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Hemorrhage Control

From EverybodyWiki Bios & Wiki


Traumatic hemorrhage is “the leading cause of preventable death” among trauma patients.[1], it accounts for 40% of mortality[2], 85% of who die before leaving the emergency department[3]. Improved hemorrhage control has been shown to significantly improve patient outcomes[4], and control of deadly bleeding should be the first priority[5]. Hemorrhage control measures will vary by training level and clinical setting.

Direct pressure[edit]

The first step to stopping a bleed is to provide direct pressure. Although there is a paucity of research to support how best to perform the skill[6] all major trauma textbooks recommend it as the first intervention[7][8]; they don't specify however: how hard or for how long to push, what to push with. The American College of Surgeons’ (ACS) Hartford Consensus offers the following guideline for how hard to push: “use both hands… press as hard as you can”[9]. Recommendations for how long to hold pressure vary; but generally speaking a minimum five to ten minutes[10] with a move to more aggressive measures if hemorrhage control fails after one minute[11] are generally accepted standards, although neither recommendation is based on clinical research. The best evidence may come from a meta-analysis of hemostat devices that found an average of 20 minutes was needed for hemostasis[12].

Dressings[edit]

Direct pressure is typically applied while using a dressing. Dressings can be manufactured, or improvised, hemostatic or non-hemostatic. Hemostatic dressings contain pro-coagulants to speed clotting time, with different dressings speed coagulation in different ways

Unlike specialty dressings there is a paucity of literature comparing hemostasis, infection rates, or ease of use between different traditional dressings, as such traditional dressings can be considered equivalent[13]and any dressing that allows for the application and maintenance of direct pressure to the wound, while offering absorbency and protection from contamination should be used. Dressings should not be layered[14]. Layering diffuses pressure and may hasten bleeding rates by increasing the capillary action of the dressing[15]. If dressings becomes saturated hemorrhage control measures should be assessed to ensure pressure is being directly applied to the wound, and to assess if measures need to be escalated with wound packing or by using a tourniquet.

Wound Packing[edit]

Wound packing increases direct pressure on injured vessels within the wound. The ACS recommends packing as next step for small bleeds not controlled with direct pressure, for large open wounds, or for injuries at the junction of trunk and limb[16]. To pack a wound clean cloth, gauze or hemostatic dressing should be pressed as deeply and firmly into the wound as possible until the wound is completely filled[17]. Once the wound is packed it should be covered with a dressing and the highest possible level of direct pressure maintained bimanually or through tight bandaging.

Bandages[edit]

Bandaging is used to bind wounds and maintain pressure. Experimental data suggests that bandaging with an elastic bandage maintains a higher average direct pressure on the wound bed (88 mmHg) than inelastic dressings (33 mmHg)[18]. Dressings with an integrated “pressure bar” to focus pressure can result in a three-fold increase in direct pressure[19], with case reports suggesting that improvised “pressure bars” may also be beneficial[20], although these dressings have been widely used by western militaries with good effect, experimental data to demonstrate their superiority to other dressings is lacking. Research does shows however that elasticized bandages can be safely used without producing a tourniquet effect on limbs, and that when compared against direct pressure or cloth bandage, they maintain a higher and more consistent pressure and stayed in place better[21][22]. These bandages can improvised by firmly pressing gauze to the wound, and wrapping a tensor bandage as tightly as possible, over the smallest area possible with increasing tension[23]

Tourniquets[edit]

Although Tourniquets have been successfully used for hundreds of years, until very recently they have been considered a measure of last resort due to their perceived risk for limb damage[24]. There is excellent evidence showing tourniquets to be safe and effective, with a very low risk for complication in both military[25], and civilian use[26]. Tourniquets are circumferential bands placed on long bones (never over a joint) proximal to extremity wounds, that are tightened until arterial blood flow (and therefore bleeding) is stopped. Tourniquets can be improvised or commercially manufactured, but commercial tourniquets have more evidence to support their use[27]. Incorrectly applied tourniquets may result in venous only tourniquet, and will result in increased venous pressure and dilation, which will hasten bleeding[28]. Care must be taken to ensure adequate pressures are generated to stop the bleed and ensure pulses are no longer palpable, the time of application should be noted, and the tourniquet left in place until definitive management of the bleed can be achieved[29]. If hemorrhage control is not achieved with one tourniquet, an additional tourniquet should be placed in the same manner proximal to the first tourniquet.

