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282
P. B. McBeth and S. M. Hameed
Ultrasound
The use of ultrasound-guided central line placement has
become a standard of care. Ultrasound provides a real-time
window of vascular anatomy with the ability to directly visualize placement of central lines into a vessel. Traditional use
of anatomical-based land marking for central venous access
has resulted in failure, and complication rates are as high as
19% and 30%, respectively [32]. Ultrasound-guided CV line
placement has been demonstrated to signicantly decrease
the failure rate, complication rate, and number of attempts
required for successful access [34–36].
A recent randomized, multicenter trial using ultrasoundguided CV cannulation reported ultrasonographic guidance
had an odds improvement of 53.5 (6.6–440) times higher than
landmark-based technique for success of cannulation [37].
The average number of cannulation attempts was also signicantly lower in the ultrasound-guided group. The frequency
of complications related to line placement is reduced with the
use of ultrasound. For internal jugular line placement, arterial
punctures are reduced from 9.4% to 1.8%, hematomas 2.2%
to 0.4%, and pneumothorax 0.2% to 0% [38–40].
Resuscitative Thoracotomy
A resuscitative thoracotomy (RT) is an emergency procedure
used to gain access to the chest in severely injured patients.
The decision to perform an RT should be guided by consideration of mechanism of injury and signs of life. The rationale
for performing an RT is: (1) release of cardiac tamponade, (2)
control intrathoracic hemorrhage, (3) evacuation of air embolism, (4) performance of open cardiac massage, and (5) cross-
clamping the descending thoracic aorta [41, 42]. Given the
potential risk involved to healthcare workers, the decision to
undertake an RT must be made in the context of an anticipated successful clinical outcome. Trauma patients arriving
to the emergency department (ED) pulseless should be
assessed for clinical history, cardiac rhythm, and a brief neurologic examination prior to commencement of an RT.Patient
management is guided initially by mechanism of injury,
downtime, and ECG recording. Victims of blunt trauma with
no signs of life upon arrival to the ED universally have poor
survival rates (<1%) [42, 43]. The authors suggest RT should
not be performed in this population when the duration of
downtime is greater than 5min. Patients with penetrating thoracic injury with previously witnessed cardiac activity within
15min of presenting to a trauma center or unresponsive with
hypotension (SBP <70mmHg) despite ongoing resuscitation
with a narrow complex ECG rhythm should be considered for
an RT. Relative indications for RT include: penetrating thoracic injury with traumatic arrest with previously witnessed
cardiac activity, and penetrating non-thoracic injury with
traumatic arrest with previously witnessed cardiac activity
(pre-hospital or in-hospital). Other indications for urgent thoracotomy include (1) chest tube output >1000mL, (2) evidence of ongoing bleeding following placement of a tube
thoracostomy at a rate of 200 to 300mL/h for 4 h, (3) massive
chest tube air leak, (4) cardiac tamponade, and (5) air embolism [41–43]. Despite these indications, providers must also
consider the patient disposition for denitive surgical repair
following a successful RT.Limitations in hospital infrastructure and personnel may prevent successful outcomes. An RT
is conducted through anterolateral thoracotomy along the
fth intercostal space on the side of the injury. Detailed surgical steps of an RT are provided in Table33.4 [44].
