Transcript
Hello.
I'm Ray Castle, and I wanna thank you for joining me on this continuing education course.
The focus, as you see here, will be on in looking at the effectiveness of tourniquets in managing mass hemorrhage injuries.
Specifically, we're gonna look at various topics related to this, a lot of the research that's been conducted, looking at civilian and also military settings and that how it translates.
So let's go ahead and get started.
First off, conflicts of interest.
I have no conflicts of interest or relationship with any product or device identified in this presentation.
And any product to demonstrate or device that I'm providing in here is for demonstration and not an endorsement of one particular product.
Let's go ahead and get started.
So as far as learning objectives, the we have couple bullet points here we're going to address today.
One is Hopefully, you will see a historical use of turnikits and what this has looked like, especially over the last 15 to 20 years for and how it translates from military to civilian used today.
We'll briefly cover types and limitations of various types of commercial available turnkey kits.
And also look at what an important part of this is briefly looking into pathophysiology of mass hemorrhage injuries and and really think about what are the outcomes that have occurred over in different settings.
You'll also get a full view of what some of the more current evidence based studies that is we've seen in positive clinical outcomes and using various types of tonnicates.
In military trauma, also how that translates into civilian use.
In prehospital care, we wanna also think about the evidence based decision making criteria area for using tourniquets and and how that's made an outcome.
And then finally, looking at how the tourniquets have been used in various settings and how would it means in terms of relationship to the pre preemergency care, healthcare provider in reducing delivery times to medical facilities, and also most importantly, saving lives.
Here are several pages or slides with references for this presentation for you review.
I encourage you to use these as you need to, and we'll discuss a lot of these today.
So as far as a single take home message for this topic in in tourniquet use, and especially when it relates to primary assessment for for hemorrhagic injuries.
There are 3 things that have to occur.
So you have to be thinking about this from a clinical standpoint, what you're doing or what you have for your protocols, is number 1 is we have to recognize and stop the bleed immediately.
Along those lines, as far as a rapid trauma assessment, we we stopped the bleed.
And then also establish that patient airway and resolve a 2 deficit.
Otherwise, they're gonna continue down at cascade.
We'll con I'll talk a little more about that.
In a little bit.
And then also think about that.
Anything any other life threatening threats to the body, we have to address those.
But if we don't stop to believe initially, nothing else will help out in that process because of the role that the bleeding blood has one on volume, but also oxygen.
So first off, let's discuss briefly when we recognize exactinating trauma, what does that look like?
And so one of the things has come out over the probably the last in 2009, a study came out by Merlin and colleagues looking at what is estimation.
So The quick question I have for you is how looking at this picture and you use that red square as the size of of of of your fist as an example.
Is the MARP method uses that, and the question whether how effective that is.
So just real quick, you could guesstimate how much blood loss occurred.
So we'll go on with that, and you can always come back to this.
And the answer is around 2:50.
Even that's a rough estimation.
And I and I give this article because there is a lot of debate on whether and how providers and late personnel estimate actual blood loss.
So you see here that, you know, recognizing that a a 5th size, average 5th may equal on the ground of about 20 milliliters of fluid.
So you could figure it's about 250 depending of probably more than that based under the person, so probably around 400, but just on what you can see right there, you give an idea of what that looks like.
So the problem with the even though it's it is used, it can be used, there's a lack of evidence supporting consistency in how we visual estimation of blood.
So that becomes part of the problem if we're already seeing how much blood occurs or not.
And here are just some example studies that were seen, and all of these were inconsistent in identifying the the who was being in the study, being tested in the study or utilizes subject in the study and how they actually estimated blood loss.
And this is important for you as the provider is to and also teaching late personnel what is something that's consistent that they can rely on as a visual blood loss?
So in one study by in Philips, and was they looked at a 125 late people.
They had short videos of of hemorrhage situations.
Looking at, you know, victim gender, volume, blood loss, and camera perspective were systematically manipulated.
