All Bleeding Stops… Eventually

1. Peter D’Souza, MD Jessica Pierog, DO Division of Emergency Medicine Stanford University School of Medicine May 20, 2010 All Bleeding Stops… Eventually

2. Presenters have no financial interest in any of the products or companies discussed in this presentation Disclosures

3. Address the problem of hemorrhage • Review methods of hemorrhage control • Direct Pressure • Pressure Point • Tourniquets • Hemostatic Agents • Describe the controversies regarding hemorrhage control Goals and Objectives

4. The Problem with Hemorrhage • Inadequate organ perfusion • Inadequate tissue oxygenation • ….Death • If recognized early, we can stop or slow the process, saving lives & limbs

5. Direct Pressure • Placing pressure on the wound • Constriction of blood vessels manually • Stem any blood flow

6. Pressure Point • Constriction of the major artery which feeds the point of the bleed

7. Tourniquet • Prototype • 199 BCE-500 CE • Concept & Design • Simple • Materials • If it ain’t broke, don’t fix it

8. History of tourniquets • Roman Empire • 16th Century • First surgical use • Modification • 17th Century • Windlass tourniquet • The Civil War

9. Types of tourniquets • Windlass Mechanism • Crank Used to Cinch • Block and Tackle: • Belt latch and turn key operation • Pneumatic: • Inflatable cuffs provide pressure

10. Temporary (distal ischemia) • Soft tissue injury > 2 hr • Irreversible injury > 6 hr • Tension/limb circumference ratio • Wider is better • Label date/time of application • Communicate Effective Tourniquets

11. Time proportional to tissue damage Complications: a function of time

12. 550 injured prehospital • Tourniquets applied to 91 (16%) • In < 15 minutes in 88% of cases • Almost no complications • Ischemic time 83 ± 52 min • Conclusion: • Effective & easily applied (by medical & nonmedical personnel) for preventing exsanguination in the military prehospital setting.

13. 499 patients, 862 tourniquets on 651 limbs • Conclusion: • Early tourniquet application, before the onset of shock, saves lives with little to no associated complications

14. Tourniquet = amputation Only for extremities that will be amputated Last resort Only indicated in shock The myths

15. The truth will set you free: • The Research • Surgical & Animal TQ studies • NOT Hemorrhage/amputation model • Amputations from TQ placement • Are rare • Prehospital TQ placement before onset of shock associated with survival • Amputations may not require a TQ • Mangled/crushed/penetrating injuries • May benefit

16. Don’t just ‘Set it and forget it’ • Gauge tension • Re-bleeding • Resuscitation is a dynamic process Improving outcomes: Primum non nocere

18. Do they work? • Standard part of most curriculums • Can be effective if done correctly • But, what are the challenges to these techniques? • Do you have any other tasks to perform? • How long do you have to hold pressure? • Which patients can you use this on? • Single system vs. Polytrauma Direct Pressure and Pressure Point

19. Single System vs. Polytrauma

20. They do free up the provider to perform other tasks and can be effective • Much of their use has been in blast injuries involving massive tissue loss • These injuries are not common in the civilian population • Tourniquets are not without side effects What About Tourniquets

21. Tourniquet use can result in venous complications • Increased bleeding if improperly applied • Thrombosis from venous stasis • Compartment syndrome – may be due to injury itself • Pain from tourniquet itself

22. Ideally, you want to stop the bleeding – “just set it and forget it” • Bleeding, even arterial bleeding, is not unexpected • The body is designed to form clots and, depending on degree of injury, maintain flow – but sometimes it needs a little bit of help Too Much Late night TV…

23. What Is the Best Bleeding Control? • The components are already in the blood!

24. A hemostatic agent is designed to help create a clot, preventing further hemorrhage Ideally, once the clot is formed, there will not be a need for continued direct manual pressure This could free up the provider to perform other tasks Depending on the injury, may still have perfusion, preventing ischemic injury Enter the world of Hemostatic Agents

25. Stop large-vessel arterial and venous bleeding within 2 minutes of application, even when applied to an actively bleeding site through a pool of blood • Ready to use – no mixing or prep • Simple to apply with minimal training • Lightweight and durable • Long shelf life even in extreme conditions • Safe to use – no risk of infection or injury • Inexpensive

26. 1999 • Red Cross Dry Fibrin Dressing • Add thrombin, fibrinogen, and factor 13 to biodegradable gauze • These agents are purified from human blood • Effective in animal models but was never FDA approved for routine use, only in combat • $1000 per bandage First Generation

27. Second generation agents focused on concentrating the clotting factors already present in the blood • Zeolite granules – QuikClot • Adsorbs the liquid from the plasma, leading to concentration of the clotting factors • Exothermic reaction: issue with burns • QuikClot sponge was designed to keep granules from spreading and also minimize heat production • Chitosan – cross link RBCs to form clot independent of usual clotting mechanisms • Celox granules: cross link RBCs and adsorbs water • Hemcon dressing: stiff material – serves as a matrix to attract RBCs and start clot formation Second Generation

28. Quik Clot

29. Chitosan

30. Attempts to address complications previously noted • New trend: use gauze impregnated with the clotting agent • QuikClot: new material – kaolin • Activates the clotting cascade • Celox Gauze • ChitoGauze: by HemCon Third Generation

31. QuikClot Gauze • 4 inch x 4 inch gauze • 3 inches x 12 feet

32. Celox Gauze • 3 inches x 5-10 feet

33. ChitoGauze • 4 inches x 12 feet

34. Compared kaolin-coated gauze to smectite granules • Smectite granules caused endothelial damage and made them nonviable for primary surgical repair • NOTE: WoundStat product (smectite) was pulled by the FDA in 2009 over concerns of embolization • Vessels treated with QuikClot gauze or control (Kerlix dressing) remained patent with no thrombus or blood clot in their lumen Are They Safe?

35. Stop large-vessel arterial and venous bleeding within 2 minutes of applications, even when applied to an actively bleeding site through a pool of blood • Ready to use – no mixing or prep • Simple to apply with minimal training • Lightweight and durable • Long shelflife even in extreme conditions • Safe to use – no risk of infection or injury • Inexpensive

37. Research/Testing: • Animals & surgical patients • Injury to blood vessels/tissues • Prevent primary surgical repair • Interaction varies in every patient • Impractical materials • Expensive Hemostatic agents: Problematic

38. Hemostatic Agents: When YOUR life is at stake… • Too much risk • Too many complications • Too many variables to consider • Too expensive • Too many unknowns

39. Civilian Use of Tourniquets

40. “The tourniquet is to be regarded with respect because of the damage it may cause, and with reverence because of the lives it undoubtedly saves. It is not to be used lightly in every case of a bleeding wound, but applied courageously when life is in danger” Hamilton Bailey, Surgery of Modern Warfare 1941 Closing thought

41. Doyle GS, Taillac PP. Tourniquets: a review of current use with proposals or expanded prehospital use. Prehospital Emergency Care 2008;12(2):241‐256 • Kheirabadi BS et al. Safety evaluation of new hemostatic agents. J Trauma. 2010;68: 269-278 • Kragh JF et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249: 1-7 • Lakstein D et al. Tourniquets for hemorrhage control on the battlefield. J Trauma. 2003;54: S221-S225 • Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emergency Medical Journal 2008;24(8):584‐587 • Pusateri AE et al. Making sense of the preclinical literature on advanced hemostatic products. J Trauma. 2006;60: 674-682 • Taillac PP. Tourniquet first! Safe & rational protocols for prehospital tourniquet use. JEMS October 2008. • http://www.jems.com/resources/supplements/the_war_on_trauma/tourniquet_first.html References: