Public access hemorrhage control devices

It is increasingly clear that rapid hemorrhage control contributes to better outcomes in critically injured trauma patients. The American College of Surgeons Committee on Trauma (ACS-COT) has stated that bleeding must be controlled by prehospital providers as quickly as possible. Recent products to control external bleeding have been introduced into the EMS market by various manufacturers.

However, in cases of severe bleeding, it’s possible that trained professionals may not arrive in time to stop it before the patient exsanguinates. The question becomes whether untrained laypersons could be the first part of the chain of survival, providing basic first aid before EMS arrives. Fortunately, there is precedence in this area of first response.

Lay person defibrillation

In the early 1980’s the first FDA-approved automated external defibrillator (AED) became available in the United States.[1] Soon, researchers demonstrated these devices in the hands of trained EMS personnel [2-6] and even trained non-medical personnel posed little risk and were effective at saving lives.[7-11] In fact, AEDs are so simple to use, sixth graders with no previous AED instruction were able to meet similar performance goals as trained emergency medical responders.[12]

Today, AEDs have become part of the landscape in many areas of the country. In 2000, under the direction of President Clinton, the Department of Health and Human Services [13] began preparing guidelines for establishing public access defibrillation (PAD) programs in federal facilities. In 2006, the American Heart Association recommended that States enact legislation in support of the lay public’s access to defibrillators.[14] To date, this legislation includes protection from liability when bystanders use the devices in good faith, and legislation to require certain business, schools, and public gathering areas to implement PAD programs.[15]

The argument for public access hemorrhage control

Hemorrhage is the second leading cause of death for patients injured in the prehospital environment, accounting for 30-40 percent of all mortality.[16] Many of the patients who hemorrhage do so after suffering vascular injuries in one or more extremities.

The annual incidence of extremity vascular injuries in the U.S. ranges from a low of 12.4 injuries at a rural trauma center in Missouri [17] to a high of 55 lower extremity injuries at a high-volume urban trauma center in Houston.[18] In a study of isolated penetrating injuries to the extremities, 57 percent of the patients who died had injuries that might have been amenable to tourniquet application.[19]

Current state of EMS care

A panel of experts in prehospital trauma care convened by the American College of Surgeons recently recommended the prehospital personnel, from emergency medical responders to paramedics incorporate the early application of tourniquets into clinical practice for controlling extremity hemorrhage when direct pressure is ineffective or not practical.[20] The panel further recommends tourniquets selected for use at a local level be a commercially produced windlass, pneumatic, or ratcheting type device with demonstrated efficacy at arterial flow occlusion.

Half of the EMS agencies in a California survey already incorporate tourniquet use into clinical practice for the control of severe extremity hemorrhage while the prehospital use of hemostatic gauze was extremely rare.[21] Half of the local regions that allowed EMS personnel to apply tourniquets allowed improvised tourniquets rather than commercially produced devices.

Three commonly cited reasons for failure to implement Tactical Casualty Combat Care recommendations were the differences in injury patterns between combat and civilian casualties, a perception of no proven benefit in the civilian arena and the perception of harm from prehospital application.

However, prehospital application of tourniquets appear safe even when the tourniquet remains in place for one or two hours [22], with a reported complication rate of about 2 percent.[23] Based on the past and continuing positive experiences from the military, it is likely that more and more EMS systems will implement treatment guidelines for the use of the prehospital tourniquets.[24]

For maximum efficacy, tourniquets must be applied before the patient has developed shock.[25] During Operation Iraqi Freedom, tourniquets applied in the prehospital environment and before the onset of shock were strongly associated with survival.[26] In this study, when field personnel applied the tourniquet before the onset of shock, rather than waiting for shock symptoms to develop mortality virtually disappeared (4 percent vs. 96 percent respectively).

Can the public help?

First aid courses often teach bystanders to compress a wound in an effort to control bleeding. Unfortunately, with severe injuries, compression may not be enough. However, an interesting question to consider is whether tourniquets applied before EMS arrival by ordinary citizens without medical training would provide additional morbidity and mortality advantages.

As you can well imagine, definitive evidence in favor of bystander application of tourniquets is sparse. Of the 243 patients injured during the Boston Marathon bombing, 66 had at least one extremity injury.[27] Of those sixty-six, 29 (44 percent) presented with life-threatening limb exsanguination including 15 patients with 17 traumatic amputations of the lower extremities and ten patients with 14 major vascular lower extremity injuries. Of the 29 patients with life-threatening limb exsanguination, 27 had improvised tourniquets applied in the field with one-third applied by EMS and the remainder applied by non-EMS personnel or by an unknown person.