Table 33.4 Operative technique for resuscitative thoracotomy
Surgical step Description Equipment
Sterilization of skin Application of Chlorhexidine to the skin surface
Draping as appropriate
Surgical incision Anterolateral incision at the fourth or fth intercostal space
Division of the intercostal muscles
Placement of the rib spreader with ratchet mechanism facing downward
Mobilization of the lung Divide the inferior pulmonary ligament Metzenbaum scissors
Bleeding control Apply digital control or pack the chest with surgical sponges Surgical sponges
Pericardiotomy Lift the pericardial sac with forceps and cut pericardium with scissors
Extend incision caudal-to- cephalad to avoid injury to the phrenic nerve
Aortic cross-clamping Bluntly dissect surrounding tissue. Identify esophagus
Apply temporary vascular clamp to aorta
Hilar cross-clamping Identify the pulmonary hilum
Apply temporary vascular clamp
Cam-shell exposure Anterolateral incision across the sternum to the right fourth or fth
intercostal space
Divide the sternum with a Lebsche sternal knife
Reposition rib spreader as appropriate
Chlorhexidine
Surgical draps
#10 Scalpel blade
Mayo scissors
Rib spreader
Metzenbaum scissors
Vascular clamp
Vascular clamp
Surgical sponges
#10 Scalpel blade
Lebsche sternal knife
Rib spreader
33 Emergency Critical Care Procedures
283
Outcomes
A clinically successful RT in the setting of blunt trauma is
rare (<1%); therefore, the authors advocate its use in only
selected situations. Improved outcomes are seen in patients
with penetrating (8–10%) injuries. The greatest survival
advantage is an RT performed for stab wounds (18–24%).
Survival following a gunshot wound with an RT is 4–5%
[45].
Contraindications
Contraindications for an RT include: blunt injury without
witnessed cardiac activity, penetrating trauma without cardiac activity (CPR>15min) with no signs of life (pupillary
response (in the absence of epinephrine administration),
respiratory effort, or motor activity), asystole or wide complex rhythm, non-traumatic cardiac arrest, severe head injury,
severe multisystem injury, improperly trained team, and
insufcient equipment [42, 43].
Volume Expansion
Patients presenting with the need for an RT are often volumedepleted and require uid resuscitation. As such, appropriate
IV access is required to achieve administration of crystalloid
or blood products. Fluid administration is titrated to achieve
end organ perfusion. The use of vasopressor support should
be limited and used only as a temporary measure to support
blood pressure in a crashing patient, especially in the setting
of pure hemorrhagic shock [46]. The use of vasopressors has
been shown to be deleterious [47].
role for a trauma laparotomy in the ED.In pre-arrest patients,
the decision for transfer to a standby OR for denitive management should be considered. This decision is based on the
injury patterns of the patient, anticipated clinical course, and
availability of an OR and support staff. A recent study by the
Western Trauma Association demonstrated improved outcomes when patients were managed in the OR or in the ED
with equipment setup similar to the OR [48]. Successful RT
requires denitive surgical repair in the OR.Management of
cardiac injuries, injuries of the great vessels, lung, tracheobronchial tree, esophagus, and thoracic aortic rupture should
be denitively managed in the OR [44, 49]. This should be
done by a trained trauma surgeon or cardiothoracic surgeon.
Diagnostic Peritoneal Lavage
Diagnostic peritoneal lavage (DPL) is a diagnostic procedure
used to provide information in the evaluation of patients with
blunt or penetrating trauma. With the widespread integration
of FAST ultrasound and improved resolution of computed
tomography (CT), some believe DPL has become a lost procedure [50–53]. This has led to a poor understanding of current indications for DPL [54]. Despite the low frequency of
use, DPL remains the most sensitive test to identify mesenteric and hollow viscus injury [55].
In the era of modern trauma care, DPL may be indicated
in the following clinical circumstances [54–57]:
• Hemodynamically unstable patients with suspected multicavitary bleeding but with negative or indeterminate
FAST.
• Stable patients with anterior abdominal stab wounds with
proven peritoneal violation in the absence of peritonitis.
Management
The decision to perform an RT should be guided by the algorithm outline above. Once the decision for an RT is made,
OR staff should be put on hold in anticipation of denitive
management in the OR.Team dynamics and organization is
orchestrated by the TTL in order to maximize patient and
healthcare provider safety. As described above, each team
member should have pre-dened roles within the resuscitation team. Protective equipment should be worn by all team
members. The patient-directed goal of RT in the ED should
be to temporize thoracic injury and re-establish systemic
oxygen delivery. Temporizing measures in the ED should be
limited to digital compression of cardiac or vascular injuries,
aortic or pulmonary hilar cross clamping, or packing of chest
wall injuries with denitive repair and continued resuscitation done in the controlled connes of the OR.There is no
A variety of surgical techniques have been described for
performing a DPL. The most commonly used are the open
and Seldinger techniques. These methods are described elsewhere [58]. A supraumbilical approach should be considered
in patients with pelvic fractures, pre-existing lower midline
surgical incisions, or early pregnancy. Decompression of the
stomach and bladder is important to prevent iatrogenic
injury.
