Bleeding Control Techniques Research Articles

A Survey of Hospitalized Trauma Patients in Hemorrhage Control Education: Are Trauma Victims Willing to Stop the Bleed?

The Stop the Bleed (STB) campaign was developed in part to educate the lay public about hemorrhage control techniques aimed at reducing preventable trauma deaths. Studies have shown this training increases bystanders' confidence and willingness to provide aid. One high-risk group might be better solicited to take the course: individuals who have been a victim of previous trauma, as high rates of recidivism after trauma are well-established. Given this group's risk for recurrent injury, we evaluated their attitudes toward STB concepts. We surveyed trauma patients admitted to 3 urban trauma centers in Baltimore from January 8, 2020 to March 14, 2020. The survey was terminated prematurely due to the COVID-19 pandemic. Trauma patients hospitalized on any inpatient unit were invited to complete the survey via an electronic tablet. The survey asked about demographics, prior exposure to life-threatening hemorrhage and first aid training, and willingness to help a person with major bleeding. The Johns Hopkins IRB approved waiver of consent for this study. Fifty-six patients completed the survey. The majority of respondents had been hospitalized before (92.9%) and had witnessed severe bleeding (60.7%). The majority had never taken a first aid course (60.7%) nor heard of STB (83.9%). Most respondents would be willing to help someone with severe bleeding form a car crash (98.2%) or gunshot wound (94.6%). Most patients admitted for trauma had not heard about Stop the Bleed, but stated willingness to respond to someone injured with major bleeding. Focusing STB education on individuals at high-risk for trauma recidivism may be particularly effective in spreading the message and skills of STB.

415 Surgical and endovascular practice patterns in patients undergoing c-section for placenta accreta spectrum

The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion of pelvic vessels or the aorta has been incorporated into the management protocols of this pathology. We aimed to examine the surgical and endovascular practice patterns among pregnant women with PAS treated at the same institution during an 8-year period, focusing on changes in bleeding control techniques. The study evaluated a retrospective cohort including all patients with PAS treated from December 2011 to December 2019 at a Latin American hospital. We compared the clinical results obtained according to the type of endovascular device used. Ninety-seven patients were included (Table 1), and seventy-nine of them were prenatally diagnosed: 30 received Internal Iliac Artery Occlusion Balloons (Group 1), 40 used Resuscitative Endovascular Balloon Of the Aorta (Group 2), and 9 did not use arterial balloons due to S1 involvement, with a low risk of bleeding (Group 3). The remaining 18 women were diagnosed during a c-section for another reason (Group 4), receiving non-protocolized management by staff without formal training in AIP. Group 2 patients had a bleeding volume (average: 1,700 mL) and frequency of transfusions (42%) slightly lower than those of Group 1 patients (2,000 mL and 50% transfusions, respectively), with a lower hysterectomy frequency (65% vs. 77% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS, placenta percreta and S2 compromise. Group 3 patients had the lowest volume of blood transfusion frequency of the entire population studied Multiple valid strategies are available to prevent massive bleeding due to PAS. Some selected patients can be safely managed without endovascular devices in specialized centers.

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database.

Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment. A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing (PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI). Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%) underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was 37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than PP alone (17.9% vs. 6.8%, p = 0.036). Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of interventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management underscores the need for an evidence base to standardize care. Therapeutic, Level IV.

Ligating the Corresponding Inflow and Outflow Vessels during Hepatectomy: A Prospective Randomized Controlled Trial and Animal Study

Background: We have devised a simple bleeding control technique ligating the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection during hepatectomy. The main objective of this study is to investigate the role of this simple technique on postoperative metastasis and survival. Methods: During the past 10 years, 330 patients with primary HCC were performed hepatectomy with the new hemorrhage control technique, and prospective randomized controlled trial was applied. Circulating tumor cells (CTC) were detected in 24 hours postoperatively. We further applied a mice model ligating the pedicle of the lesion-located hepatic lobe before hepatectomy to imitate the clinic practice, and evaluated the role of the new technique on postoperative metastasis and survival. Results: The new technique prolonged postoperative overall and disease-free survival for patients with primary HCC, and reduced the number of circulatin CTC postoperatively, when compared with the conventional hepatectomy. In the animal model, hepatectomy with the new technique showed lower metastasis, and longer survival when compared with conventional surgery. Human specific-AFP expressed at a high level in the serum of the metastasis bearing mice, but not expressed in metastasis-free mice. Conclusion: Ligating the inflow and outflow vessels of the lesion-located hepatic lobe before hepatectomy reduces postoperative metastasis and prolongs survival of primary HCC. These results also indicate a potential mechanism that the new technique prevents hematogenous metastasis owing to its coincidence to principles of oncological surgery to avoid the intraoperative spread of tumour cells during hepatectomy.