Overall results is that typically, this subject group, they overestimated small volumes, which is probably on the better side, But when you underestimate the larger volumes, that is definitely problematic.
So and also what's interesting with this is blood loss underestimated more for female victims and less likely classified as life threatening.
So that was that in itself presents several things from potential user, the the late person, and how they're interpreting.
So this could radically affect the person's health immediate outcome.
When we look at rural trauma, and this is always a problem in emergency medicine, and we think of it just occurring in this in a metropolitan area.
But with the laid times and also shortages.
We have to be thinking about that today is what that impact is.
We have to think of even in metropolitan areas, you may have a 15 minute call time for an angle.
Or or longer.
So that becomes problematic, especially for a a status 1 or status 2 call where you're seeing, you know, potential.
Cart or significant trauma that may occur.
So in this one particular study by bedridden colleagues, this was done in in 2020 are published.
They look at the records of adults admitted to an adult, an academic level 1 trauma center.
And when you look at the, you know, the non indicated turner kits, they got a higher on admission, blood profiles that require less surgery.
No complications, and they had a 123 minute rule versus 48 minute urban.
That's a pretty significant time when you look at far as a response time.
But we're Think about where that applies and how the need to do early intervention and and you look at what happens in military setting, where they're in a forward front position, they may have a longer response time.
So this also translates over in terms of care.
As far as emergency preparedness is concerned, you know, when we think about just taking a step back that what, you know, man made a natural disaster So, you know, you may see, you know, an explosion.
You may see now the the frequency, high frequency, of intentional acts that are being done.
It is here in the US, but worldwide, you have tornadoes.
You know, you look at examples in tough Luca Alabama several years ago.
And also that what we saw in at frontline, the picture here is a bomb site 1.
The Boston Marathon bombing.
So all these are, you know, natural inmate made disasters.
At the end of the day, they present themselves the same.
It just matter having adequate resources there.
An interesting study was in analytic assays, and we're we're thinking about And again, this was several years ago in how public spaces are equipped to facilitate rapid point of injury, hemorrhage control after mass casualty, And even this has changed radically.
Just I think there's probably about 400 or 500 mass casualty incidents have been identified in the US alone just during the last 11 months as of December of 22 when this recording is taking place.
So we've seen this on a more rapid scale and then also the types of injuries and how fast they occur.
We take a step back.
Look at the Hartford consensus.
Hartford consensus actually was initiated after the Sandy Hook shootings in December of 2012.
Which the time president Obama initiated a group, large group of which a number of large organization stakeholders and and experts in the country were brought together.
And the first focus was on April 2nd, they They published the improving survivability from an active shooter event.
Shortly thereafter 13 days later, Boston Marathon bombing and therefore they reconvened.
And now we saw the next Hartford consensus looking at active shooter and intentional mass casualty incidents.
Then moving forward in 15 is how we implement bleeding control into the late perversion where you're seen this and also stop the bleed initiative, and then also in 16 more events occurring.
And we're, you know, how do we have a national resilience to mass casualty trauma?
And you look at the uninsured public, and then you look at for this is focuses mainly for athletic trainers, but you could plug in any provider based on a level of training.
You're looking at whether it's, you know, a physician at an event or other, you know, at a facility, etcetera, you see where responding law enforcement, EMS fire rescue had moves into definitive trauma and just know that for EMS, they will not move into a site with bleeding unless there is a controlled environment.
So Therefore, law enforcement today is gonna take place first.
So I mentioned to stop the bleed initiative.
This was led by Doctor Richard Hunt, who was the director of medical preparedness policy at the National Security Council staff.
And this was also, you know, from an athletic training perspective, we were involved at that at the at the this initial level developing the initial Hartford consensus this.
So so what are some lessons learned from the Boston Marathon bombing?
And I think, you know, this article is an excellent article to take time to read by gates.
And what we're looking at is lessons learned, and this was the one of the earlier one, the more recent ones that really showed the role of the late person and what improvised turnkey kits can do from survivability and what we saw there that day and and looking at and speaking just personally from bombsite.
