Tourniquet: high and tight vs just proximal to the wound

[DrMetal]

we have a nice little pissing contest going on here on the waterfront: Tourniquet: high and tight vs just proximal to the wound

Was curious what you operational bubbas might think:

me personally:

The reason why we've gone back and forth on this debate so much is that it is a poor question (high-and-tight vs just proximal to the wound). The better question (and what I think we should be teaching) is: Should we use a tourniquet at all to treat that wound?

For most distal wounds (that don't directly involve exsanguination from large caliber vessels)...direct pressure is enough and tourniquets should be avoided. Distal wounds typically involve small caliber vessels. Most times, a tourniquet (applied 2-3 inches north of such a wound) does very little to occlude these vessels (unless you happen to land the tourniquet right on said small vessel). Hard to do, too risky, you're more likely to cause more damage.

Take the case of a traumatic ankle amputation: place the tourniquet on the tib-fib plateau ( a few inches "proximal" of the wound) and bear down, and you're more likely to fracture the fibula and cause more harm. Place the tourniquet "high and tight" on the femoral artery, and you'll stop the bleeding, but you will also compromise the rest of the leg (now you have an above-the-knee amputee). It's much better to just forgo the tourniquet, apply several direct pressure-type dressings to the ankle stump, and get the patient out of there.

The body also does a marvelous job of occluding small caliber (distal wound) vessels. Many cases have been documented where bleeding stops on it own, even without rigorous pressure.

Tourniquets are really best for large caliber vessels, and we should be teaching their use only when patients are directly bleeding from such large caliber vessels (an above-the-knee amputation involving the femoral artery, an above the elbow amputation involving the brachial artery, etc etc).

If the wound is distal enough and not invovling a large vessel, avoid the tourniquet (keep it on standby), go for direct pressure, resuscitate and medevac quickly.


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[Matthew9Thirtyfive]

We train high and tight in the dark or when it's not possible to find the most proximal wound for certain, then reposition when able. Otherwise, just proximal to the wound.

We also train to convert to direct pressure dressings whenever possible as soon as possible unless they are looking shocky, the wound is an amputation, or the situation is otherwise unstable. Personally, I'd rather throw on a tourniquet and take it off than delay its use. I can dig up the studies, but switching to aggressive tourniquet use has definitely saved lives.

 

[DrMetal]

We train high and tight in the dark or when it's not possible to find the most proximal wound for certain, then reposition when able. Otherwise, just proximal to the wound.

We also train to convert to direct pressure dressings whenever possible as soon as possible unless they are looking shocky, the wound is an amputation, or the situation is otherwise unstable. Personally, I'd rather throw on a tourniquet and take it off than delay its use. I can dig up the studies, but switching to aggressive tourniquet use has definitely saved lives.

Ok. But for the stable patient, not in shock, clearly a distal wound....you would er on the side of a direct pressure dressing, right?

Applying a tourniquet proximal to a wound (in the neighborhood of small caliber vessels) doesnt confer that much occlusion, vs a good pressure dressing, right? (Again: im speaking mostly of the stable patient with a distal wound.....if unstable or shocky, do what you gotta do)

 

[Matthew9Thirtyfive]

Ok. But for the stable patient, not in shock, clearly a distal wound....you would er on the side of a direct pressure dressing, right?

Applying a tourniquet proximal to a wound (in the neighborhood of small caliber vessels) doesnt confer that much occlusion, vs a good pressure dressing, right? (Again: im speaking mostly of the stable patient with a distal wound.....if unstable or shocky, do what you gotta do)

Yeah. If they are stable and it is apparent that they are not going to exanguinate, I will skip the tourniquet. We actually just had something like that happen recently. Fall from pretty good height resulting in an open distal LE wound that was pretty bloody. Direct pressure worked fine. No need for a tourniquet in a stable patient that clearly doesn't need one. I just err on the side of caution. If I'm not sure, I'll throw it on. I can always take it off.

 

[DrMetal]

Yeah. If they are stable and it is apparent that they are not going to exanguinate, I will skip the tourniquet. We actually just had something like that happen recently. Fall from pretty good height resulting in an open distal LE wound that was pretty bloody. Direct pressure worked fine. No need for a tourniquet in a stable patient that clearly doesn't need one. I just err on the side of caution. If I'm not sure, I'll throw it on. I can always take it off.

Exactly. The only problem I foresee in the operational setting is---although you might personally do a good job in keeping an eye on said tourniquet---once the patient leaves your hands, who knows who's going to keep an eye on it? Of course you communicate with the medevac team that there is a tourniquet, but if someone forgets its there and you patient passes out with it on, bad things can ensue. But ok, if it's needed it's needed.....

You raised a good point and something we should always think about first: what's the hemodynamic status and stability of our patient? Let that guide you, more than anything else.

 

[backrow]

The question you have to answer in the military, deployed setting is: what is easiest for 18 year old E2 Johnny to understand and apply correctly while providing buddy care to his best friend while taking fire from the enemy.

