Advertisement

Current Trauma Reports

, Volume 5, Issue 3, pp 129–136 | Cite as

Prehospital Hemorrhage Control and REBOA

  • Eric M. CampionEmail author
  • Charles J. Fox
Vascular Trauma (C Cribari, Section Editor)
  • 102 Downloads
Part of the following topical collections:
  1. Topical Collection on Vascular Trauma

Abstract

Purpose of Review

Review the current state of the art in prehospital hemorrhage control and the role of resuscitative endovascular balloon occlusion of the aorta (REBOA).

Recent Findings

Prehospital data demonstrate improved hemorrhage control and decreased blood product transfusions with tourniquet use. Minimal complications have been noted (temporary nerve palsy) and no tourniquet-related amputations have been reported in modern series. Junctional tourniquets are effective in stopping arterial flow and controlling bleeding in preclinical trials. Clinical data is lacking. Hemostatic bandages have been shown in animal studies to improve time to hemorrhage control and survival. Limited clinical data supports improved hemorrhage control and no morbidity. The REBOA catheter is a promising technology with a clear role in severe pelvic fractures. The role of REBOA in the prehospital setting remains undefined.

Summary

Preclinical and clinical data are supportive of both prehospital tourniquet and hemostatic bandages. Junctional tourniquets are promising but lack clinical data. The REBOA catheter is an effective bleeding control adjunct for which prehospital indications are still being defined.

Keywords

Prehospital hemorrhage control Tourniquet Hemostatic agents Junctional tourniquet REBOA Prehospital trauma 