1, that there were no great commercial termicates per se.
We had all improvised termicates from belts to other clothing and what that mean from that.
So when we also think about what's, you know, that is it lost in translation.
And I think the one thing that's come about, you know, you look at this article, there's some amazing data that came out of that, that one is there were 27 turnikits that were actually applied.
And there it did result in 17 amputations and 15 patients.
And the big thing is is that while those were there were 3 fatalities.
There was this is where this looks at from a standpoint of the of turnkey use those those casualties occur those fatalities occurred almost instantaneously versus you're looking at the other talking specifically about turnigits, there was a mortality rate of 0 and also looking at access to level 1 trauma centers and the number sheer number of medical personnel that were there at the finish lines and those sites plus Boston Fire, Boston EMS, etcetera.
So when we look at the types, the the one we wanna always navigate towards and use and have access to as a commercial turnkey.
The input these are by far more effective than any improvised tourniquet, but you would still use those if needed to in a unique situation.
So these are several types.
They're not inclusive.
So when we look at tourniquets or commercial tourniquet devices, they're 4 main types.
1, you have a bladder.
You saw that one previous picture.
You have a cargo strap.
Which gets into they some have just a basic strap that you can pull or ratchet type system.
You do have the improvised, and then you have a rubber tie rubber tube, which I'm sorry, 5 being the and also a win last, which is the one we've seen most commonly over the years and and another presentation that's definitely worth looking at is what is just a history of turnikits and what that looks like from you know, from several 100 years back, what's been done how we've evolved over time.
Currently, the committee on trauma for CCC is looking at tactical combat casualty care committee on that.
In December 21, they this is a recognition of what do they what do they recommend and also civilian use and also military use as well.
When you look at non pneumatic tourniquets such as the cat tourniquet and the Sam X T and ratchet tourniquets or the RMT tactical or the soft tea These are the ones that they are recommending for use.
So if you're not to say you can buy others, but if you're buying 1, these are the ones that are most highly recommended or seen as most effective.
There are some that are linomatic.
You see more more of these that were probably used in military settings.
There's also hemostatic dressing such as you're looking at CLOCS gauze or Other types of device I would say devices or dressings such as Xstat is a as an example is actually in a syringe, you inject it into, like, for example, abdominal trauma.
And then you have a junctional hemorrhage control They and then also airway management.
Those are those again, and it's important to note that airway management devices are really crucial and part of this being able to control mass hemorrhage, being able to stabilize the patient until more definitive care arrives.
So briefly, let's talk a little bit about pathophysiology of the sanguinating trauma.
So, obviously, from a standpoint of the types of types of shock that occur.
Hypo bulimic is gonna be from hemorrhagic or non hemorrhagic or example of even burn.
So the focus here is on we're thinking about hypovolemic shock or hemorrhagic shock.
When we classify acute hemorrhage or bleeding, the American College of Surgeons has a for classification scale looking at the amount of blood loss.
And with this, you start this is where you start to see or you would see this the changes in vital signs.
And when they start to getting into compensatory and noncompensatory shock.
So this is very important to understand just from a standpoint if you see blood and you see where the patient is from a mental like, for example, for mental status.
In addition to other things that may be going on, and how we're how they're having to address that, what the pulse rate is, what blood pressure, etcetera, where you start to see that.
So just know that a person may have 7, you know, up to 1500 liters approximately, and they still may have a relatively normal blood pressure at that point in time.
So this is being they're compensating to a certain point.
When we look specifically at what happens from a blood loss standpoint, we have to look at acute traumatic curriculopathy or ATC.
And this is more or less common as that that is referred to as the trauma triad of death.
You look at the right And so the easiest way to understand this is that, you know, when you when you look at this chart, the the algorithm, You have a trauma.
It could be internal or external bleeding.
There's there's hemorrhage that occurs.
And if you continue to lose blood product, out of the circulatory system, then the body starts to compensate, you move into shock, you get you then get into hypoparfusion.