Whatever that answer is that saves the life is the correct answer.


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[Cooperd0g]

You also have to ask yourself how long a tourniquet needs to be on before you actually get concerned about viable tissue. If it is squirting and I'm busy I would do a tourniquet as proximal as possible regardless of how distal the wound is. You have many hours to re-asses and change to direct pressure before you worry about a leg amputation from a tourniquet to the upper thigh. If it is oozing and I have nothing else going on then direct pressure makes sense.

 

[Matthew9Thirtyfive]

You also have to ask yourself how long a tourniquet needs to be on before you actually get concerned about viable tissue. If it is squirting and I'm busy I would do a tourniquet as proximal as possible regardless of how distal the wound is. You have many hours to re-asses and change to direct pressure before you worry about a leg amputation from a tourniquet to the upper thigh. If it is oozing and I have nothing else going on then direct pressure makes sense.

The current TCCC guidelines are to attempt to convert within 2 hours I believe, as the time where you start worrying about ischemia-reperfusion is somewhere between 1-3 hours depending on which study you read. There have only been a few instances of limb amputation 2/2 battlefield tourniquet use during the last 16 years. Two were when the patients were left with coalition forces and their tourniquets were left on for 6+ hours. The other was a soldier whose tourniquet was left on for greater than 8 hours. Otherwise, TACEVAC times have been so fast that there hasn't really been the chance to leave the tourniquet on that long. At least not that has been reported as of 2015 or so.

 

[Homunculus]

The question you have to answer in the military, deployed setting is: what is easiest for 18 year old E2 Johnny to understand and apply correctly while providing buddy care to his best friend while taking fire from the enemy.

Whatever that answer is that saves the life is the correct answer.

110% agree. whatever is simplest as least likely for them to F up is the correct answer. the nuances of placement, oozing vs spurting, when to remove, reperfusion issues are all beyond the scope of most medics. if I'm the patient I want whatever will work until I get to where the docs and their toys are. it's why they have de-emphasized IV placement, and I would argue even crics in most cases are probably superfluous. I had a patient s/p EFP who had devastating abdominal trauma and for some reason the medic cric'd him. completely unnecessary and a waste of time (not that it ended up mattering in the end) but when you put too many branches in the medic though process the easier it is for them to lose track of the big picture.

if you are asking as the "doc," personally as a non-trauma and non-EM specialty I'm putting it wherever the hell it will go and stop the bleeding, which in reality is between your answers. if it happens to be proximal so be it. salvaging limbs isn't really our primary directive. my concern with pressure and pressure dressings is that you can't see under your bandage to know how much blood loss is occurring and the subsequent transport which may be via track, wheeled vehicle, or MEDEVAC all of which aren't exactly smooth rides. it's easy to hide it under a pile of kerlix and make yourself feel better, until you see the blood soaked kerlix a few minutes later.

--your friendly neighborhood just keep adequately perfusing the brain w/ oxygen somehow caveman

 

[Matthew9Thirtyfive]

110% agree. whatever is simplest as least likely for them to F up is the correct answer. the nuances of placement, oozing vs spurting, when to remove, reperfusion issues are all beyond the scope of most medics. if I'm the patient I want whatever will work until I get to where the docs and their toys are. it's why they have de-emphasized IV placement, and I would argue even crics in most cases are probably superfluous. I had a patient s/p EFP who had devastating abdominal trauma and for some reason the medic cric'd him. completely unnecessary and a waste of time (not that it ended up mattering in the end) but when you put too many branches in the medic though process the easier it is for them to lose track of the big picture.

if you are asking as the "doc," personally as a non-trauma and non-EM specialty I'm putting it wherever the hell it will go and stop the bleeding, which in reality is between your answers. if it happens to be proximal so be it. salvaging limbs isn't really our primary directive. my concern with pressure and pressure dressings is that you can't see under your bandage to know how much blood loss is occurring and the subsequent transport which may be via track, wheeled vehicle, or MEDEVAC all of which aren't exactly smooth rides. it's easy to hide it under a pile of kerlix and make yourself feel better, until you see the blood soaked kerlix a few minutes later.

--your friendly neighborhood just keep adequately perfusing the brain w/ oxygen somehow caveman

Yeah that's why we train high and tight until you or someone with better training can reassess. I always train that it's better to use it and not need it than try to use it late and have a poorer outcome.

 

[HighPriest]

I wouldn't turnicate any of the injuries for which I might be called.

 

[backrow]

I wouldn't turnicate any of the injuries for which I might be called.

Neurosurgeon? Dermatologist? Ophthalmologist? Radiologist?




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[dpmd]

Neurosurgeon? Dermatologist? Ophthalmologist? Radiologist?




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Could be urologist

 

[Promethean]

One of the big issues with tourniquets is the flood of lactic acid, K+, clots, etc flooding back into systemic circulation after reperfusion. Everyone worries blood loss. Too few remember the PEs and arrhythmias that have the potential kill the patient if that tourniquet comes off after being kept tight beyond a couple of hours (and which increases dramatically with longer durations.)