Interpretation ofResults
If the initial aspiration of peritoneal uid yields 5–10cc of
gross blood, the test is positive. In the absence of gross blood
on the initial aspiration, 1L of normal saline is infused into
the peritoneal cavity. The mixed uid is then sampled. The
following is suggestive of a positive test: in the setting of
blunt abdominal trauma a red blood cell count (RBC) more
284
P. B. McBeth and S. M. Hameed
than 100,000/cc is considered a positive test; for penetrating
trauma, there is no consensus; however, for anterior abdominal injuries more than 100,000/cc, RBC is considered positive; other positive results include more than 500/cc white
blood cell count or the presence of gross or microscopic
enteric contents [55–57].
Complications of DPL include: catheter misplacement,
vascular injury, intrabdominal or retroperitoneal organ
injury, and wound infection.
In summary, DPL is a useful adjunctive diagnostic test
despite the widespread use of FAST ultrasound and CT
scans. Knowledge of the different diagnostic criteria based
on the mechanism of injury is required [54].
Summary
In summary, this chapter provides an integrated approach to
emergency critical care procedures including surgical airway
management, vascular access, tube thoracostomy, resuscitative
thoracotomy, and diagnostic peritoneal lavage. The combination of teamwork, organization, closed-loop communication,
and uncompromising attention to technical detail are essential
for successful management of critically ill patients.
Key Notes
Key notes of this chapter are as follows:
• The team architecture and dynamic is centered
around a trauma team leader (TTL) whose responsibility is to provide oversight in the management of
critically ill patients.
• A generalized approach and description of indications, contraindications, controversies and common
pitfalls of surgical airway management, vascular
access, tube thoracostomy, resuscitative thoracotomy, and diagnostic peritoneal lavage are outlined.
• Clear communication is essential when resuscitating a critically ill patient and performing emergency
procedures.
• The health and safety of each team member are critical. Personal protective equipment should be worn in
all emergency procedures. In the era of the COVID19 pandemic, N-95 respirators should also be worn
for any aerosol-generating medical procedures.
• Post-procedure debriengs provide opportunities
for learning and evaluation of quality healthcare
delivery.
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REBOA andNovel Hemorrhage Control
Methods
NoriL.Bradley, ShaunCowan, andMeganBrenner
34
Introduction
Hemorrhage is a leading cause of mortality in trauma [1, 2].
New and emerging technologies and devices are broadening
the trauma resuscitationists’ toolbox with options to control
a variety of challenging bleeding injuries [3, 4]. The basic
principles of managing massive bleeding include hemorrhage control and hemostatic resuscitation. The latter refers
to the maintenance of thermoregulation and protection from
heat loss, balanced blood product resuscitation (including
whole blood) with point of care-directed factor resuscitation,
where available, and correction of coagulopathy. This chapter will focus on hemorrhage control; hemostatic resuscitation is detailed in the Damage Control Resuscitation
chapter.
When considering the options for hemorrhage control, it
is useful to consider compressible versus incompressible
sites of hemorrhage to select appropriate and effective interventions [5, 6]. In general, compressible hemorrhage occurs
in extremities, while non-compressible hemorrhage is truncal. The junctions between the neck, axilla, and groins are
referred to as junctional hemorrhage, and can be compressible or not, depending on the anatomical location and severity of the injury. Non-compressible hemorrhage is difcult to
control quickly but can be managed with the implementation
of effective teams and appropriate tools. In this chapter, we
discuss a variety of hemorrhage control adjuncts for both
massive compressible and non-compressible hemorrhage
(Table34.1).