So it's my early oxygenation in maintaining an airway and 02 deficits using a pulse oximeter, It's not the identifying point, but it's definitely provide some valuable data point.
It's moving them, make sure they have a high flow oxygen, if there is rapid bleeding as soon as possible.
And then we're also thinking about trying to control bleeding, and then it's a point where it starts to becoming diluted.
From a resuscitation standpoint.
So if they're adding just not blood, you're not adding just fluid, but not blood product, then you also have you lose clotting factor.
So as you see on the right hand side, you see blood loss, if you don't have if you don't have blood, you don't have the ability to clot, and then you start moving into other processes as you start to see increase lactic acid in the blood at the cellular level.
You start having acidosis.
You heart cardiac performance now deteriorates.
You start dropping in temperature, and then you and it just becomes a very vicious cycle here.
When we look at at the at the onset for a patient though, and this gonna occur within a minute to 2 minutes where you start seeing the onset onset of shock where it becomes compensatory shock.
More significant issues occur.
So understand that with bleeding, it's not just to bleed the injury itself that occurred, but it's also other organs that are starting to that are being compromised.
Think of the think of the brain in terms of lack of oxygen.
Other systems, liver, kidney, other areas that can occur.
So early on, you're not losing blood and you think the amount of blood loss occurs over time, if you don't control the oxygenation and the bleeding, they're going to continue to move down this pathway towards system cardiovascular system failure or moving into full blown shock, which then becomes irreversible.
So it's really important that we think about what happens in the first minute or 2 and how that projects on the outcome of the patient from preventing sepsis or have an organ failure or changing, you know, capnography is another area of looking about CO2 levels in the body and also acid levels in overall mortality rates.
So let's move forward and we're talking really about the evidence and where this came into play and where we're seeing this from a military setting, and we saw this transition over into just the journal public, athletic settings, etcetera, wherever this occurs.
So the early battle tested evidence, there are 2 studies that came out, and we're looking at 2005 2008 by one by Walters and other by Beekley.
And they're looking at what they saw in this.
And and the one on the left is critical, and it really is a trans it transcended through civilian use as well as the Cat Tourniquet and army surgeon general Kevin Cauley they were seeing recognizable delays in data and potential for inaction, and this was start this was recommended as the go to equipment for military personnel starting around 2004, 2005.
And what they started seeing was started seeing rapid control, you know, looking at where you see that 57% of death were by were prevented by early tourniquet use.
This is the early studies that came out with no significant outcomes, and this is where it comes into civilian side is where we were taught using attorney get, you know, up until the seventies or eighties, and then we're talk no.
It's bad.
And you now you have a philosophical change in in mindset.
And that the inaction of applying a tonic where there is, it's been documented very little damage to nerve palsy, etcetera.
And again, the focus is saving life.
When you look at Craig, the battle casual survivability, so this was a this was a great study that came out was tremendous evidence.
When you're looking at 651 limbs or 49 patients, 16 had undicated tourniquets, and they were plowed a maximum of 2 hours.
In this study, all these patients with no morbidity cases at all.
So one of the things we that they were seeing though even in the early side of this was where is it being misused or the overutilization of of tourniquets.
So or you're having issues that broke or, you know, issues with the tourniquet itself, which can occur in those forward front positions or other areas as well.
So the things that we're seeing that the take home points in the study in these 2 different time periods of the pooled data is that if you apply early onset of a tourniquet use.
And you've heard this time and time again probably is that, but if you apply before the onset of shock, then you're for the most part, you're having a 96 survivability versus if a patient with a tourniquet and you have shock as present they or they've already in the shot before applying it.
This may be a minute, 2 minutes where it's already starting to shot in to to show or observable signs of shock, then you have a 4% survivability.
So very significant data in itself.
So where did where did the military move from Tourniquets from 2001 to 2010?
This study looked at where you have 40 over almost 43100 casualties, 30% had a tourniquet use and 70%.