In a ten-year evaluation of isolated penetrating or blunt extremity injury requiring either arterial revascularization or limb amputation, only 2 percent of patients had a tourniquet applied before arriving at the trauma center and all were improvised tourniquets applied by police officers or bystanders.[28] An additional 2 percent of patients had a tourniquet applied by emergency department staff within one hour of arrival. While a very small number of patients without a tourniquet exsanguinated, no patient with a tourniquet died.

During a seven-year period, researchers at Boston Medical Center identified 11 patients who had an improvised tourniquet applied in the field by EMS [29]. Only one patient died, however, that patient was in cardiac arrest when EMS arrived on the scene. Of the 10 patients who survived, all had complete neurologic function in the affected extremity despite having the tourniquet in place for as long as 167 minutes (mean 75 +\- 38 minutes).

Summary

The military experience has demonstrated that complications associated with tourniquet use are rare, even when the tourniquet is improvised. The limited civilian data supports the safety of the devices. With untrained bystanders as part of the definition of a first responder, the Office of Health Affairs at the Department of Homeland Security recommends the availability of both tourniquets and hemostatic agents in the early management of severe bleeding.[30]

References

1. Cummins, R.O., Eisenberg, M. S., Bergner, L., Hallstrom, A., Hearne, T., & Murray, J. A. (1984). Automatic external defibrillation: Evaluations of its role in the home and in emergency medical services. Annals of Emergency Medicine, 13(9 Pt. 2), 798-801. doi:10.1016/S0196-0644(84)80441-2
2. Eisenberg, M. S., Hallstrom, A. P., Copass, M. K., Bergner, L., Short, F., & Pierce, J. (1984). Treatment of ventricular fibrillation: Emergency medical technicians and paramedic services. Journal of the American Medical Association, 251(13), 1723-1726. doi:10.1001/jama.1984.03340370055030
3. Heber, M. (1983). Out-of-hospital cardiac arrest using the “Heart Aid,” an automated external defibrillator-pacemaker. International Journal of Cardiology, 3(4), 456-458. doi:10.1016/0167-5273(83)90118-3
4. Jaggarao, N. S., Heber, M., Grainger, R., Vincent, R., Chamberlain, D. A., & Aronson, A. L. (1982). Use of an automated external defibrillator pacemaker by ambulance staff. Lancet, 2(8289), 73-75. doi:10.1016/S0140-6736(82)91692-0
5. Stults, K. R., Brown, D. D., Schug, V. L., & Bean, J. A. (1984). Prehospital defibrillation performed by emergency medical technicians in rural communities. New England Journal of Medicine, 310(4), 219-223. doi:10.1056/NEJM198401263100403
6. Weaver, W. D., Copass, M. K., Bufi, D., Ray, R., Hallstrom, A. P., & Cobb, L. A. (1984). Improved neurologic recovery and survival after early defibrillation. Circulation, 69(5), 943-948. doi:10.1161/01.CIR.69.5.943
7. MacDonald, R. D., Mottley, J. L., & Weinstein, C. (2002). Impact of prompt defibrillation on cardiac arrest at a major international airport. Prehospital Emergency Care, 6(1), 1-5. doi:10.1080/10903120290938689
8. O’Rourke, M. F., Donaldson, E. E., & Geddes, J. S. (1997). An airline cardiac arrest program. Circulation, 96(9), 2849-2853. doi:10.1161/01.CIR.96.9.2849
9. Page, R. L., Joglar, J. A., Kowal, R. C., Zagrodzky, J. D., Nelson, L. L., Ramaswamy, K., Barbera, S. J., Hamdan, M. H., & McKenas, D. K. (2000). Use of automated external defibrillators by a U.S. airline. New England Journal of Medicine, 343(17), 1210-1216. doi:10.1056/NEJM200010263431702
10. Valenzuela, T. D., Roe, D. J., Nichol, G., Clark, L. L., Spaite, D. W., & Hardman, R. G. (2000). Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New England Journal of Medicine, 343(17), 1206-1209. doi:10.1056/NEJM200010263431701
11. Wassertheil, J., Keane, G., Fisher, N., & Leditschke, J. F. (2000). Cardiac arrest outcomes at the Melbourne Cricket Ground and Shrine of Remembrance using a tiered response strategy — a forerunner to public access defibrillation. Resuscitation, 44(2), 97-104. doi:10.1016/S0300-9572(99)00168-9
12. Gundry, J. W., Comess, K. A., DeRook, F. A., Jorgenson, D., & Bardy, G. H. (1999). Comparison of naïve sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation, 100(16), 1703-1707. doi:10.1161/01.CIR.100.16.1703
