Vol. 6.2
1. Manual Pressure Points Technique for Massive Hemorrhage Control—A Prospective Human Volunteer Study. Gavriely RP, Lior Y, Gelikas S, et al. Prehospital Emergency Care 2023;27:586-591.
2. Prehospital tourniquet placement in extremity trauma. Gushing J, Blair SG, Albrecht RM , et al. Am J Surg 2023 Article in press https://doi.org/10.1016/j.amjsurg.2023.08.007
3. Efficacy of the Military Tactical Emergency Tourniquet for Lower Extremity Arterial Occlusion Compared with the Combat Application Tourniquet. Samutsakorn D, Carius B. J Spec Operations Med. 2023; 23(2):36-39.
4. Temporal changes in the prehospital management of trauma patients: 2014-2021. Bradford JM, Teixeira PG, Dubose J, et al. Am J Surg. 2023, Article in press.
International Prehospital Medicine Institute Literature Review, September 2023
1. Manual Pressure Points Technique for Massive Hemorrhage Control—A Prospective Human Volunteer Study. Gavriely RP, Lior Y, Gelikas S, et al. Prehospital Emergency Care 2023;27:586-591.
Elevation of extremities and pressure points once widely recommended were dropped from bleeding control protocols over a decade ago.
Tourniquets and wound packing, with or without hemostatic dressings, are effective methods for hemorrhage control for wound of the limbs. Junctional hemorrhage poses are more difficult hemorrhage control challenge. While a variety of junctional tourniquets are available, their assembly and use can be difficult if not practiced in advance.
The authors hypothesized that manual compression at pressure points may be helpful in managing junctional hemorrhage. In this prospective, non-randomized study, human volunteers were used. The volunteers were assigned to be either responders or patient models. The responders were trained to apply supraclavicular and femoral pressure points. Pulse wave Doppler was used to measure blood flow at the brachial and posterior tibial arteries and baseline determinations of arterial flow velocities were performed on the patient models. The primary outcome measure was complete cessation of arterial blood flow distal to the compression site within 2 minutes of compression application. Compression was to be maintained for 3 minutes.
The study involved 38 subjects and all but three of them participated once as a patient model and once as a responder. The initial success rates at applying MPP or Manual Pressure Points to both femoral and supraclavicular arteries was 97.1%. Responders were faster at applying pressure to the femoral site than the supraclavicular site (5.5 + 4.3 vs. 12.5 + 20.9 seconds). They were also able to maintain the pressure at the femoral location longer into the three minute measurement period compared to the supraclavicular site (98.7% vs. 76.2% of the 3 minute period).
Limitations of this study include the fact that this was a controlled environment rather than a live or clinical situation. Not all potential pressure points were studied. Finally, all of the study participants were young able bodied, combat medics and further studies should determine the effectiveness across a broader demographic sampling.
In their conclusion, the authors state that “Manual pressure on the supraclavicular and femoral points is an applicable and efficient method for temporary hemorrhage control distal to the pressure point.” Further study could lead to this technique being reconsidered for inclusion in prehospital education and protocols.
2. Prehospital tourniquet placement in extremity trauma. Gushing J, Blair SG, Albrecht RM , et al. Am J Surg 2023 Article in press https://doi.org/10.1016/j.amjsurg.2023.08.007
The reemergence of tourniquet use in the military, along with its adoption by EMS systems and first response systems in the last ten years has saved countless lives. The American College of Surgeons Stop the Bleed campaign has trained and empowered civilians in the application of tourniquets when faced with life threatening bleeding prior to EMS and first responder arrival. The authors of this retrospective study examined the appropriateness and effectiveness of tourniquets applied prior to hospital arrival as well as the type of responder placing the device.
During the 54 month study period ending June 30, 2022, there were 226 patients who presented to the emergency department of the level 1 trauma center with a tourniquet applied prior to arrival. Fifteen patients were excluded from the study due to age, death, or incomplete data. This resulted in 221 patients being enrolled in the study group. Information collected in the prehospital phase of patient care included vital signs (systolic blood pressure, heart rate), wound packing with specific dressing material used, tourniquet information including commercial vs. non-commercial, second tourniquet application if needed, location and time of application and documentation of wound type.
The predominant mechanism of injury was penetrating trauma, with gunshot wounds dominating at 34% of the total tourniquet applications. Wounding locations were above the knee (33.7%), below the elbow (25.6%), below the knee (24%) and above the elbow (16.5%). Of note, 5 patients had the tourniquet place at or below the site of the wound.