What they what they saw in the military was when you're looking at the abbreviated injury scale from one being minor to a 6 being maximal or it's untreatable, that where they were seeing was that by the use of early use of turnikits is that the main AIS score from third it it rose, but the survivability increased significantly.
So where you're seeing a seeing those, so you're seeing a higher incident rate or a higher injury and having better outcomes over time.
So that means they were they were able to treat prior to shock and and for a longer period of time, the patient was out in the field before Advanced Medical Care.
So when we think about where the structure translated the combat to civilian care, there are two studies here that were from door lock and SugarMAN.
And the one problem that came out early on was still that it was even though they were seeing excellent results in the military setting where this translated civilian care still took time and it was nonconclusive not that there that it wasn't effective.
It's just a a lack of evidence.
And this particular study by DORLAC, you know, they started to see over a large patient pool of 75,000 patients.
And they, you know, ate a they ate were had a minimal prehospital injuries.
I mean, they could have survived those out of those 14 Sugarmint is looking at guidelines for field triage and, you know, they recognize they did recognize early positive military data.
But again, they'd, you know, like to not include tourniquet use as a criteria.
1, there was limited data there were it varied the use varied among EMS systems.
It was not a standard of care at that point, and then possible overuse and over triage.
And that they recommended more research.
So this is in 2000 level from the CDC.
So, you know, what are some earlier barriers that we saw which is also changing, you know, philosophical mindsets.
As one is, you're looking at, you know, 28 local emergency medical services agent directors in California.
And what we're seeing is, you know, they were they were seeing these different barriers is they didn't see the results.
They thought it was dangerous.
Or or the expensive or no proven benefit at all.
So that becomes problematic in the early on in the EMS system as well.
So bottom line is, you know, think about look at these what this occurs, the tourniquets work and civilian care.
So This is one of these earlier studies again where you're seeing a number of patients, you know, they had improvised tourniquets applied, They and again, these earlier these patients, they tend to be more hypotensive and acidotic.
When they're when they're coming into a medical facility.
Others had, you know, 6 died without tourniquets.
Which means and then or or with early trying to get survived.
So you're seeing some of this even early in other areas in the world.
So, you know, one of the things that occurred is looking at the early on was the study by Tubular And this is actually the study, but this is actually the evidence based prehospital guidelines back in 2013 2014.
And the thing the key points on that study is, 1, they recognize that the TCCC guidelines.
They were seeing significant reductions.
Obviously, the Boston Marathon bombing was a a key factor there It's it's a very forward front in the large mass casualty event.
However, turnikits and hemostatic agents were not wobbly widespread in 2013, 14, etcetera.
You're looking as also the EMS national model of practice or education model had minimum in 2007 started that turnkey's minimum skill set.
However, even from a teaching standpoint, it still takes time for that to roll into actual clinical practice or on units and the same thing for other providers as well.
One of the things they saw because there was a lack of evidence.
And again, this is kind of a high lightness that, you know, these were had some of the look at some of these areas for what these key points that came out of that out of those practice guidelines.
Is that, you know, you you can read these and see what they were against.
And there were some pretty good evidence here and they even occurs today as, for example, you know, use against the use of narrow elastic or bungee type devices.
There's some out there.
They're still out there because they're better than than the the basic improvised.
But, again, those the pneumatic and the the windlass tend to be the most effective.
The other thing about the point was I wanna point back is that is they recommended against releasing a tonic it.
Again, in military settings, they've seen 4 or 6 hours without any damage to the patient at all when still have possible main outcomes.
The other things came out of this.
The study was actual having a prehospital hemorrhage control protocol.
This this should be in any in every pro emergency protocol, especially for wound and how this is treated.
And as a standard of practice, and you're seeing this throughout in medicine.
And here in the US, this is a standard of protocol.
And even what is even taught in stop the bleed program.
When we look at some of these larger scale studies, now we're getting into definitely a, you know, moving into higher level of evidence of studies, you know, when you're looking at this from a more frequent use when is that transitional point now.
Ternicus have been military as a whole cell for a good 6 or 7 years.
It's now moving into the trauma centers as well.
