Photos courtesy Jonathon Hedrick
- Describe the steps of escalating hemorrhage control.
- Recognize the difference between venous and arterial hemorrhaging.
- Explain the importance and utility of invasive hemorrhage control methods in the prehospital environment.
- Arterial hemorrhage: Loss of blood associated with a disruption to the integrity of a moderate caliber artery.
- Mean arterial pressure (MAP): An averaging of the force exerted on an artery's wall during one cardiac cycle.
- Venous hemorrhage: Loss of blood from a disruption in a vein.
Since the birth of prehospital emergency medicine, treating people for trauma has been a paramount focus. Much of this profession's existence has been necessitated by needing to get injured people stabilized and to definitive care quickly.
During our initial training, most of us likely spent several classes learning about how EMS came to be: the first transporting EMS system on the French battlefields during Napoleon's reign; and more importantly, the 1966 white paper, Accidental Death and Disability: The neglected disease of modern society, that began conversation about the need for a U.S. trauma system and a developed EMS delivery model. The white paper reported that nearly 110,000 people were dying yearly from trauma, and many of the deaths could likely be prevented by access to definitive surgical care.1
Even with all the advances in prehospital emergency medicine, traumatic injury still represents a leading cause of death in persons under the age of 45.2
When isolated non-survivable traumatic brain injury is removed from the equation, massive hemorrhage and subsequent exsanguination remains the leading the cause death from traumatic injuries overall.3,4
Many of these hemorrhagic deaths are potentially avoidable if the patients are able to reach an operating room expeditiously. Most of these deaths are a consequence of internal hemorrhage,5 which prehospital management offers little definitive care aside from early recognition and rapid transport in most cases.
However, even when specifically looking at severe, uncontrolled external hemorrhage, the burden of death is nearly 80%.6
A blistering prospective review of all traumatic deaths in Berlin found a majority of preventable deaths occurred due to ineffective external hemorrhage control in the prehospital setting.7 Although this study looked at an isolated system with a potentially isolated problem, it's a good jumping off point.
Simple but severe hemorrhage has been a leading cause of death for the entire existence of human life, and yet we still can't stop the bleeding! With all of the devices, medications and therapies available to our field, why in the world is direct pressure still the mainstay of severe hemorrhage control? Sadly, this very point echoes the haunting line from Jullette Saussy, MD's, recently publicized resignation letter from the D.C. Fire and EMS: "People are dying needlessly because we are moving too slow."8
However, make no mistake; this article is one of optimism, not pessimism. There are new technologies, therapies and techniques readily at our disposal that can make a significant difference in our practice and in the lives and outcomes of our patients. However, I challenge you: As you read this article and others published by JEMS, are you going to take this information and say, "Hmmm, that's interesting," or are you going to take this information and go to your medical directors and operations managers and say, "We aren't moving fast enough!"?
Anatomy & Physiology
When considering severe, life-threatening external hemorrhage in the prehospital setting, we're almost always speaking of arterial hemorrhage. In particular, hemorrhage associated with a disruption to the integrity of a moderate caliber artery.
The larger the artery, the greater the force being exerted on the vessel wall by the mean arterial pressure (MAP): an averaging of the force exerted on an artery's wall during one cardiac cycle.
The closer an artery is to the left ventricle, the greater the force exerted on that vessel's wall. The more proximal an arterial vessel is to the heart, the greater the amount of force needed to tamponade the vessel and stop hemorrhage. For example, in the case of femoral artery hemorrhage, it would take at least 120 pounds of pressure proximal to the injury to stop the hemorrhaging.9 (See Figure 1, below.)
The force exerted by a vessel's MAP is complicated by the caliber of the vessel. Not only does the MAP increase as you travel proximally along a vessel, but so does the vessel's diameter and blood-carrying capacity.
For this reason in particular, treat any apparent arterial hemorrhage with a source more proximal than the distal third of an extremity as an imminent life threat. Anytime blood is seen spurting or pulsing at an injury site, it should be presumed arterial until proven otherwise. These injuries warrant immediate attention. The speed and pressure of the hemorrhage at these sites can become life-threatening in just moments.
Venous hemorrhage is much more controllable. Anatomically speaking, most veins are more superficial when compared to their arterial counterparts. The pressure within the venous system is much lower. Additionally, the histological makeup of a vein's wall is nowhere near as elastic as an artery. These factors make veins much more susceptible to mechanical compression. Venous hemorrhage, even from large caliber vessels, is typically controllable via direct pressure, but warrants aggressive management all the same.
If the patient is still bleeding after a basic maneuver is deployed, quickly escalate your care.
Hemorrhage and exsanguination account for one of the greatest proportions of trauma deaths in the prehospital setting. In fact, exsanguination is the most common cause of death in trauma patients who die prior to the arrival of EMS. Hemorrhage is also responsible for the largest number of trauma-related fatalities within the first hour of arrival at a trauma center, 80% of operating room deaths, and 50% of deaths within the first 24 hours of definitive trauma care.3
Although it's impossible to correspond exact amounts of blood loss to prognosis, it has certainly been well-demonstrated that as blood loss increases, so does the incidence of hypotension, acidosis, hypothermia, multisystem organ failure and subsequent death.3 At the risk of sounding overly cliché, uncontrolled minor hemorrhage only adds insult to injury in the face of severe hemorrhage at another site.
Approaches to Therapy
All of the approaches to definitively controlling external hemorrhage have their pros and cons, each modality has its risks and benefits, every product has advantages and disadvantages when compared to the next, and none of these I consider the "gold standard" in hemorrhage control. However, let me make this point: definitively stopping all blood loss in patients with severe hemorrhage is the gold standard.
Aggressively managing the airway has typically been taught as the first priority when caring for a trauma patient. However, in trauma situations where there's severe hemorrhage-or the potential for severe hemorrhage-providers should consider adapting the traditional Pre-Hospital Trauma Life Support/Advanced Trauma Life Support (PHTLS/ATLS) approach to the primary survey. A C-ABCDE approach, where the initial "C" stands for "control massive hemorrhage," is more appropriate for patients with severe external bleeding.10 The reasoning behind this shift in dogma is simple: a trauma patient will die in mere seconds from a groin wound that results in a femoral artery hemorrhage;9 however, it takes 3-5 minutes for a patient to die from anoxia secondary to an obstructed airway.
Regardless of the approach, preparation and planning is of the utmost importance. Simulation and practice with hemorrhage control devices such as tourniquets or hemostatic agents is hugely important, and frequent review of the procedure for their deployment is key to successful hemorrhage control.
Planning begins with the dispatch and pre-arrival information. If your dispatch information is scant or limited at best, take the time to advocate for your patients and your practice, and make a push for improved pre-arrival information. "Details to follow," "details PRN," and "information provided as needed" aren't acceptable.
Figure 1: The left femoral triangle
Once the dispatcher has provided a mechanism of injury, location of injury, and a general description/severity of injury, you should begin to plan treatments. In particular, how your treatments are going to escalate care and what the triggers for escalation are going to be.
If the patient is still bleeding immediately after a basic maneuver is deployed, quickly escalate your care. This is no time for titration or a wait-and-see approach. At the first indication that hemorrhaging is persisting, it's time to get more aggressive and get more invasive. Don't waste precious seconds trying to decide if a tourniquet is needed.
Most venous hemorrhages or simple arterial hemorrhages from the distal third of an extremity are generally well controlled with an absorbent bandage placed directly over the wound and digital pressure applied directly to the source of the bleeding and maintained for 3-5 minutes. Bleeding should immediately cease. Commercial devices that apply local pressure to the site of the bleeding can be extremely helpful with these wounds, as maintaining uninterrupted direct pressure in the transport setting can be problematic.10
Although elevation is generally not recommended for the treatment of significant hemorrhage, these distal extremity wounds benefit from elevation. Compression of the proximal pulse point may also be beneficial. In particular, consider pulse point compression and elevation to be a temporary bridge to other therapies. Maintaining any of these modalities while in a moving ambulance or helicopter may not be possible or in the best interest of the patient's outcome and provider's safety.
These arterial hemorrhages are proximal to the distal third of an extremity or any complicated arterial hemorrhage such as a mangled limb. Any artery from this location should be considered an immediate life threat. Direct pressure will certainly be your first go-to. However, if not immediately effective, move to a commercial tourniquet.11 Place the tourniquet about three inches proximal to the wound and tighten it until distal pulses are lost and the wound ceases to hemorrhage. For most extremity hemorrhages, this treatment is safe and incredibly effective.11
For proximal extremity wounds, mangled extremities, and especially junctional wounds (e.g., groin, axilla, shoulder and neck), tourniquets may not be effective or even applicable. These wounds must be immediately packed, preferably with gauze impregnated with a hemostatic agent.11
There are several methods available for effective wound packing but I won't discuss them here because many systems still don't allow for wound packing by EMTs or even paramedics. Regardless of the method or product used, wounds must be fully packed and direct pressure must be held on the site of the wound for five minutes. The wound should be dressed and snuggly wrapped if possible.
