Operative Techniques and Recent Advances in Acute Care and Emergency Surgery. Springer International Publishing AG; 2019.
Glass NE, Burlew CC. Preperitoneal pelvic packing: how and when. Curr Trauma Rep 2015;1(1):1–7. DOI: 10.1007/s40719-014- 0001-8.
Lim CS, Jang JY, Lee SE, et al. Comparison of various methods of vessel ligation: what is the safest method? Surg Endosc 2013;27(9): 3129–3138. DOI: 10.1007/s00464-013-2866-y.