See also[edit]

References[edit]

  1. ↑ Spahn, D. R., Bouillon, B., Cerny, V., Coats, T. J., Duranteau, J., Fernández-Mondéjar, E., ... & Neugebauer, E. (2013). Management of bleeding and coagulopathy following major trauma: an updated European guideline. Critical care, 17(2), R76.
  2. ↑ Curry, N., Hopewell, S., Dorée, C., Hyde, C., Brohi, K., & Stanworth, S. (2011). The acute management of trauma hemorrhage: a systematic review of randomized controlled trials. Critical care, 15(2), R92.
  3. ↑ Tien, H. C., Spencer, F., Tremblay, L. N., Rizoli, S. B., & Brenneman, F. D. (2007). Preventable deaths from hemorrhage at a level I Canadian trauma center. Journal of Trauma and Acute Care Surgery, 62(1), 142-146.
  4. ↑ Kragh Jr, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of surgery, 249(1), 1-7.
  5. ↑ Forrest, M., Lax, P., van der Velde, J. (2014). Anesthesia, Trauma, and Critical Care Course Manual 2014. Retrieved from https://www.ataccgroup.com/wp-content/uploads/2017/04/ATACC-Manual-version-8-low-resolution-v2.pdf
  6. ↑ Naimer, S. A., Anat, N., Katif, G., & Team, R. (2004). Evaluation of techniques for treating the bleeding wound. Injury, 35(10), 974-979.
  7. ↑ Assid, P., Blank-Reid, C., Bokholdt, M., Brathcer, C., Cornell, A., … Wolff, A. (2014). Trauma Nursing Core Course (TNCC) Provider Manual (7th Ed). Des Plains, IL. Emergency Nurses Association.
  8. ↑ Rotondo, M., Fildes, J., Brasel, K., Kortbeek, J., Al Turki, S., … McIntyre, C. (2012). Advanced Trauma Life Support (ATLS) Student Course Manual (9th Ed). Chicago, IL. American College of Surgeons.
  9. ↑ Pons, P., Jacobs, L., SAVE A LIFE: What Everyone Should Know to Stop Bleeding After an Injury. (2017). American College of Surgeons
  10. ↑ Day, M. W. (2016). Control of Traumatic Extremity Hemorrhage. Critical care nurse, 36(1), 40-51.
  11. ↑ Forrest, M., Lax, P., van der Velde, J. (2014). Anesthesia, Trauma, and Critical Care Course Manual 2014. Retrieved from https://www.ataccgroup.com/wp-content/uploads/2017/04/ATACC-Manual-version-8-low-resolution-v2.pdf
  12. ↑ Dahal, K., Rijal, J., Shahukhal, R., Sharma, S., Watti, H., Azrin, M., ... & Lee, J. (2017). Comparison of Manual Compression and Vascular Hemostasis Devices after Coronary Angiography or Percutaneous Coronary Intervention through Femoral Artery Access: A Meta-analysis of Randomized Controlled Trials. Cardiovascular Revascularization Medicine.
  13. ↑ Picard, C. (2017). Hemorrhage control, a fundamental skill: a review of direct pressure, dressings, wound packing, and bandages for life saving. The Canadian Journal of Emergency Nursing, 40(2), 26-27.
  14. ↑ Forrest, M., Lax, P., van der Velde, J. (2014). Anesthesia, Trauma, and Critical Care Course Manual 2014. Retrieved from https://www.ataccgroup.com/wp-content/uploads/2017/04/ATACC-Manual-version-8-low-resolution-v2.pdf
  15. ↑ Holley, J., Filips, D. (2014). 10 Hemorrhage Control Myths. Journal of Emergency Medical Services, 39, 12
  16. ↑ Pons, P., Jacobs, L., SAVE A LIFE: What Everyone Should Know to Stop Bleeding After an Injury. (2017). American College of Surgeons
  17. ↑ Pons, P., Jacobs, L., SAVE A LIFE: What Everyone Should Know to Stop Bleeding After an Injury. (2017). American College of Surgeons
  18. ↑ Naimer, S. A., Anat, N., Katif, G., & Team, R. (2004). Evaluation of techniques for treating the bleeding wound. Injury, 35(10), 974-979.
  19. ↑ Shipman, N., & Lessard, C. S. (2009). Pressure applied by the emergency/Israeli bandage. Military medicine, 174(1), 86-92.
  20. ↑ Rudge, W. B., Rudge, B. C., & Rudge, C. J. (2010). A useful technique for the control of bleeding following peripheral vascular injury. Annals of the Royal College of Surgeons of England, 92(1), 77.
  21. ↑ Shipman, N., & Lessard, C. S. (2009). Pressure applied by the emergency/Israeli bandage. Military medicine, 174(1), 86-92.
  22. ↑ Naimer, S. A., Anat, N., Katif, G., & Team, R. (2004). Evaluation of techniques for treating the bleeding wound. Injury, 35(10), 974-979.
  23. ↑ Picard, C. (2017). Hemorrhage control, a fundamental skill: a review of direct pressure, dressings, wound packing, and bandages for life saving. The Canadian Journal of Emergency Nursing, 40(2), 26-27.
  24. ↑ Kragh Jr, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of surgery, 249(1), 1-7.
  25. ↑ Kragh Jr, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of surgery, 249(1), 1-7.
  26. ↑ Scerbo, M. H., Mumm, J. P., Gates, K., Love, J. D., Wade, C. E., Holcomb, J. B., & Cotton, B. A. (2016). Safety and appropriateness of tourniquets in 105 civilians. Prehospital emergency care, 20(6), 712-722.
  27. ↑ Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., ... & White, L. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173.
  28. ↑ Day, M. W. (2016). Control of Traumatic Extremity Hemorrhage. Critical care nurse, 36(1), 40-51.
  29. ↑ Day, M. W. (2016). Control of Traumatic Extremity Hemorrhage. Critical care nurse, 36(1), 40-51.


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