N. L. Bradley (*)
Department of Surgery, University of Alberta,
Edmonton, AB, Canada
Department of Medicine, University of British Columbia,
Vancouver, BC, Canada
e-mail: Nori.Bradley@albertahealthservices.ca
S. Cowan
Department of Surgery, University of Alberta,
Edmonton, AB, Canada
Department of Critical Care Medicine, University of Alberta,
Edmonton, AB, Canada
e-mail: cowan@ualberta.ca
M. Brenner
School of Medicine– Surgery, University of California Riverside
School of Medicine, Riverside, CA, USA
e-mail: MBrenner@mednet.ucla.edu
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_34
287
288
Table 34.1 Non-operative/procedural hemorrhage control tools for trauma resuscitation
Compressible hemorrhage sites
Digital/manual pressure
Packing gauze
Hemostatic gauze
Hemostatic powders
Tourniquets
Pneumatic
Strap and windlass style
a
If wound accessible for compression
b
In development
Packing gauze
Hemostatic gauze
Hemostatic powders
Foley catheter
Pelvic binder
Abdominal aortic tourniquet
Junctional tourniquet
REBOA
a
a
a
N. L. Bradley et al.
Non-compressible hemorrhage sitesExtremity hemorrhage Junctional hemorrhage
Pelvic binder
External aortic manual compression
Abdominal aortic tourniquet
Intra-abdominal foam
REBOA
b
Resuscitative Endovascular Balloon
Occlusion oftheAorta
Resuscitative Endovascular Balloon Occlusion of the Aorta
(REBOA) is a well-described percutaneous approach to noncompressible torso hemorrhage, as an alternative to traditional open aortic cross-clamping [7]. The original report
from Lieutenant Colonel Carl Hughes in 1954 described
internal aortic balloon occlusion as an approach for managing abdominal trauma during the Korean War [8]. Fifty years
later, endovascular aortic balloon occlusion was described
for emergent management of ruptured abdominal aortic
aneurysms [9]. Subsequent military interest in endovascular
hemorrhage control and military-civilian partnerships led to
trauma surgeons utilizing the available technology in civilian
trauma centers [10, 11]. While early reports supported
REBOA as an alternative to resuscitative thoracotomy in
shock from hemorrhage below the diaphragm, the development of smaller 7 French sheath introducers and wireless
technology has led to international uptake of REBOA as part
of hemorrhage control protocols in high and low-to-middle
income countries [12–15]. Use of REBOA has been described
in austere, pre-hospital, rural, and transfer environments
[16–21]. The recent report of a new, smaller COBRA-OS
device—a 4 French Control of Bleeding, Resuscitation,
Arterial Occlusion System—may also extend the role of aortic occlusion in a variety of clinical settings [22].
Clinical algorithms for REBOA have been well described
(Fig.34.1) [23, 24]. Trauma patients in hemorrhagic shock
without suspected major thoracic vascular injury (e.g., aortic, cardiac, major thoracic vascular) may be candidates for
REBOA.Chest X-ray should be performed urgently to identify or rule out a treatable cause of shock (e.g., tension pneumothorax, hemothorax). If there are no indications for tube
or nger thoracostomy, Focused Abdominal Sonography for
Trauma (FAST) should be performed to assess for intraabdominal hemorrhage and rule out pericardial tamponade.
Patients with persistent hypotension (sBP <90 mmHg)
despite blood product resuscitation with positive FAST or
compressible source of hemorrhage (e.g., pelvic fracture) are
potential candidates for REBOA.Balloon deployment within
the aorta is either within Zone 1 or Zone 3. Zone 1 of the
aorta extends from the left subclavian to the celiac artery.
Zone 3 extends from the lowest renal artery to the aortic
bifurcation [24] (Fig.34.1). Patients in cardiac arrest or with
non-compressible hemorrhage below the diaphragm warrant
Zone 1 deployment, while those with hemorrhage due to pelvic fracture warrant Zone 3 deployment.