Notes

Compliance with Ethical Standards

Conflict of Interest

Dr. Fox has nothing to disclose. Dr. Campion has nothing to disclose.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors were performed in accordance with all applicable ethical standards including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Drake SA, Holcomb JB, Yang Y, Thetford C, Myers L, Brock M, Wolf DA, Cron S, Persse D, McCarthy J, Kao L, Todd SR, Naik-Mathuria BJ, Cox C, Kitagawa R, Sandberg G, Wade CE Establishing a regional trauma preventable/potentially preventable death rate. Ann Surg 2018.Google Scholar
  2. 2.
    Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, et al. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004. Ann Surg. 2007;245(6):986–91.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Jacobs LM, McSwain NE Jr, Rotondo MF, Wade D, Fabbri W, Eastman AL, et al. Improving survival from active shooter events: the Hartford consensus. J Trauma Acute Care Surg. 2013;74(6):1399–400.PubMedGoogle Scholar
  4. 4.
    Fisher AD, Carius BM, Lacroix J, Dodge PM, Dodd J, Soderlund E, Thompson D, Loos P, Fannin J, Montgomery HR, et al. National Stop the Bleed Day: the impact of a social media campaign on the Stop the Bleed program. J Trauma Acute Care Surg. 2019.Google Scholar
  5. 5.
    Kragh JF Jr, Swan KG, Smith DC, Mabry RL, Blackbourne LH. Historical review of emergency tourniquet use to stop bleeding. Am J Surg. 2012;203(2):242–52.PubMedGoogle Scholar
  6. 6.
    Navein J, Coupland R, Dunn R. The tourniquet controversy. J Trauma. 2003;54(5 Suppl):S219–20.PubMedGoogle Scholar
  7. 7.
    Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):S28–37 discussion S.Google Scholar
  8. 8.
    Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.PubMedGoogle Scholar
  9. 9.
    Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008;64(2 Suppl):S38–49 discussion S-50.Google Scholar
  10. 10.
    Kauvar DS, Miller D, Walters TJ. Tourniquet use is not associated with limb loss following military lower extremity arterial trauma. J Trauma Acute Care Surg. 2018;85(3):495–9.PubMedGoogle Scholar
  11. 11.
    Dorlac WC, DeBakey ME, Holcomb JB, Fagan SP, Kwong KL, Dorlac GR, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma. 2005;59(1):217–22.Google Scholar
  12. 12.
    Passos E, Dingley B, Smith A, Engels PT, Ball CG, Faidi S, et al. Tourniquet use for peripheral vascular injuries in the civilian setting. Injury. 2014;45(3):573–7.PubMedGoogle Scholar
  13. 13.
    Kue RC, Temin ES, Weiner SG, Gates J, Coleman MH, Fisher J, et al. Tourniquet use in a civilian emergency medical services setting: a descriptive analysis of the Boston EMS Experience. Prehosp Emerg Care. 2015;19(3):399–404.PubMedGoogle Scholar
  14. 14.
    Schroll R, Smith A, McSwain NE Jr, Myers J, Rocchi K, Inaba K, et al. A multi-institutional analysis of prehospital tourniquet use. J Trauma Acute Care Surg. 2015;79(1):10–4 discussion 4.PubMedGoogle Scholar
  15. 15.
    • Scerbo MH, Mumm JP, Gates K, Love JD, Wade CE, Holcomb JB, et al. Safety and appropriateness of tourniquets in 105 civilians. Prehosp Emerg Care. 2016;20(6):712–22 A single-center study adjudicating all complications in a large cohort with tourniquet placement. No tourniquet-related complications identified after ajudication. PubMedPubMedCentralGoogle Scholar
  16. 16.
    McNickle AG, Fraser DR, Chestovich PJ, Kuhls DA, Fildes JJ. Effect of prehospital tourniquets on resuscitation in extremity arterial trauma. Trauma Surg Acute Care Open. 2019;4(1):e000267.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Inaba K, Siboni S, Resnick S, Zhu J, Wong MD, Haltmeier T, et al. Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015;79(2):232–7 quiz 332-3.PubMedGoogle Scholar
  18. 18.
    • Smith AA, Ochoa JE, Wong S, Beatty S, Elder J, Guidry C, et al. Prehospital tourniquet use in penetrating extremity trauma: decreased blood transfusions and limb complications. J Trauma Acute Care Surg. 2019;86(1):43–51 A single-center study of patients with extremity injury comparing patients with tourniquets to matched patients without. Reduced complications and transfusions in the tourniquet group. PubMedGoogle Scholar
  19. 19.