Is we're looking at, you know, at the time, it was the largest evaluation of of trying to get used in the civilian today at that time in the day.
Big results here was we're looking at, you know, look over to the table 2 is you're seeing what the Also, table 1, looking with the injury score was what their physiologic profiles are, and then really what the outcomes are.
And what the complication rates are.
So, you know, you can see what was occurring and see where that's occur what's happening even in the civilian settings, not as many, and it's not as high as the severity level in the military, but nonetheless, still having effective outcomes.
So another study came out from Shoal was in the Journal of Trauma And Acute Care Surgery was that we're looking at this comparison of civilian to military experience and, you know, you look at the Obviously, you look at that multistitutional study that came through.
You're looking at what the demographics are.
You're looking at, excuse me, what profiles are.
You're looking at basic mortalities over Obviously, they can military having a higher type of acuity of injury.
However, these are still relatively low numbers from 3% to 11%, whether shock or shock present, they still present similarly and also relatively low from a nerve pulsing standpoint.
The smaller dataset, but nonetheless, it does present some good data on the efficacy of tourniquet use in both settings.
More recent studies, again, these two provide some other larger scale studies from one being a multilevel trauma center study, and they saw a sixfold mortality reduction with the internicate application versus and also the study by Smith.
You're looking at a tourniquet group.
You had no palsy or secondary infection, and those were in 204 patients.
When we start looking at really the more recent studies the last couple of years and just earlier this year, this recent study came out in looking at what is prehospital trying to get used for trauma in the US.
And this was a larger scale study where they identified 7161 turnikets were applied among over 44,500,000 trauma activations.
They were looking at a excuse me, a match pairing or a match with those cohorts over 7000.
And what they're seeing the the take home points here.
1 is the transport time with no they were no versus no tourniquet cohort.
They had a transport time of 18 minutes versus 14 minutes.
You prehospital deaths, you see in the 1% versus a a half% with applying a tourniquet.
And then we're still looking at other datasets.
This is the one of the better studies to date that's come out showing the true efficacy of of what that would've looked like in the in the US.
Other things we look at also what's the which is interesting study because this really hits to the core and we need to kind of take a step back and really look at the training that is occurring and and how formal training is embedded into organizations whether it be stop the bleed or other things as well.
This is a randomized clinical trial.
Looking at the stop the bleed program.
And while it's being taught, for the cat tourniquet.
The problem is occurring that it's not translatable to other tourniquet types.
So and look and there is a disconnect or it's from the study here pretty significant between what tourniquet.
So if you're using a combat application tourniquet or cat tourniquet versus using a special operations or soft tea tourniquet or even a ratchet tourniquet you're seeing some different processes.
So it's really important to understand this from a training standpoint to train up to what the device is, and we know that based on the setting as well.
So in in wrapping this up, there, I wanna give you with this 5 take home points as with that.
So one is that we've seen so far, we continue to see a number of smaller studies, even larger studies, they're strong hospital evidence for using tourniquets.
Also, there is, as you saw, there was really no studies or you'll be very hard pressed to find any study if there was.
With low policy trauma, this is seen in military.
It's also being translated over civilian area.
Early application is key, especially before the onset of shock.
Shock occurs.
You it's part of your overall plan in your from delivery of care is making sure you have a determined response.
And what that means is we can't predict all types of injuries or situations or mask out situations that occur.
However, you train to that and you can have a determined response on what that looks like.
And lastly, is making sure that when you're evaluating your emergency action plans and your general protocols is where do late people play into this?
They're public access kits, and other types of information that are out there that, again, it's about activating the late person whenever possible.
So with that, the last leading point I'll with is that, you know, those think of this is within your EAP and your own protocols is that when you're training as well that you're performing, you always in the persons that are being here, always train to the level of training not typically not the potential.
So thank you very much, and I appreciate you taking time to listen to this and view this presentation.
Effectiveness of Tourniquet Use in Managing Mass Hemorrhage Injuries
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Updated Jan 22, 2024
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