Specic details regarding the technical aspects of REBOA
deployment are described elsewhere [25]. The basic steps
include: insertion of arterial sheath (size dependent on device
being used), insertion of REBOA catheter to appropriate
location, conrmation of position, balloon ination, balloon
deation, catheter removal, and sheath removal.
Arterial access to deploy REBOA should be via the common femoral artery (CFA) [22]. Obtaining CFA access is the
rate-limiting step in deployment, and introducing the device
through non-CFA sites increases complications [26]. Early
reports from the AORTA registry noted 50% open surgical
cut-down for CFA access [27], which decreased to 17–24%
in more recent reports [15, 28]. However, surgical cut-down
is more likely to be required for patients in cardiac arrest
[29]. Percutaneous approaches relied on landmarks more
often than ultrasound, 51% versus 21%, respectively [28].
Small studies in laboratory or animal settings have suggested
longer time to access but potentially higher CFA access success rates using ultrasound for percutaneous access. Thus, a
pre-assembled kit for REBOA deployment containing all
supplies required to gain access (open or percutaneous),
deploy the balloon, and secure the device must be available
in areas where REBOA will be deployed [30].
Insertion depth of the REBOA catheter should be based
on pre-assessed external landmarks. Newer generation catheters have standard distance markings for Zone 1 and Zone
3, but data for validation in clinical use is not yet available
[31]. At this time, X-ray or uoroscopy should be used to
conrm position prior to balloon ination. Ultrasound may
identify wire position within the aorta but has limitations in
identifying balloon position [32]. Deferring radiographic
conrmation should be limited to exceptional circumstances
ZONE
ab
34 REBOA andNovel Hemorrhage Control Methods
289
ZONE
1
3
Fig. 34.1 Algorithm for Zone 1 and Zone 3 REBOA , insertion with relevant trauma anatomy highlighted. Panel a STC REBOA Algorithm from
Trauma Acute Care Surg. 2014 Aug;77 (2):286–91, with permission. Panel b demonstrates placement zone 1 versus zone 3 ballon placement from
BEST© course content, with permission.
(such as active cardiopulmonary resuscitation); conrmation
should then be obtained as soon as possible [33].
Balloon ination should follow manufacturer’s instructions for use and avoid over-ination. Balloon rupture, arterial rupture, and death have been associated with over-ination
[34]. Real-time feedback with increase in blood pressure via
arterial line tracing from above the balloon should be
observed. Loss of the contralateral femoral pulse should also
be conrmed in the absence of cardiac arrest. Documentation
of balloon ination time is required, and updates to commercially available catheters have made this process more
user-friendly.
Once the balloon has been inated, denitive hemorrhage
control must be obtained as soon as possible. Guidelines
based on physiologic end-points in animal research and clinical use recommend Zone 1 ination no more than 30minutes and Zone 3 ination no more than 60 minutes [33,
35–38]. Institutional pathways to facilitate these timelines
should be in place and reviewed regularly for optimization.
Balloon deation should occur as soon as hemorrhage con-
trol is obtained. The time of deation should be documented.
If partial REBOA is utilized, this should also be part of the
documentation [31].
Removal of the catheter from the sheath should occur as
soon as possible. Distal blood ow should be conrmed and
documented, ideally with angiography prior to leaving the
OR, IR, or hybrid suite. The sheath should also be removed
as soon as possible. This may not be feasible at the time of
hemorrhage control due to coagulopathy, need to transfer to
intensive care, or other logistical constraints. However,
increased duration of sheath dwell time increases the risk of
limb complications. The limb and access site should be monitored regularly for 24hours, and a CFA US should be performed within 72 hours in order to assess for hematoma,
CFA pseudoaneurysms, or arteriovenous stulas [33].
