HEMORRHAGE CONTROL PRIOR TO OPERATIVE INTERVENTION & STABILIZATION

When a DCBI casualty arrives at the Role 2 or Role 3, immediate blood transfusion and hemorrhage control are the priority. All TQs should be assessed for continued hemostasis and may frequently need to be tightened after transfusion starts and the casualty’s blood pressure improves. In some circumstances with high AKAs or bad perineal wounds, the injuries are too proximal for TQ to successfully control the hemorrhage. In these scenarios, there are currently three procedures which can help with hemorrhage control – but they should not delay the casualty getting to the operating room.

1. The first is a junctional TQ. Junctional TQs compress the common femoral vessels. It takes practice to be able to apply effectively. They are non-invasive and some can also act to bind/stabilize a pelvic fracture.
2. The abdominal aortic junctional (AAJT) TQ is a device that likely has some efficacy but has never been well adopted. It was developed for prehospital use, but because it is bulky and causes pain with application, medics have not included it in their aid bags. However, it has efficacy at distal aortic occlusion in animal studies. The AAJT can be applied relatively rapidly, but the casualty will require pain control or intubation. The devices use pressure on the aortic bifurcation to provide proximal control. Ensuring that bleeding is from below the aortic bifurcation is important. There is also a concern that application of this device may cause enteric injury.
3. The last option is Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). REBOA has emerged as a hemorrhage control adjunct in traumatic shock. The use of REBOA is not widely adopted because the data for Zone 1 occlusion has been mixed.9-11 However, Zone 3 (distal aortic) REBOA would provide inflow control for high AKAs (not amenable to a high and tight TQ) and pelvic/perineal injuries from DCBI. Proper REBOA use requires training and should be done by an experienced provider. If the casualty does not have evidence of intraabdominal injuries (will not require a laparotomy), the use of Zone 3 REBOA just prior to the OR, or in the OR is very effective at proximal hemorrhage control. Like any method of arterial occlusion, REBOA causes distal ischemia and subsequent reperfusion injury; if Zone 3 REBOA is being used, close monitoring of the time of balloon occlusion must be monitored. The longer the distal tissue is ischemic – the higher risk of further tissue damage/necrosis; invasive fungal infection (IFI), and continued myonecrosis. While a safe timeline for Zone 3 occlusion is unknown, the duration of aortic occlusion should be as short as possible. Once the balloon is deflated, distal perfusion must be assessed to avoid secondary ischemic injury to tissue that is already greatly compromised from the primary injury.12 It should be noted that the utility of the REBOA may be significantly limited by the morphology of injury, particularly if affecting the standard femoral access sites.13-15

Refer to JTS Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock CPG for further guidance.12