Splinting can also be of great utility in many of these scenarios. Extremity immobilization helps maintain anatomical position and natural blood flow, which may help direct blood to another vessel away from the hemorrhage site. For instance, in the case of a lacerated radial artery, maintaining the wrist's natural position ensures patency of the ulnar artery, ensuring that injury site isn't under more pressure than it normally would be. Immobilization may also help prevent dislodging a formed clot.
For pelvic and femur fractures, hemorrhage is always a significant concern. Even though these are usually forms of internal hemorrhages, prehospital splinting may help blunt internal blood loss. Simply realigning the bones helps to reduce hematoma accumulation at the fracture site. Splinting also maintains some semblance of the bone's natural integrity, possibly also helping to minimize severe bleeding.
There are some novel therapies that are showing great promise.
The self-expanding polymer foams/sponges are an interesting option. When packed into a wound, these products are able to absorb 30 times their weight in water while rapidly expanding many times their size.12 This action serves two purposes: 1) the expansion provides compression and tamponade-like force onto the source of hemorrhage; and 2) by absorbing water from the hemorrhage source, they concentrate blood products naturally used by the body for clotting. They show promise as a form of damage control hemostasis in open thoracic and abdominal trauma (i.e., gunshot wounds and stab wounds).12
A new therapy with perhaps the greatest potential of controlling severe and massive hemorrhage is a group of products known as procoagulant supplementors.12 These dressings are impregnated with highly concentrated human clotting factors and calcium. These dressings outperform most other hemostatic agents at immediately stopping hemorrhage and promoting wound clotting, but because they contain human-derived biologically active compounds, they're estimated to be nearly 100 times more expensive than other current products.12
As simple and basic as hemorrhage control should be, there's a fair amount of minutia and nuance to effectively stopping the bleeding. As with all things in EMS, the devil is in the details and in your critical thinking and decision-making.
Think of hemorrhage control as a staircase. Minor hemorrhages only needing a simple dressing are on the floor below the stairs. Junctional hemorrhages, where the risk of death from exsanguination is only moments away, should make you want to run to the top of the stairs and completely pack the wound with a hemostatic gauze and apply strong pressure.
If your protocols or scope of practice don't allow for wound packing, bring this article and others like it to the attention of your medical director and advocate for the advancement of prehospital emergency medicine. Our profession, careers and patients deserve the kind of advocacy the pushes boundaries and challenges the status quo. As we've seen too many times in recent years, doing something because it's the way we've always done it is a dangerous way to practice medicine.
1. National Academy of Sciences and National Research Council: Accidental death and disability: The neglected disease of modern society. National Academies Press: Washington, D.C., 1966.
2. Centers for Disease Control and Prevention. (June 24, 2015.) Leading causes of death reports, national and regional, 1999-2014. Retrieved April 1, 2016, from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html.
3. Kauvar D, Lefering R, Wade C. Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3-S11.
4. World Health Organization. (2002.) Injury: A leading cause of the global burden of disease, 2000. Retrieved May 12, 2016, from www.who.int/violence_injury_prevention/publications/other_injury/injury/en/.
5. MacKenzie E, Rivara F, Jurkovich G, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366-378.
6. Rhee P, Brown C, Martin M, et al. QuikClot use in trauma for hemorrhage control: Case series of 103 documented uses. J Trauma. 2008;64(4):1093-1099.
7. Kleber C, Giesecke MT, Tsokos M, et al. Trauma-related preventable deaths in Berlin 2010: Need to change pre-hospital management strategies and trauma management education. World J Surg. 2013;37(5):1154-1161.
8. Hermann P. (Feb. 9, 2016.) D.C. Fire Department medical director resigns, delivers scathing exit letter. The Washington Post. Retrieved April 1, 2016, from www.washingtonpost.com/local/public-safety/dc-fire-departments-medical-director-resigns/2016/02/09/e8c8edd0-cf6f-11e5-88cd-753e80cd29ad_story.html.
9. Blaivas M, Shiver S, Lyon M, et al. Control of hemorrhage in critical femoral or inguinal penetrating wounds - An ultrasound evaluation. Prehosp Disaster Med. 2006;21(6):379-382.
10. Sharpe D, Barneby E, Russell R. New approaches to the management of traumatic external hemorrhage. J Trauma. 2011;13:47-55.
11. Bulger E, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163-173.
12. Granville-Chapman J, Jacobs N, Midwinter M. Pre-hospital haemostatic dressing: A systematic review. Injury. 2011;42(5):447-459.