Complications associated with REBOA use have been
well described [34, 39]. In general, these can be classied as
balloon deployment related or access site related. As mentioned, balloon deployment complications can lead to arterial injury (e.g., dissection) or rupture (aorta, iliac artery) and
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devastating hemorrhage. Inappropriate locations for deployment can also result in mesenteric ischemia or acute kidney
injury due to visceral or renal artery occlusion. Access siterelated complications can include bleeding/hematoma
(including retroperitoneal), or arterial injury such as pseudoaneurysm or dissection both at the arteriotomy site or
more proximally into the iliac vessels. Thrombus from the
access site or along the balloon catheter can embolize, leading to limb ischemia or even limb loss. Awareness of the
complications and rigorous protocols for assessment and
treatment are critical to prevent and mitigate complications.
REBOA Programs
Implementation of REBOA within a healthcare and/or hospital system requires a thoughtful, multidisciplinary approach.
Credentialing, equipment resources for balloon insertion and
deployment, human resources for balloon deployment, monitoring, and post-removal care, patient pathways, and quality
assurance and quality improvement need to be considered
[40]. Multidisciplinary training, both via formalized courses
and ongoing system learning, is key for successful program
implementation and maintenance [23, 40]. A local REBOA
coordinator, such as a surgeon champion, can bridge the gaps
between the stakeholder departments and is recommended.
A multidisciplinary approach with surgical presence during
deployment is critical to a successful program [30].
Partial REBOA
Partial REBOA is dened as partially deating the REBOA
balloon to allow for some distal ow [41]. Some centers and
providers have reported experience with partial REBOA
[42]. However, partial ination of a REBOA balloon can
result in balloon migration and intimal injuries [43]. It also
requires continuous blood pressure monitoring above and
below the balloon [42]. Despite some successful reports in
military contexts [44], data to guide partial REBOA in civilian settings are limited [42]. A recent report using partial
REBOA in a high volume trauma center supported feasibility but failed to show a survival benet [45]. At this time,
partial REBOA is not recommended in multiple national
civilian REBOA consensus guidelines and should be considered with caution [33, 38]. New products with balloons specic for partial REBOA and subsequent dedicated research
may modify these recommendations.
Intermittent REBOA
Intermittent REBOA is periodic deation of the REBOA balloon and is hypothesized to extend the therapeutic time
frame of REBOA by allowing transient distal ow with
cyclic balloon ination and deation [41]. Reports from
swine models have shown mixed results. Small studies have
reported improved survival [46] and distal ischemia [47] or
no improvement when compared with partial REBOA [48].
Further translational research will be required to determine
the role of intermittent REBOA in human trauma
resuscitation.
Pre-hospital andTransfer REBOA
The use of REBOA in a pre-hospital setting may have a role
where expedited transport (i.e., achieve Zone 1 and 3 target
timelines) to an appropriate facility with immediate surgical
capabilities exists and can be rapidly mobilized. US Special
Forces medical providers have reported success with eld
implementation of this technique as a bridge for transport
[17, 19]. European civilian EMS systems have also successfully deployed the technology, with physician presence [19,
20]. Use of REBOA has also been described in a US rural
civilian setting where transfer to higher level of care was
achieved [19]. Limitations of pre-hospital and transfer
REBOA use include exceeding recommended balloon ination times, and the logistics plus human resources required to
successfully transport a patient to denitive surgical intervention and reperfusion. Bringing REBOA closer to the
point of injury means taking it farther away from hemorrhage control. The signicant coordination and resources
required for pre-hospital and/or transfer REBOA exceeds
local capabilities in most non-military jurisdictions. Overall,
we support Lamhaut and colleagues (2018) who caution that
it is “imperative REBOA is developed within a system that
can rapidly transport to denitive repair.”