170 Use of Transthoracic Ultrasound to Confirm Placement of Resuscitative Endovascular Balloon Occlusion of the Aorta in Medical Cardiac Arrest

The objective of this study is to assess the feasibility of using bedside ultrasound to visualize and confirm aortic placement of resuscitative endovascular balloon occlusion of the aorta (REBOA) within an emergency medicine (EM)-initiated multi-disciplinary protocol in non-traumatic OHCA. REBOA is a hemorrhage control technique involving the intra-vascular occlusion of the thoracic aorta using a balloon catheter and may help to increase coronary and cerebral perfusion during non-traumatic out-of-hospital cardiac arrest (OHCA) by directing blood flow to the upper body. We are conducting a single-arm early feasibility study of REBOA initiated in the emergency department (ED) for OHCA using an investigational device approval by the Food and Drug Administration (FDA) with an exception from informed consent. During CPR, an emergency physician obtains common femoral access using a 7Fr introducer sheath while the REBOA catheter is prepared and subsequently advanced by an interventional radiologist (IR). While sheath introducer placement can be confirmed with ultrasound views of the common femoral artery, we seek to confirm intrathoracic REBOA placement using transthoracic bedside ultrasound. Our goal is to enroll 20 patients into this study and use transthoracic ultrasound to confirm REBOA placement in each. Two of the initial twenty patients were enrolled between January and February 2020, with a temporary pause in enrollment due to the COVID pandemic from March to July 2020. In both enrolled patients, transthoracic views were obtained confirming intra-thoracic aortic placement of REBOA by an emergency physician. In our initial two cases, thoracic aortic placement of the REBOA in non-traumatic OHCA was confirmed by emergency physicians using transthoracic ultrasound. This demonstrates correct placement of aortic endovascular devices can be confirmed using emergency physician operated ultrasound. Further research is needed to determine what factors may impact emergency physicians’ ability to successfully identify and confirm aortic device placement.

364 Feasibility Study of Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Medical Cardiac Arrest

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control technique involving the intra-vascular occlusion of the thoracic aorta using a balloon catheter and may help to increase coronary and cerebral perfusion during out-of-hospital cardiac arrest (OHCA) by blocking blood flow to the lower body. Primary Objective: The primary objective of this study is to assess the feasibility of an emergency medicine (EM)-initiated multi-disciplinary protocol for REBOA in non-traumatic OHCA. Secondary Objectives: Secondary objectives are procedural outcomes (eg, attempts required for common femoral access), hemodynamic outcomes before and after aortic occlusion (end-tidal carbon dioxide, diastolic blood pressure), and rates of return of spontaneous circulation (ROSC) and survival to hospital discharge with a favorable neurologic outcome. This single-arm early feasibility study of REBOA initiated in the emergency department (ED) for OHCA uses an investigational device approval with a community exception from informed consent. Subjects under 80 years of age with witnessed OHCA and down time under 45 minutes are eligible. On arrival to the ED, an emergency physician obtains common femoral access using a 7Fr introducer sheath while the REBOA catheter is prepared and subsequently advanced by an interventional radiologist (IR). Two patients were enrolled between January and February 2020, with a temporary pause in enrollment due to the COVID pandemic from March - August 2020. To our knowledge, this is the first trial of ED-initiated REBOA involving emergency physicians for non-traumatic OHCA (two similar recent reports exist in the anesthesia and critical care literature). Our initial patient was a 77-year-old man who presented in refractory ventricular fibrillation. The emergency physician placed the common femoral sheath on the first attempt using ultrasound guidance under chest compressions and the REBOA catheter was then advanced by the interventional radiologist. After inflation of the aortic balloon, investigators noted immediate improvements in mean arterial pressure (MAP) (37 to 50 mmHg) and end-tidal carbon dioxide (ETCO2) (35 to 50 mmHg), with transient non-sustained ROSC. The second patient, a 63-year-old man, underwent successful REBOA placement with similar improvements in MAP (22 to 50 mmHg) and ETCO2 (33 to 43 mmHg). Unfortunately, both patients were in refractory ventricular fibrillation and despite multiple defibrillation attempts and antiarrhythmics they did not survive to hospital admission. REBOA has been hypothesized to improve outcomes in OHCA by blocking blood flow to the lower body and redirecting it towards the heart and brain, improving the perfusion of these vital organs. In both cases, REBOA was temporally associated with improved hemodynamics during chest compressions with transient ROSC in one case. Performance of REBOA by a multi-disciplinary team for OHCA in the ED was feasible in these initial two cases. Future research will examine the feasibility of REBOA catheter advancement by the emergency physician and further quantify the hemodynamic effects associated with aortic occlusion.

