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

S E Van Oostendorp,E C T H Tan,L M G Geeraedts

doi:10.1186/s13049-016-0301-9

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.

Highlights

Junctional haemorrhage Junctional haemorrhage is defined as bleeding from a junction of the torso to the extremities, i.e., the base of the neck, shoulder, axilla, perineum, buttocks, gluteal area and the groin [33]
A study of casualties in the U.S combat forces from 2001 to 2011, noted that 17.5 % of potentially preventable prehospital deaths resulted from junctional haemorrhage [2]
If bleeding persists despite an adequately applied tourniquet or the site of bleeding is too proximal to apply a tourniquet, military guidelines advocate to start with a haemostatic gauze in combination with direct pressure [33]

Summary

Introduction

Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. Haemorrhage due to trauma is the leading preventable cause of death in the military setting, accounting up tot to 90 % of potentially preventable deaths [1, 2]. It is the second most leading cause of death in trauma patients, studies report: 26–40 % [3, 4]. Early (e.g., prehospital) haemorrhage control allowing for bridging to definitive surgical care, may yield a large survival advantage. Haemorrhage control, among shock resuscitation and prevention of trauma-induced coagulopathy, are the mainstays of treatment of imminent exsanguination in the prehospital arena as well as in the definitive care facility [9]

Objectives

Methods

Results

Discussion

Conclusion