Vena Cava Occlusion
Major trauma that results in inferior vena cava (IVC) injuries
has not shown the same reduction in mortality as severe
hepatic injuries over time, especially for retrohepatic caval
injuries [49]. Given the challenging exposure for more cranial IVC injuries, endovascular approaches have been
described in a small number of animal studies. Resuscitative
34 REBOA andNovel Hemorrhage Control Methods
291
Endovascular Balloon Occlusion of the Vena Cava
(REBOVC) prolonged time to death and decreased blood
loss in a swine model [50]. More recently, a swine model
using a combined approach with REBOVC plus REBOA to
achieve total hepatic isolation provided superior hemodynamic stability than REBOVC alone or with a Pringle
maneuver [49]. While signicant physiologic derangements
were observed, both studies concluded that REBOVC could
potentially “buy time” while obtaining denitive surgical
bleeding control. More research is needed in this area. The
advantages to balloon occlusion in this setting include a
potential reduction in trauma to the IVC during clamping, as
well as the ability to allow partial ow remotely.
Disadvantages can be life-threatening, as the reduction in
preload can have dire consequences, some of which can be
avoided with central resuscitation.
Aortic Occlusion inNon-trauma Settings
REBOA use has been reported in non-traumatic hemorrhage,
such as massive gynecological bleeding (active or anticipated) during morbidly adherent placenta [15], massive gastrointestinal bleeds [51, 52], visceral artery and aneurysm
rupture, and hemorrhagic necrotizing pancreatitis [52].
Similar to trauma, use of REBOA in these settings serves as
a temporizing bridge to denitive control via interventional
radiology or surgical bleeding control and repair. Also similar to trauma, the institutional considerations mentioned
above still apply to REBOA use in non-trauma settings in
order to optimize patient safety and clinical performance.
Tourniquets
While conceptually not new, the resurgence of tourniquets
has occurred over the last several decades due to the military experiences caring for casualties in Afghanistan and
Iraq [53]. In both the military and civilian prehospital setting, tourniquet use temporarily controls extremity hemorrhage, allowing for evacuation to denitive care. In civilian
settings, pre-hospital tourniquet placement signicantly
decreases mortality and volume of blood transfusions compared to waiting until arrival to hospital for tourniquet
application [54, 55]. Within the hospital, tourniquet use can
temporarily control extremity hemorrhage, allowing the
resuscitation team to focus on identifying and addressing
other threats to life associated with multi-system trauma.
This is especially relevant during multi- or mass-casualty
situations so that limited provider resources can temporize
extremity hemorrhage and continue to support disaster
management [56].
The trauma resuscitationist should understand considerations for tourniquet use and removal. In orthopedic surgery,
tourniquets are routinely used to create a blood-free surgical
eld and are often in place for up to two hours [57]. Data
from combat injuries note good outcomes with tourniquet
times up to four hours of duration, and in select patients and
circumstances [55], limb recovery is documented for tourniquet times up to 16hours, although outcomes beyond four
hours are variable [58]. The goal should be to obtain hemorrhage control while minimizing tourniquet time.
Considerations inTourniquet Use
Placement of an arterial tourniquet should be 3–5cm above
the injury on the affected extremity, and as distal as possible,
while avoiding positioning over a joint. Extremity bony anatomy consists of two-bone (distal) and one-bone (proximal)
compartments. Tourniquet effectiveness is relative to tissue
volume and is most effective more distal than proximal as a
function of the lesser compressed tissue volume in two-bone
compartments. Upper thigh tourniquet placement can often
require the placement of two or more windlass-style tourniquets for effective hemorrhage control [56, 59].
There are two hard endpoints of tourniquet tightening: (1)
cessation of bleeding and (2) obliteration of distal arterial
circulation. The latter can be conrmed by assessing for the
absence of a distal pulse by palpation (e.g., in eld settings),
Doppler ultrasound, or using cuff pressures of 20% above
systolic pressure (e.g., using a pressure-controlled pneumatic
tourniquet). Blood pressure cuffs and improvised tourniquets
offer suboptimal performance and should be avoided in tourniquet management of traumatic injuries. Improvised devices
as tourniquets are shown to be less effective than commercial
devices and should not be relied upon [56].