The majority of the tourniquets used were commercial CAT type (76%). The remaining were either field expedient/improvised non-commercial tourniquets or were not documented. Nearly 60% of the tourniquets were placed by EMS with the remaining placed prior to EMS arrival. Law enforcement personnel placed 67 of those applied prior to EMS arrival and the remaining 22 placed by laypersons or other medically trained non-EMS personnel. Wound packing was attempted in 36% of patients prior to tourniquet application. The total mean tourniquet time was just over 60 minutes. Assessment of the appropriateness of the indication for tourniquet placement revealed that only 75 of 211 patients had an indication for tourniquet application.
Fifty-nine (36%) of the patients with a tourniquet in place had palpable pulses on initial examination by the physician in the emergency department (ED). After removal of the tourniquet 89 (43.8%) patients had bleeding documented in the Emergency Department. Of those that were bleeding, 81 (74.3%) had arterial bleeding and 28 (25.7%) were venous. Of the group, 92 required surgical intervention, 19 were admitted to the ICU, 32 to a general floor and 2 to other units. Of the cohort, 53 were discharged to home with one (1) signing out against medical advice. Thirty-seven (37) patients received some type of blood product during their time in the hospital.
This study is limited by the fact it involved only one trauma center and depended on retrospective review of available data which were limited in some cases.
It is clear that tourniquets save lives, but as with any medical procedure, especially those performed by the lay public or minimally trained first responders, the overuse or improper application of a technique or procedure cannot be overlooked. This study demonstrated that 36% of the study group had palpable distal pulses at arrival at the hospital. This finding clearly demonstrates either an application or a reassessment issue that should be addressed. When evaluated in the ED, 25% of patients had only venous bleeding noted. The application of direct pressure was not specifically reported and wound packing was only attempted prior to tourniquet application in slightly over one-third of the patients. It should be noted however that in 25% of the cases the reason for tourniquet application was documented as bleeding not controlled by pressure. These observations do not take into account scene logistics or care under fire scenarios where the tourniquet may be the logical first choice during a gun battle. This study does demonstrate that training and training reinforcement is needed across all levels of care provided by all responder levels in the prehospital environment.
3. Efficacy of the Military Tactical Emergency Tourniquet for Lower Extremity Arterial Occlusion Compared with the Combat Application Tourniquet. Samutsakorn D, Carius B. J Spec Operations Med. 2023; 23(2):36-39.
The Combat Application Tourniquet (CAT) was the first of a number of tourniquets that are recommended by the Committee on Tactical Combat Casualty Care (CoTCCC). These devices have been tested and proven to be reliable at quickly controlling exsanguinating extremity hemorrhage. As demand for CAT tourniquets has increased and their use has moved into the civilian marketplace, counterfeit and look alike CAT tourniquets have begun to emerge on the open market. These look alike tourniquets are often lower priced than the original CAT tourniquet and frequently sold via web-based retailers. Cheaper devices may be the result of reduced quality of materials, engineering, or manufacturing processes. Tourniquet failure or delay in successful application can result in the loss of lives from uncontrolled exsanguinating hemorrhage.
This study compared the efficacy and ease of use of one such CAT look alike tourniquet, the Military Tactical Emergency Tourniquet (MTET) to the CAT. Both devices meet the CoTCCC’s requirement that they be 3.81 cm in width or greater, creating the inverse relationship with the necessary pressure to stop arterial blood flow. Visually both devices appear almost identical with the MTET being offered at approximately half the price of the CAT.
The authors conducted a randomized crossover trial using volunteer US Army Combat Medic instructors at Joint Base San Antonio – Fort Sam Huston. Volunteer participants were excluded if they had documented injuries to their lower extremities or had physical limitations that challenged their ability to effectively place a tourniquet. Basic demographics were collected from each of the 50 volunteers (86% male, 14% female with a median age of 33). Additionally, their thigh circumference was measured (medium circumference of 53 cm) and a Doppler device was used to locate and mark their dorsalis pedis pulses. All volunteers were well practiced in placing CAT tourniquets with a goal of stopping all arterial blood flow distal to the tourniquet.
The study participants were randomly split into four cohorts (right leg first CAT, left leg first CAT, right leg first MTET and left leg first MTET). Cohorts were given a new tourniquet and instructed to effectively place it mid-thigh on their designated leg. They were not told which device they would be using, either the CAT or MTET. They were timed on how long it took to apply the tourniquet and tighten it to a point that the participant felt completely occluded distal blood flow. The Doppler device was then used over the pre-marked dorsalis pedis site to determine if blood flow was indeed stopped. The tourniquet was then removed, and same test repeated on their other leg using the other of the two tourniquets being studied.
The CAT was successfully applied in less than 60 seconds, with a complete occlusion of blood flow to the dorsalis pedis artery by all 50 study participants (100%). The MTET was placed successfully by 40 participants (80%) with a mean application time greater than the CAT (29 seconds for the CAT and 35.3 seconds for the MTET). All MTET failed applications exceeded 60 seconds. Observed mechanical reasons for MTET failures included torn stitching, flawed buckles and bent windless rods.
One of the limitations of this work was the prior familiarity the volunteers had with the CAT tourniquet. Additionally, although the participants were not told which tourniquet they were given, they were obviously not truly blind to which tourniquet they were self-applying to their thigh.
Individuals purchasing limb tourniquets for public safety agencies, military units, or for personal use need to remember the adage “if a deal looks too good to be true, it probably is”. While purchasing agents need to remain fiscally responsible, they also have a responsibility to provide the proper resources and devices to the end user. In the case of extremity tourniquets, it is wise to remain loyal to CoTCCC recommended devices which have undergone rigorous testing.
4. Temporal changes in the prehospital management of trauma patients: 2014-2021. Bradford JM, Teixeira PG, Dubose J, et al. Am J Surg. 2023, Article in press.
Prehospital providers have a myriad of treatment options available for the management of the severely injured trauma patient. Recent research suggests many of these interventions do not improve outcomes and may worsen outcomes. Prehospital endotracheal intubation (ETI) has not been shown to improve outcomes in patients with severe traumatic brain injury (TBI) compared to less invasive airway management. Prehospital intravenous (IV) crystalloid fluids worsen mortality in patients with penetrating trauma. Routine prehospital spine immobilization may contribute to longer scene times, more difficult airway management, increased intracranial pressure, and pressure ulcers over time. However, some more recent prehospital interventions may improve outcomes. Prehospital tourniquet application in penetrating trauma results in less blood product transfusions and fewer limb-related complications. Hypotensive patients who receive prehospital plasma, packed red blood cells (PRBC) or whole blood have lower mortality compared to those receiving crystalloid fluids.
The aim of this study is to quantify the frequency of prehospital interventions (PHI) performed by EMS from 2014 to 2021. An additional aim of the study is to assess the impact of these changes on mortality. The authors hypothesized that the frequency of PHI increased over time, but that no PHI independently improved ED or in-hospital mortality.
This was a retrospective chart review of adult trauma patients (aged 18-89 years) transported from the scene to an American College of Surgeons (ACS) verified Level 1 trauma center in Austin, TX. The annual frequency of PHI was calculated as the ratio of total annual interventions over annual transports.
A total of 3035 patients were included in the study, of which blunt injury accounted for 66% and 34% had penetrating injury. Between the first and last year of the study period the frequency of the following interventions increased: thoracostomy (6% vs 9%), pelvic stabilization (1% vs 13%), tourniquet application (4% vs 12%), TXA administration (0.3% vs 33%), whole blood administration (0% vs 20%), and plasma administration (0% vs 1%). The following procedures decreased from the first to last year of the study period: advanced airway procedures (21% vs 12%), IV crystalloid administration (57% vs 36%), cervical collar placement (66% vs 43%), and backboard placement (75% vs 27%). During the study period, ED mortality decreased (11% vs 8%) and in-hospital mortality decreased (20% vs 13%). On multivariate analysis which adjusts for potentially confounding variable, no single PHI was independently associated with an increase or decrease in mortality.
The authors demonstrate a significant change in prehospital practices for the care of the trauma patient from 2014 to 2021. In this system, the frequency of advanced airway procedures, spinal motion restriction, and IV fluid administration decreased while whole blood transfusion, pelvic stabilization, tourniquet application, and TXA administration increased. No prehospital intervention was associated with an improvement or decrease in survival.
This study has several limitations. It is a retrospective study and limited to the inherent deficiencies of that type of study. It is a single-center study and may not be applicable to all trauma centers. Additionally, this study was done in an advanced EMS system and the results may not apply to other types of EMS systems.
This study demonstrates the changes in EMS trauma care over time. More advanced care now includes blood and TXA administration with less emphasis on spine immobilization, crystalloid use, and advanced airway techniques. The trend shows an overall decrease in ED and in-hospital mortality, although the authors were unable to demonstrate an overall benefit from any one particular intervention. Further studies are definitely warranted.