    Goodwin T, Moore KN, Pasley JD, Troncoso R, Jr., Levy MJ, Goolsby C. From the battlefield to main street: tourniquet acceptance, use, and translation from the military to civilian settings. J Trauma Acute Care Surg 2019.Google Scholar
  20. 20.
    •• Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163–73 Evidenced-based expert panel guideline on prehospital hemorrhage control. PubMedGoogle Scholar
  21. 21.
    Smith S, White J, Wanis KN, Beckett A, McAlister VC, Hilsden R. The effectiveness of junctional tourniquets: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2019;86(3):532–9.PubMedGoogle Scholar
  22. 22.
    Lyon M, Johnson D, Gordon R. Use of a novel abdominal aortic and junctional tourniquet to reduce or eliminate flow in the brachial and popliteal arteries in human subjects. Prehosp Emerg Care. 2015;19(3):405–8.PubMedGoogle Scholar
  23. 23.
    Lyon M, Shiver SA, Greenfield EM, Reynolds BZ, Lerner EB, Wedmore IS, et al. Use of a novel abdominal aortic tourniquet to reduce or eliminate flow in the common femoral artery in human subjects. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S103–5.PubMedGoogle Scholar
  24. 24.
    Kragh JF, Kotwal RS, Cap AP, Aden JK, Walters TJ, Kheirabadi BS, et al. Performance of junctional tourniquets in normal human volunteers. Prehosp Emerg Care. 2015;19(3):391–8.PubMedGoogle Scholar
  25. 25.
    Kragh JF Jr, Parsons DL, Kotwal RS, Kheirabadi BS, Aden JK 3rd, Gerhardt RT, et al. Testing of junctional tourniquets by military medics to control simulated groin hemorrhage. J Spec Oper Med. 2014;14(3):58–63.Google Scholar
  26. 26.
    • Gaspary MJ, Zarow GJ, Barry MJ, Walchak AC, Conley SP, Roszko PJD. Comparison of three junctional tourniquets using a randomized trial design. Prehosp Emerg Care. 2019;23(2):187–94 Study of junctional tourniquets during transport. Demonstrated signifcant failure rate during transport of simulated patients. PubMedGoogle Scholar
  27. 27.
    Croushorn J. Abdominal aortic and junctional tourniquet controls hemorrhage from a gunshot wound of the left groin. J Spec Oper Med. 2014;14(2):6–8.PubMedGoogle Scholar
  28. 28.
    Croushorn J, Thomas G, McCord SR. Abdominal aortic tourniquet controls junctional hemorrhage from a gunshot wound of the axilla. J Spec Oper Med. 2013;13(3):1–4.PubMedGoogle Scholar
  29. 29.
    Klotz JK, Leo M, Andersen BL, Nkodo AA, Garcia G, Wichern AM, et al. First case report of SAM(r) Junctional tourniquet use in Afghanistan to control inguinal hemorrhage on the battlefield. J Spec Oper Med. 2014;14(2):1–5.Google Scholar
  30. 30.
    Bennett BL. Bleeding control using hemostatic dressings: lessons learned. Wilderness Environ Med. 2017;28(2S):S39–49.PubMedGoogle Scholar
  31. 31.
    Sohn VY, Eckert MJ, Martin MJ, Arthurs ZM, Perry JR, Beekley A, et al. Efficacy of three topical hemostatic agents applied by medics in a lethal groin injury model. J Surg Res. 2009;154(2):258–61.PubMedGoogle Scholar
  32. 32.
    Devlin JJ, Kircher S, Kozen BG, Littlejohn LF, Johnson AS. Comparison of ChitoFlex(R), CELOX, and QuikClot(R) in control of hemorrhage. J Emerg Med. 2011;41(3):237–45.PubMedGoogle Scholar
  33. 33.
    Johnson D, Westbrook DM, Phelps D, Blanco J, Bentley M, Burgert J, et al. The effects of QuikClot combat gauze on hemorrhage control when used in a porcine model of lethal femoral injury. Am J Disaster Med. 2014;9(4):309–15.Google Scholar
  34. 34.
    Rall JM, Cox JM, Songer AG, Cestero RF, Ross JD. Comparison of novel hemostatic dressings with QuikClot combat gauze in a standardized swine model of uncontrolled hemorrhage. J Trauma Acute Care Surg. 2013;75(2 Suppl 2):S150–6.PubMedGoogle Scholar
  35. 35.
    Cox JM, Rall JM. Evaluation of XSTAT(R) and QuickClot(R) combat gauze(R) in a swine model of lethal junctional hemorrhage in coagulopathic swine. J Spec Oper Med. 17(3):64–7.Google Scholar
  36. 36.
    Leonard J, Zietlow J, Morris D, Berns K, Eyer S, Martinson K, et al. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma. J Trauma Acute Care Surg. 2016;81(3):441–4.PubMedGoogle Scholar
  37. 37.
    Zietlow JM, Zietlow SP, Morris DS, Berns KS, Jenkins DH. Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in civilian trauma care. J Spec Oper Med. 2015;15(2):48–53.Google Scholar
