Mohamed is an academic Emergency Physician and EMS director. His main areas of interest are Critical Care, Ultrasound, Prehospital Resuscitation, and Medical Education. Find him on Twitter @HagahmedMD
Aspiring Medical Student and current Critical Care RN. Enjoys everything outdoors but can also be found inside nerding out on her medical education artwork.
The Pre-brief
Hemorrhage is the number one preventable cause of death due to trauma. In exsanguinating trauma, if we change our ABC paradigm to CCAB, we can dramatically reduce the number of deaths due to hemorrhage. Immediate management can be the most critical; therefore, it is important that we encourage and empower our EMS colleagues to provide the best care for patients in the earliest phases of their treatment.
Types and Physiology of Shock
The main classes of shock are the following:
- Cardiogenic
- Distributive
- Obstructive
- Hypovolemic
In massive hemorrhage due to trauma, GI bleed, etc., patients enter a hypovolemic shock state; the degree of shock correlates with how much blood has been lost. There is much controversy over the use of this classification, but it may be helpful for new learners. An easy way to remember the % blood volume lost for each class is by remembering that hemorrhage is the ultimate tennis match for survival!1
As the bleeding patient progresses through these classes of shock, it can be useful to know what signs to look for to determine approximately how much blood has been lost and what treatments could benefit the patient. We should mention that even though this table serves as a general guide, clinicians should take into consideration the individual factors that can alter or even mask the presentation of shock. Think, for example, of an 80 y/o patient who is on beta blockers and digoxin for their A-fib, and now presents with polytrauma and bleeding. A HR < 100 and stable BP in this patient may not necessarily mean they are safe for discharge. The same concept applies to pregnant and pediatric patients who generally compensate well before crashing.
The items circled in red highlight the signs that are newly abnormal for each subsequent class. For example, Class II is present when there is an increased pulse and decreased pulse pressure. The hallmark of Class IV is altered mental status.
What are the basics of hemorrhage control?
While these techniques most certainly work in the prehospital and ED realms, they are also important in the ICU (think accidental arterial stick during central line on an anticoagulated patient).
Direct pressure:
- Placing direct pressure on the wound with a sterile dressing can help to tamponade the bleeding
- Proper technique is important
- Focused force is better than distributed force
- Use your fingers, not your palm
- Continue to apply pressure until the bleeding stops
- Location of pressure application can depend on nature of bleeding
- If arterial, consider placing pinpoint pressure just proximal to the point of bleeding
- Elevate extremity above heart if able
- Don’t check to see if it worked; give venous bleeds 2 to 4 minutes, give arterial bleeds 5 to 10 minutes before checking to see if it worked.
Wound packing:
- For penetrating wounds
- Combine with direct pressure to stop bleeding quicker
- For GSW, wound can be a large cavity into which you can pack lots of gauze
- Better bleeding control sooner
- Be careful not to increase the size of the wound or penetrate into any cavities (peritoneal, pleural, etc.)
Tourniquet use:
- Control arterial blood flow proximally
- Use after trying direct pressure and wound packing (if applicable)
- Many different kinds of tourniquets
- CAT
- RAT
- SOF-T
- MET
- MAT
- EMT
- SWAT-T
- Most amount of research supports the CAT tourniquet
Pelvic Binder:
- Compresses the pelvis in patients with fracture to stop internal bleeding
- Helps tamponade internal bleeding
- Bed sheet can be used as well
- Appropriate placement is important
- Greater trochanter
- May not be as useful in those with lateral compression fractures
Long bone fractures:
- You can lose lots of blood from femur fractures
- Pull traction to anatomic length and splint ASAP to decrease bleeding
- Check neurovascular status distally
So you’ve done your best to control external bleeding, but the patient is still not doing well. What now?
Damage Control Resuscitation
- Permissive hypotension2
- In a bleeding patient, don’t try to aggressively volume resuscitate to reach an SBP of 90 mmHg. Higher blood pressures can accelerate bleeding, prevent clot formation, or dislodge formed clots.
- There is lots of swine hemorrhage research that shows improved outcomes with a lower MAP or SBP target.
- A 2018 systematic review and meta-analysis demonstrated a survival benefit for permissive hypotension (pooled odds ratio 0.7 with 95% CI 0.53 – 0.92). Permissive hypotension may offer a survival benefit over conventional resuscitation for patients with hemorrhagic injury.3
- Avoid this technique in TBI patients; any episode of hypotension or hypoxia can be detrimental.
- There is some controversy over this technique.
- Early blood products
- If the patient is bleeding, don’t waste time giving the patient salt water; give them what they are losing: blood.
- As there are risks with blood, it may be reasonable to try a liter of lactated ringers before moving to blood. Large volumes of crystalloids will dilute coagulation factors and worsen acidosis and hypothermia.
- Remember to use a balanced resuscitation (1:1:1) with platelets and plasma – both contain important components for hemostasis.
- Consider using real-time TEG to guide your resuscitation.
- Assess for anticoagulation use and the need for reversal
- Tranexamic Acid
- TXA stabilizes clots; it does not promote the creation of clots. Therefore, it is crucial that you use mechanical methods of bleeding control first.
- Give within three hours of the injury
- May have benefit in mild to moderate TBI (GCS 9 -15)
- Damage control laparotomy4
- A prolonged operation in a patient with profound physiological derangements should be avoided.
- Instead, a focused procedure is performed to obtain quick control of any bleeding and repair major wounds.
- Definitive repair is performed in a subsequent operation after the patient’s physiology is improved.
The Debrief
- Hemorrhage control is a crucial skill for any clinician, regardless of trade. In fact, we should be teaching it to the public!
- Recognize signs of shock early
- Direct pressure, wound packing, and tourniquet application can help control external bleeding. Consider a pelvic binder for pelvic fractures and traction splint for long bone fractures.
- Damage control resuscitation can prevent further morbidity and mortality in severe hemorrhage.
Giving a lecture to EMS about bleeding/hemorrhage control. Most important things to address with them/or talk about? @DrRatEMTP @christifulli88 @MRamzyDO @ResusPadawan @mededgene @EMSAvenger @EM_RESUS @srrezaie @EMSwami @emscritcare @EMSWolfpack @EMS1 @emresidents @EMS_Nation
— Shyam Murali (@smuramed) March 10, 2019
References
- Battlefield advanced trauma life support (BATLS). J R Army Med Corps. 2001 Jun;147(2):187-94. doi: 10.1136/jramc-147-02-14. PMID: 11464412.
- Samuels JM, Moore HB, Moore EE. Damage Control Resuscitation. Chirurgia (Bucur). 2017 Sept-Oct;112(5):514-523. doi: 10.21614/chirurgia.112.5.514. PMID: 29088551; PMCID: PMC6231718.
- Tran A, Yates J, Lau A, Lampron J, Matar M. Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2018 May;84(5):802-808. doi: 10.1097/TA.0000000000001816. PMID: 29370058.
- Weber DG, Bendinelli C, Balogh ZJ. Damage control surgery for abdominal emergencies. Br J Surg. 2014 Jan;101(1):e109-18. doi: 10.1002/bjs.9360. Epub 2013 Nov 25. PMID: 24273018.
Great post! Very informative
Great pearls in here. Crystalloids in hemorrhagic shock = No bueno. This study is old, but worth a read: https://www.nejm.org/doi/full/10.1056/NEJM199410273311701