Stop the Bleed: Effective Training in Need of Improvement

BackgroundThe “Stop the Bleed” (StB) campaign aims to educate laypersons on performing bleeding control techniques in any setting that requires hemorrhage control, such as motor vehicle crashes or mass casualty incidents. Participants undergo a didactic and practical session, the latter incorporating a mannequin. We hypothesized that participants would increase content knowledge after StB participation and that the training could be improved by a more life-like bleeding modification of the mannequin. Materials and methodsFrom July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training. Participants provided demographic data regarding prior emergency training and were asked pre- and post-test questions (five-point Likert scale) regarding their response to hemorrhage. Individuals also evaluated the mannequin on bleeding simulation. Scores were reported as means with standard deviation or medians with interquartile ranges (IQRs) with subset analysis stratified by experience. ResultsOf 402 participants, 310 provided complete data. On the composite, pre-test self-assessment, participants had a median score of 24 of 30 points (IQR 16-30). Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 25-30, P < 0.05). Subset analysis by prior emergency training (n = 102) demonstrated that both those with prior emergency training and those with no prior emergency training had significant improvement. On evaluation of the mannequin, participants reported that a more realistic model would increase their confidence in technique. Both subgroups reported that training would be enhanced if the mannequins were more realistic. ConclusionsStB is an effective education program. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement. Regardless of background, participants reported overwhelmingly that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating pulsatile blood flow and cessation of hemorrhage could enable learners to actually “Stop the Bleed”.

Hemorrhage Control Training: Preparing Adolescents to Act at Home, at School, or in Public.

Uncontrolled bleeding is the leading cause of preventable death after a traumatic event, and early intervention to control bleeding improves opportunities for survival. It is imperative to prepare for local and national disasters by increasing public knowledge on how to control bleeding, and this preparation should extend to both adults and children. The purpose of this study is to describe a training effort to teach basic hemorrhage control techniques to early adolescent children. The trauma and emergency departments at a combined level I adult and level II pediatric trauma center piloted a training initiative with early adolescents (grades 6-8) focused on 2 skills: packing a wound and holding direct pressure, and applying a Combat Application Tourniquet. Students were evaluated on each skill and completed presurveys and postsurveys indicating their likelihood to use the skills. Of the 194 adolescents who participated in the trainings, 97% of the students could successfully pack a wound and hold pressure, and 97% of the students could apply a tourniquet. Before the training, 71% of the adolescents indicated that they would take action to assist a bleeding victim; this increased to 96% after the training. Results demonstrate that basic hemorrhage control skills can be effectively taught to adolescents as young as 6th grade (ages 11-12 years) in a small setting with age-appropriate content and hands-on opportunities to practice the skills and such training increases students' perceived willingness to take action to assist a bleeding victim.

Emerging hemorrhage control and resuscitation strategies in trauma: Endovascular to extracorporeal.

This article reviews four emerging endovascular hemorrhage control and extracorporeal perfusion techniques for management of trauma patients with profound hemorrhagic shock including hemorrhage-induced traumatic cardiac arrest: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, extracorporeal life support, and emergency preservation and resuscitation. The preclinical and clinical studies underpinning each of these techniques are summarized. We also present an integrated conceptual framework for how these emerging technologies may be used in the future care of trauma patients in both resource-rich and austere environments.

Circulatory Trauma: A Paradigm for Understanding the Role of Endovascular Therapy in Hemorrhage Control.

The pathophysiology of traumatic hemorrhage is a phenomenon of vascular disruption and the symptom of bleeding represents one or more vascular injuries. In the Circulatory Trauma paradigm traumatic hemorrhage is viewed as injury to the circulatory system and suggests the underlying basis for endovascular hemorrhage control techniques. The question "Where is the patient bleeding?" is replaced by "Which blood vessels are disrupted?" and stopping bleeding becomes a matter of selective vessel access and vascular flow control. Control of traumatic hemorrhage has traditionally been performed via external access to the end organ that is bleeding followed by the application of direct pressure, packing, or clamping and repair of directly affected blood vessels. In the circulatory trauma paradigm, bleeding is seen as disruption to vessels which may be accessed internally, from within the vascular system. A variety of endovascular treatments such as balloon occlusion, embolization, or stent grafting can be used to control hemorrhage throughout the body. This narrative review presents a brief overview of the current role of endovascular therapy in the management of circulatory trauma. The authors draw on their personal experience combined with the last decade of published experiences with the use of endovascular techniques in trauma and present general recommendations for their evolving use. The focus of the review is on the use of endovascular techniques as specific vascular treatments using the circulatory trauma paradigm.

Laparoscopic partial splenectomy with temporary occlusion of the trunk of the splenic artery in fifty-one cases: experience at a single center.

Laparoscopic partial splenectomy (LPS) for splenic benign space-occupying lesions has been reported by many researchers; however, few studies have described methods to control intraoperative bleeding. Trustworthy experience in LPS with a satisfactory intraoperative hemorrhage control technique is therefore necessary. The current study aims to present our experience in LPS with temporary occlusion of the trunk of the splenic artery for controlling intraoperative bleeding with a large sample of 51 cases and to evaluate the safety, feasibility, and reproducibility of this technique. Fifty-one patients from August 2014 to April 2019 who underwent LPS in our institution were retrospectively analyzed. Surgical techniques were described in detail. All patients had successfully undergone LPS with temporary occlusion of the trunk of the splenic artery. Conversions to open surgery, hand-assisted laparoscopic splenectomies, or blood transfusions were not needed. The operative time was 94.75 ± 18.91min, the estimated blood loss was 71.13 ± 53.87ml, and the volume of resected spleen was 34.75 ± 12.19%. The range of postoperative stays was 4-14days. One female patient (2%, 1/51) suffered from postoperative complications. No perioperative mortality, incision infections, postoperative pancreatic fistulas (POPFs), splenic infarctions, or portal/splenic vein thromboembolic events occurred. LPS is an effective spleen-preserving surgery. Although there are many other bleeding control methods, temporarily occluding the trunk of the splenic artery was found to be a safe, feasible, and reproducible technique in LPS. The outcomes of this technique and the efficacy of splenic parenchyma preservation are acceptable.

B-CON Course: Skills Acquired at Training in Bleeding Control Techniques for the Prevention of Exsanguinating Hemorrhage

B-CON Course: Skills Acquired at Training in Bleeding Control Techniques for the Prevention of Exsanguinating Hemorrhage

Hemorrhage-Control Training in Medical Education.

Objectives:To evaluate and analyze the efficacy of implementation of hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of students with controlling major hemorrhage and they will find this a valuable skill set for medical and other healthcare professional students.Methods:After IRB and institutional approval was obtained, hemorrhage-control education was incorporated into the surgery clerkship curriculum for 96 third-year medical students at the University of Arkansas for Medical Sciences using the national Stop The Bleed program. Using a prospective study design, participants completed pre- and post-training surveys to gauge prior experiences and comfort levels with controlling hemorrhage and confidence levels with the techniques taught. Course participation was mandatory; survey completion was optional. The investigators were blinded as to the individual student’s survey responses. A knowledge quiz was completed following the training.Results:Implementation of STB training resulted in a significant increase in comfort and confidence among students with all hemorrhage-control techniques. There was also a significant difference in students’ perceptions of the importance of this training for physicians and other allied health professionals.Conclusion:Hemorrhage-control training can be effectively incorporated into the formal medical school curriculum via a single 2-hour Stop The Bleed course, increasing students’ comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education. We believe this should be a standard part of undergraduate medical education.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary control of arterial hemorrhage. However, its effectiveness and clinical outcomes are unclear. MethodsUsing a nationwide database (2004–2016) in Japan, trauma patients with survival data were identified. Patients were divided between REBOA and non-REBOA groups, and a propensity score was developed using multivariate logistic regression. Survival to discharge was compared between the groups after propensity score matching. ResultsAmong 82,371 patients included in this study, 385 were treated with REBOA. After propensity score matching, 117 pairs were selected. Survival to discharge was significantly higher among patients treated with REBOA than among those treated without REBOA (53 [45.3%] vs. 38 [32.5%]; odds ratio = 1.72; 95% CI = 1.01–2.93; p = 0.04). ConclusionsREBOA use was associated with improved survival to discharge and should therefore be considered during the management of severely injured trauma patients.