  38. 38.
    Shina A, Lipsky AM, Nadler R, Levi M, Benov A, Ran Y, et al. Prehospital use of hemostatic dressings by the Israel Defense Forces Medical Corps: a case series of 122 patients. J Trauma Acute Care Surg. 2015;79(4 Suppl 2):S204–9.PubMedGoogle Scholar
  39. 39.
    Pozza M, Millner RW. Celox (chitosan) for haemostasis in massive traumatic bleeding: experience in Afghanistan. Euro J Emerg Med. 2011;18(1):31–3.Google Scholar
  40. 40.
    Te Grotenhuis R, van Grunsven PM, Heutz WM, Tan EC. Prehospital use of hemostatic dressings in emergency medical services in the Netherlands: a prospective study of 66 cases. Injury. 2016;47(5):1007–11.Google Scholar
  41. 41.
    Warriner Z, Lam L, Matsushima K, Benjamin E, Strumwasser A, Demetriades D, et al. Initial evaluation of the efficacy and safety of in-hospital expandable hemostatic minisponge use in penetrating trauma. J Trauma Acute Care Surg. 2019;86(3):424–30.PubMedGoogle Scholar
  42. 42.
    Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma Acute Care Surg. 2011;71(6):1869–72.Google Scholar
  43. 43.
    Rasmussen TE, DuBose JJ, Asensio JA, Feliciano DV, Fox CJ, Nuñez TC, et al. Tourniquets, vascular shunts, and endovascular technologies: esoteric or essential? A report from the 2011 AAST Military Liaison Panel. J Trauma Acute Care Surg. 2012;73(1):282–5.PubMedGoogle Scholar
  44. 44.
    Azizzadeh A, Ray HM, Dubose JJ, Charlton-Ouw KM, Miller CC, Coogan SM, et al. Outcomes of endovascular repair for patients with blunt traumatic aortic injury. J Trauma Acute Care Surg. 2014;76(2):510–6.PubMedGoogle Scholar
  45. 45.
    du Toit DF, Lambrechts AV, Stark H, Warren BL. Long-term results of stent graft treatment of subclavian artery injuries: management of choice for stable patients? J Vasc Surg. 2008;47(4):739–43.Google Scholar
  46. 46.
    Reuben BC, Whitten MG, Sarfati M, Kraiss LW. Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg. 2007;46(6):1222–6 e2.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Holcomb JB. Methods for improved hemorrhage control. Crit Care. 2004;8(Suppl 2):S57.PubMedPubMedCentralGoogle Scholar
  48. 48.
    DuBose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, et al. The AAST Prospective Aortic Occlusion for Resuscitation in trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81:409–19.PubMedGoogle Scholar
  49. 49.
    US Department of Defense. CENTCOM Joint Theater Trauma System (JTTS) clinical practice guidelines. Resuscitative endovascular balloon occlusion of the aorta (REBOA) for hemorrhagic shock. http://www.usaisr.amedd.army.mil/clinical_practice_guidelines.html. Accessed 2 May 2019.
  50. 50.
    de Schoutheete JC, Fourneau I, Waroquier F, De Cupere L, O'Connor M, Van Cleynenbreugel K, et al. Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment-technical and methodological aspects. World J Emerg Surg. 2018;13:54.Google Scholar
  51. 51.
    Biffl WL, Smith WR, Moore EE, Gonzalez RJ, Morgan SJ, Hennessey T, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg. 2001;233(6):843–50.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Burlew CC, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011;212(4):628–35 discussion 35-7. PubMedGoogle Scholar
  53. 53.
    Martinelli T, Thony F, Declety P, Sengel C, Broux C, Tonetti J, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma. 2010;68(4):942–8.Google Scholar
  54. 54.
    Biffl W, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma. 2011;78:1054–8.Google Scholar
  55. 55.
    Burlew CC, Moore EE, Moore FA, Coimbra R, McIntyre RC Jr, Davis JW, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359–63.PubMedGoogle Scholar
  56. 56.
    Stahel PF, Mauffrey C, Smith WR, McKean J, Hao J, Burlew CC, et al. External fixation for acute pelvic ring injuries: decision making and technical options. J Trauma Acute Care Surg. 2013;75(5):882–7.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Ernest E. Moore Shock Trauma CenterDenver Health Medical CenterDenverUSA
  2. 2.Department of SurgeryUniversity of Colorado School of MedicineAuroraUSA
  3. 3.Department of Surgery, Division of Vascular Surgery and Endovascular TherapyUniversity of Colorado School of MedicineAuroraUSA

Personalised recommendations