Feasibility of combat hemostasis methods in civilian prehospital emergency medical care

Abstract

Uncontrolled hemorrhage is the leading cause of preventable traumatic death in both military and civilian populations. Hemorrhage often causes coagulopathy, which intensifies hemorrhage and complicates its treatment. The armed conflicts in Afghanistan and Iraq have allowed the military to test new hemostatic products and procedures in an effort to better control hemorrhage and reduce its associated morbidity and mortality rates. These methods were analyzed for efficacy and suitability in the civilian prehospital setting. Several invasive and non-invasive interventions were found to be beneficial. Despite centuries of controversy surrounding their use, emergency tourniquets can be safe, lifesaving tools for controlling severe extremity hemorrhage when adequate tourniquet designs are properly used. Hemostatic dressings are very useful as hemorrhage control adjuncts, and two products (Combat Gauze and Celox) are recommended for prehospital use based on their efficacy, mechanisms of action, ease of use, low cost, shelf-life, and other properties. Several pharmacological interventions were evaluated for prehospital use in addressing the anticoagulant and hyperfibrinolytic nature of trauma-associated coagulopathy. Recombinant activated Factor VII, commonly used in hemophiliac-related bleeding, does not improve outcomes in trauma patients. Tranexamic acid, which is commonly used to reduce bleeding in elective surgeries, has been demonstrated to significantly lower mortality in trauma patients with severe hemorrhage, especially when administered within three hours of injury. Recommendations were also made based on the results of military-developed damage control resuscitation protocols: restoration of perfusion is the best way to correct coagulopathy and prehospital fluid administration should be limited to restore perfusion and maintain systolic blood pressures of 80 to 90 mmHg. Hypothermia and hyperthermia are correlated with higher mortality in trauma patients, so temperature management was identified as a top priority in prehospital trauma care. Finally, the properties of stored blood were investigated in the setting of massive transfusion so that paramedics conducting interfacility transfers of these patients could be made aware of common complications to anticipate adverse events.