Stop the Bleed Training: Rescuer Skills, Knowledge, and Attitudes of Hemorrhage Control Techniques

BackgroundBystanders play a significant role in the immediate management of life-threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to evaluate the efficacy of STB training for rescuers from different backgrounds. We hypothesized that STB training would be appropriate to increase skills and knowledge of bleeding control techniques for all providers, regardless of level of medical training. Study designCourse participants anonymously self-reported confidence in six major areas. A five-point Likert scale was used to quantitate participant's self-reported performance. Results were stratified into medical rescuers (MR) and LRs. Students' ability to perform STB skills were objectively assessed using an internally validated 15-point objective assessment tool. Data were pooled and analyzed using Student's t-test and chi-Squared test with P < 0.05 considered significant. Results are presented as average with standard deviation (SD) unless otherwise stated. ResultsA total of 1974 participants were included in the study. Precourse confidence was lowest for both groups in management of active severe bleeding and ability to pack a bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core areas measured (P < 0.001). The most significant increases were reported in the two previous areas of lowest precourse confidence-management of active severe bleeding—LRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001—and ability to pack a bleeding wound—LR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD 0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated combined 99.3% proficiency on postcourse objective assessments. ConclusionsThis study provides quantitative evidence that Stop the Bleed training is effective, with both LRs and MRs demonstrating improved confidence and skill proficiency after a 1-h course. Future program development should focus on building a pool of instructors, continued training of LRs, and determining how often skills should be recertified.

Developing "Herd Immunity" in a Civilian Community Through Incorporation of "Just-In-Time" Tourniquet Application Training.

Herd immunity, a concept normally applied in vaccinated populations, is a preventative measure to determine if a significant portion of a population can protect vulnerable individuals against a certain disease. Like vaccines, tourniquet education can be a form of herd immunity to protect vulnerable individuals in a population and prevent the loss of life from a peripheral hemorrhage. The authors have identified a deficiency in simple, quick, and effective hemorrhage control education. Therefore, to maximize herd immunity, the novel educational platform evaluates the efficacy of "Just-in-Time" (JiT) tourniquet application training. The authors hypothesize that the utilization of JiT training will be effective in promoting both competence and confidence for individuals to utilize tourniquets in response to a disaster environment. This Institutional Review Board-approved study recruited medical students who were trained in hemorrhage control measures at a Level 1 Trauma Center. Tourniquet training sessions were held, and naïve civilians received tourniquet education. The subjects received a five- to ten-minute lesson on indications, contraindications, and application techniques of commercial and improvisational tourniquets. Participants subsequently applied a tourniquet to an instructor's arm to demonstrate proper tourniquet application for a brachial artery hemorrhage. Pre- and post-educational surveys were completed to test participant competency and confidence. Of the 104 subjects who completed the course, 97 had no prior training in hemorrhage control techniques, including commercial and improvisational tourniquet application. The mean pre-test score was 2.27/5.00 and the mean post-test score was 4.38/5.00, P <.001 (n = 97). When queried "How competent would you feel applying a tourniquet (commercial or improvisational) on an individual with a bleeding wound?" 92/97 felt confident (95%), one felt less confident, and four felt no difference in confidence levels (P <.001). Just-in-Time training is an effective method in teaching naïve civilians proper tourniquet application. This platform could serve as an alternative to more extensive training programs and requires less time, costs, and resources. If a significant number of individuals in a local community can effectively apply a tourniquet in a disaster scenario, a "herd immunity" effect could be achieved to control peripheral hemorrhages.

