HEMORRHAGE CONTROL

Goal

Stop external hemorrhage and reduce internal hemorrhage to the greatest extent possible. The first step in DCR is limiting blood loss by early and effective hemorrhage control. Interventions to control external hemorrhage are well described in the TCCC guidelines and should be applied as indicated.

- CoTCCC recommended limb tourniquets
- Wound packing
- Pressure dressings
- Hemostatic dressings (Combat Gauze, Celox Gauze, Chito Gauze, and XStat
- Junctional tourniquets
- Pelvic binders

Tourniquet notes9

- Tourniquets (limb and junctional) should be transitioned to pressure dressings within 2 hours when criteria for conversion are met (i.e. the casualty is not in shock, it is possible to monitor the wound closely for bleeding, and the tourniquets are not being used to control bleeding from an amputated extremity). Tourniquets that have been in place longer than 6 hours should not be removed unless close monitoring and laboratory capability are available.
- If the tactical situation or injury pattern does not allow for transition of a tourniquet to a pressure dressing, recognize that the priority is life over limb. At times, the decision to leave a tourniquet in place and commit the patient to an amputation is difficult. Consider telemedicine consultation.
- If a tourniquet has been applied for longer than 2 hours and the decision is made to reduce the tourniquet, resuscitation should address hyperkalemia and reperfusion syndrome, similar to crush injuries. See PFC Clinical Practice Guideline (CPG) Crush Syndrome under Prolonged Field Care.23

Wound Packing Notes

- If bleeding continues through the hemostatic dressing, reassess the wound. If the wound is fully packed and additional hemostatic dressings are available, consider removing the first dressing and packing a second dressing. If additional space exists in the wound cavity, augment the first dressing with a second hemostatic dressing or gauze dressing.
- The effectiveness of wound packing may be improved when skin closure over the packing can be achieved, either with suture, skin staples, iTClamp®, or application of a chest seal.

Emerging Technologies

Emerging technologies that may be considered for internal hemorrhage control

- Abdominal Aortic and Junctional Tourniquet (AAJT):
  - This device, although not well studied, is the only noninvasive device available for aortic occlusion. Application of the AAJT (Compression Works; http:// compressionworks.com) may be considered for occlusion of the distal aorta when the injury pattern suggests bleeding in the pelvis and/or junctional lower extremities.
  - If there is bleeding above the level of the umbilicus, in the upper abdomen or chest, application of the AAJT may increase bleeding.
  - Ideally, ultrasound of the abdomen and chest should be performed to look for bleeding before AAJT application.
  - Per manufacturer's guidelines, the AAJT should not be applied in the abdominal position for more than about 30 minutes.
  - In the absence of evidence-based protocol, providers may consider: after 15–30 minutes of active resuscitation with blood products and attention to external hemorrhage control, the AAJT should be slowly released.
  - If the systolic blood pressure drops below 90mmHg, reinflate the balloon and transfuse an additional unit of blood before releasing the balloon again. Look for other causes of hemodynamic instability.
  - Continue to repeat as resources allow until blood pressure stabilizes or arrival at surgical capability.
- Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Only an advanced resuscitation team with the capabilities for massive transfusion, ultrasound, and arterial access would be expected to obtain the capability for REBOA placement. This device may be considered for occlusion of the aorta at either the position of the diaphragm (zone I, for abdominal hemorrhage or traumatic arrest) or the distal aorta above the aortic bifurcation (zone III, for pelvic and/or junctional lower extremity hemorrhage). Balloon time should be limited to 30 minutes for zone I. Maximum zone III inflation time is not known, but is likely in the range of 2–3 hours. See Joint Trauma System REBOA CPG.24 Aggressive blood product resuscitation and balloon deflation protocol must be followed, even without surgical intervention.