An injured extremity with a tourniquet in situ can draw
signicant attention upon arrival to the Emergency
Department. The temptation for early release of a tourniquet
should be resisted and focus shifted to the usual ATLS©
approach to trauma care. Release of an extremity tourniquet
should only be attempted once a primary survey is complete
and adequate resuscitation, including reliable vascular
access, access to surgical support, and blood products, is
available. Clean dressings, hemostatic gauze, and suturing
supplies should be present. Hasty release of tourniquets can
exacerbate blood loss, and removal should follow a controlled and planned approach. Of note, the tourniquet should
remain on the limb—not be cut or removed—in preparation
for tightening if hemorrhage recurs. The time of tourniquet
release should be documented. Further, removal after prolonged occlusion can be accompanied by washout of cellular
metabolites such as potassium and lactate, which can con-
292
tribute to hemodynamic instability or even arrest. Appropriate
team communication and preparation can mitigate these
physiologic complications.
Many EMS and police departments across North America
carry commercial tourniquets, and the use of these devices is
becoming more widespread. International programs, such as
Stop the Bleed™, are teaching and advocating layperson use
of these devices as well [60].
Junctional Tourniquets
The concept of junctional tourniquets is best thought of as a
pressure device more so than a true circumferential tourniquet. Junctional tourniquets are a collection of mechanical
devices that replace manual pressure for either direct or indirect hemorrhage control in junctional anatomical locations—
groin, buttock, axillary, and clavicular regions—in which
bleeding is often difcult to control [20]. Several commercial devices available are designed and promoted to free up
manual pressure in junctional areas where pressure for temporizing control is needed for eld or inter- or intra-hospital
transportation to denitive hemorrhage control [19, 28, 29].
These devices, like many novel hemorrhage control devices,
are limited by distribution and availability at the point of use,
as well as cost. Additionally, there is a paucity of effectiveness data during live patient transport or in the eld [61].
N. L. Bradley et al.
Fig. 34.2 Abdominal aortic tourniquet in training use. (S.Cowan,
Personal File Photo)
are associated with intra-abdominal organ injury [65, 66].
These abdominal aortic tourniquets are currently in use in
military medical systems and may be encountered in arriving
trauma patients as availability and data supporting use
expand [67].
Abdominal Aortic Compression.
External compression of the abdominal aorta for control of
distal pelvic or junctional groin bleeds has been described
using manual techniques and purpose-built devices [61, 62]
(Fig.34.2).
The objective of this technique is to compress the aorta
(anterior) against the body of the spine (posterior) to occlude
distal ow and hemorrhage. Successful manual occlusion of
the aorta through trans-abdominal pressure has been demonstrated [63]. An attendant can apply sts or a knee to the
mid-abdomen in order to compress the aorta between the
sts/knee and the vertebral bodies to achieve aortic occlusion [62]. This technique has been successfully simulated in
a mannequin model, sustaining pressure up to 20minutes,
but it could not consistently be sustained during patient
transport [64].
Several commercial devices are in use in military and prehospital settings and have been successfully deployed in prehospital settings. Duration of occlusion data suggests that a
“balloon-time” of external compression target maximum of
60minutes is supported, and occlusion times beyond 1hour
Hemostatic Agents
Hemostatic agents are useful adjuncts that can aid in tamponade and accelerate hemostasis for accessible hemorrhagic injuries [68]. Despite the availability of many
hemostatic agents, not all have applications in trauma resuscitation, due to practical and logistic limitations.
Conceptually, hemostatic agents function through one or
more of three main mechanisms: (1) mechanical tamponade
or sealing, (2) concentration of clotting factors, and (3) initiating/accelerating the clotting cascade. These agents can be
categorized into ve general types: topical, chemical, physiologic, dressings, and adhesives. In trauma resuscitation,
hemostatic dressings have the broadest applicability. The
applicability of select agents in each category for use during
trauma resuscitation is described below. The utilization of
hemostatic agents should be viewed as an adjunct to effective
pressure, packing, and surgical technique in order to control
bleeding. These agents are ineffective stand-alone agents and
should be used in conjunction with traditional hemorrhage
control methods [69].