Advancing the Education of Stop the Bleed: Development of a Perfused Synthetic Cadaver Model

BackgroundAs active shootings and mass casualty incidents have become more prevalent, courses designed to teach basic hemorrhage control to laypersons have proliferated. Participants currently undergo Stop the Bleed (StB) training currently use a synthetic limb mannequin. In a prior survey of 88 participants, there was overwhelming sentiment that the mannequin was limited by its inability to demonstrate cessation of bleeding when hemorrhage control techniques were applied. We hypothesized that simulated bleeding that can be controlled by StB techniques would improve the mannequin and increase confidence of trainees in achieving bleeding control. MethodsThe mannequin was redesigned to be a self-contained model mimicking bleeding, with fluid flowing from a reservoir into a latex tubing with a laceration mimicking an arterial wound. Fluid was pumped by a rubber bulb attached to the tubing and held in the instructor's hand. Twenty StB trainers conducted beta testing of the perfused mannequin. Forty participants underwent training with both old and new models and completed posttraining surveys. ResultsBeta-testers reported positive feedback regarding both realism of the perfused mannequin and participants' ability to obtain bleeding control using StB techniques. Participants who trialed the mannequin reported increased awareness of the rate of blood flow out of a wound, which in turn increased their sense of urgency to achieve hemostasis. ConclusionsIn an effort to address shortcomings noted by participants in the current StB mannequin, we developed a novel perfused bleeding mannequin, which responds appropriately to various hemorrhage cessation techniques and is both high fidelity and low cost.

Learners’ perspectives on Stop the Bleed: a course to improve survival during mass casualty events

BackgroundIn response to increasing mass casualty events nationwide, the American College of Surgeons Committee on Trauma developed a bleeding control course (Stop the Bleed) to teach hemorrhage control techniques to...

Teaching how to stop the bleed: does it work? A prospective evaluation of tourniquet application in law enforcement officers and private security personnel.

Stop the Bleed (STB) program was launched by the White House, for the use of bleeding control techniques at the scene of traumatic injury. The purpose of this study was to conduct an STB course in private security and law enforcement personnel. Pre- and post-questionnaire using the Likert scale was shared with participants on their knowledge and comfort level with the use of tourniquets. Participants were also observed while placing tourniquets and the time for placement recorded. The didactic portion and practical session of the STB was then taught and participants were again observed placing tourniquets and a questionnaire distributed. Fisher's exact tests or Wilcoxon matched-pairs signed-ranks tests were used to compare pre-post measurements. A total of 151 subjects were enrolled over the course of seven sessions. The tourniquet was applied correctly by 17.2% (26/151) and 92.7% (140/151) at the pre- and post-instruction assessments, respectively (p < 0.001). Mean times to apply the tourniquet were 29.8 ± 18.5 and 18.7 ± 6.7s, respectively (p < 0.001). Subjects reported their level of comfort with the tourniquet to be 5.1 ± 3.3 and 8.8 ± 2.2, respectively (p < 0.001), and their familiarity with anatomy and bleeding control to be 5.2 ± 3.1 and 8.2 ± 2.4, respectively (p < 0.001). At the end of the course, the mean score in response to a question about the extent to which the explanation had helped was 9.0 ± 1.9 (95% CI 8.7-9.4) and to a question about the extent to which teaching would make them feel more secure and safe was 9.2 ± 1.9 (95% CI 8.9-9.5). STB course improved correct tourniquet placement, demonstrated dramatic improvements in application time, and increased levels of comfort. These findings validate the need for ongoing teaching and education.

Hemorrhage control during gastric endoscopic submucosal dissection: Techniques using uncovered knives.

Since the last decade, endoscopic submucosal dissection (ESD) has been used as the standard treatment for superficial gastrointestinal neoplasms. Trainees learning ESD frequently encounter difficulties such as vascularity, peristalsis, and fibrosis during the procedure. Because individual vascularity differs, it generally cannot be consistently avoided. Given that massive hemorrhages can prolong the procedure time and diminish treatment efficacy and that insufficient vessel handling may also increase postoperative bleeding, hemorrhage control during ESD becomes important to ensure procedure safety. This article discusses methods for controlling hemorrhage during gastric ESD. Endoscopists should have a basic understanding of the vascular architecture and the high‐density areas in blood vessels, which are susceptible to intraoperative hemorrhage. Efficient preventative coagulation should be performed in addition to mastering the techniques for hemorrhage control using hemostatic forceps. Techniques useful for preventing intraoperative hemorrhage at every step (e.g. submucosal injection, mucosal incision, and dissection) should be learned. Gaining procedural competence and learning hemorrhage control techniques not only during ESD but also in daily work would help provide safe and effective treatment.