13. Department of Health and Human Services. (2009) Guidelines for public access defibrillation programs in federal facilities. Federal Register. 74, 41133–41139. Retrieved from http://www.gsa.gov/graphics/ogp/FMR_Bulletin_2009-B2.pdf
14. Aufderheide, T., Hazinski, M. F., Nichol, G., Steffens, S. S., Buroker, A., McCune, R., Stapleton, E., Nadkarni, V., Potts, J., Ramirez, R. R., Eigel, B., Epstein, A., Sayre, M., Halperin, H., & Cummins, R. O. (2006). Community lay rescuer automated external defibrillation programs: Key state legislative components and implementation strategies: A summary of a decade of experience for healthcare providers, policymakers, legislators, employers, and community leaders from the American Heart Association Emergency Cardiovascular Care Committee, Council on Clinical Cardiology, and Office of State Advocacy. Circulation, 113(9), 1260-1270. doi:10.1161/CIRCULATIONAHA.106.172289
15. England, H., Weinberg, P. S., Estes, N. A. 3rd. (2006). The automated external defibrillator: Clinical benefits and legal liability. Journal of the American Medical Association, 295(6), 687-690. doi:10.1001/jama.295.6.687
16. Kauvar, D. S., Lefering, R., & Wade, C. E. (2006). Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. The Journal of Trauma, Injury, Infection, and Critical Care, 60(6), S3-S11. doi:10.1097/01.ta.0000199961.02677.19
17. Humphrey, P. W., Nichols, W. K., & Silver, D. (1994). Rural vascular trauma: A twenty-year review. Annals of Vascular Surgery, 8(2), 179-185.
18. Feliciano, D. V., Herskowitz, K., O’Gorman, R. B., Cruse, P. A., Brandt, M. L., Burch, J. M., et al. (1988). Management of vascular injuries in the lower extremities. Journal of Trauma, 28(3), 319-328.
19. Dorlac, W. C., DeBakey, M. E., Holcomb, J. B., Fagan, S. P., Kwong, K. L., Dorlac, G. R., Schreiber, M. A., Persse, D. E., Moore, F. A., & Mattox, K. L. (2005). Mortality from isolated civilian penetrating extremity injury. Journal of Trauma, 59(1), 217-222.
20. Passos, E., Dingley, B., Smith, A., Engels, P. T., Ball, C. G., Faidi, S., Nathens, A., & Tien, H. (2014). Tourniquet use for peripheral vascular injuries in the civilian setting. Injury, 45(3), 573-577. doi:10.1016/j.injury.2013.11.031
21. Galante, J. M., Smith, C. A., Sena, M. J., Scherer, L. A. & Tharratt, R. S. (2013). Identification of barriers to adaptation of battlefield technologies into civilian trauma in California. Military Medicine, 178(11), 1227-1230. doi:10.7205/MILMED-D-13-00127
22. Inaba, K., Siboni, S., Resnick, S., Zhu, J., Wong, M. D., Haltmeier, T., Benjamin, E. & Demetriades, D. (2015). Tourniquet use for civilian extremity trauma. Journal of Trauma and Acute Care Surgery, 79(2), 232-237. doi:10.1097/TA.0000000000000747
23. Kue, R. C., Temin, E. S., Weiner, S. G., Gates, J., Coleman, M. H., Fisher, J., & Dyer, S. (2015). Tourniquet use in a civilian emergency medical services: A descriptive analysis of the Boston EMS experience. Prehospital Emergency Care, 19(3), 399-404. doi:10.3109/10903127.2014.995842
24. Feliciano, D. V. (2010). Management of peripheral arterial injury. Current Opinions in Critical Care, 16(6), 602-608. doi:10.1097/MCC.0b013e32833f3ee3
25. Department of Homeland Security. (2015). First responder guide for improving survivability in improvised explosive device and/or active shooter incidents. Retrieved from http://www.dhs.gov/publication/iedactive-shooter-guidance-first-responders
26. Kragh, J. F. Jr., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 249(1), 1–7. doi:10.1097/SLA.0b013e31818842ba
27. King, D. R., Larentzakis, A., & Ramly, E. P. (2015). Tourniquet use at the Boston Marathon bombing: Lost in translation. Journal of Trauma and Acute Care Surgery, 78(3), 594-599. doi:10.1097/TA.0000000000000561
28. Kalish, J., Burke, P., Feldman, J., Agarwal, S., Glantz, A., Moyer, P., Serino, R., & Hirsch, E. (2008). The return of tourniquets. Original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries. Journal of the Emergency Medical Services, 33(8), 44–54.
29. Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., Sanddal, N. D., Butler, F. K., Fallat, M., Taillac, P., White, L., Salomone, J. P., Seifarth, W., Betzner, M. J., Johannigman, J., & McSwain, N. Jr. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173. doi:10.3109/10903127.2014.896962
30. Department of Homeland Security. (2015). First responder guide for improving survivability in improvised explosive device and/or active shooter incidents. Retrieved from http://www.dhs.gov/publication/iedactive-shooter-guidance-first-responders