The finer points of tourniquet placement becomes moot if you've made your patient go asystolic.

If you really must use a tourniquet in an uncontrolled / field setting, the less tissue distal to it and the shortest possible time using it, the better. It would be best of all to allow some intermittent bleeding or slow oozing in order to avoid prolonged ischemia and subsequent tissue injury. There is a balance to be struck between the strict avoidance of blood loss and the risk of dramatic decompensation upon ultimate release of the tourniquet.

 

[backrow]

One of the big issues with tourniquets is the flood of lactic acid, K+, clots, etc flooding back into systemic circulation after reperfusion. Everyone worries blood loss. Too few remember the PEs and arrhythmias that have the potential kill the patient if that tourniquet comes off after being kept tight beyond a couple of hours (and which increases dramatically with longer durations.)

The finer points of tourniquet placement becomes moot if you've made your patient go asystolic.

If you really must use a tourniquet in an uncontrolled / field setting, the less tissue distal to it and the shortest possible time using it, the better. It would be best of all to allow some intermittent bleeding or slow oozing in order to avoid prolonged ischemia and subsequent tissue injury. There is a balance to be struck between the strict avoidance of blood loss and the risk of dramatic decompensation upon ultimate release of the tourniquet.

I think the survival rate of the most recent conflicts would argue that stopping exsanguination at the point of injury is more important than worrying about what happens when the tourniquet is removed in a more controlled setting such as the forward resuscitation surgical group or the role 3 hospital depending on what happens. The balance you talk about is probably not worth the trouble or likely wrong application of such by the initial combat responder.

That and body armor saves lives (duh )


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[pgg]

The reperfusion hemodynamics swings can be pretty dramatic but I honestly can't remember any cases where we (in a controlled setting in a Role 3 OR) couldn't handle it.

If they reach that level of care and there's anything left of the limb that can still be saved (vs just a completion amputation) their odds of survival are pretty good.

I've seen many many lives saved by tourniquets but no salvageable limbs lost to them, and no lives lost to reperfusing the evil humors from the limb(s).

 

[Promethean]

The reperfusion hemodynamics swings can be pretty dramatic but I honestly can't remember any cases where we (in a controlled setting in a Role 3 OR) couldn't handle it.

If they reach that level of care and there's anything left of the limb that can still be saved (vs just a completion amputation) their odds of survival are pretty good.

I've seen many many lives saved by tourniquets but no salvageable limbs lost to them, and no lives lost to reperfusing the evil humors from the limb(s).

"In a controlled setting."

Use of tourniquets was once more indiscriminate. In mid 20th century first aid manuals, people in the general public were advised to use them even for minor injuries. When I was a kid, I had scouts manuals that still recommended applying tourniquets for snakebites. The considerable morbidity and mortality associated with arms and legs that had been ischemic for 4 to 6+ hours before they reached definitive care had terrible outcomes that resulted in revised recommendations. Tourniquets were found to cause far more harm than benefit for all but the most catastrophic wounds and their use among civilians began to be widely discouraged.

In ORs, tourniquet time is limited and well controlled, especially when it is first applied in that setting rather than coming in from the field already ischemic. Limbs that are deliberately put under tourniquet for orthopedic surgeries are exsanguinated prior to raising the pressure, reducing the risk of clot formation. Ischemic time is kept to a minimum, and I've seen many planned surgeries where, after 2 hours, the surgeon chose to just let the limb bleed rather than continue ischemic, while finishing the procedure. And the tourniquet is routinely placed as close as reasonable to the incision site.

A battlefield crush or ballistic injury, with a prolonged ischemic time prior to getting to definitive care, may lead to that much more hemodynamic derangement, etc. If they reach that level of care in 2 hours, indeed their odds are good. But every unit of time after increases the risk of complications directly attributable to releasing that tourniquet. Thus, my reasoning for my answer to the original question. High and tight? or proximal and no tighter than necessary? I have this rationale for saying that the less tissue distal to the tourniquet, the better... and if it only slows bleeding rather than stops it, so that direct pressure can be more effective, better still.

I am glad that you haven't seen reperfusion related anomalies that led to bad outcomes and hope that you never do. I have, and that is why I have a strong opinion on the matter. I've seen a healthy kid nearly die in a level 1 trauma center's OR when the tourniquet unit failed catastrophically at 90 minutes of tourniquet time, when the sudden hemodynamic and electrolyte shifts almost overwhelmed our capacity to respond quickly enough... despite adequate resources and an excellent anesthesiologist at the head.

As for another's suggestion that an 18 year old grunt may be difficult to teach to deploy a tourniquet close to a wound... these young people are entrusted with deadly weapons and taught to use them with skill and discretion under extreme stress. I believe they can learn best practice first aid with the same proficiency.

 

[Promethean]

I think the survival rate of the most recent conflicts would argue that stopping exsanguination at the point of injury is more important than worrying about what happens when the tourniquet is removed in a more controlled setting such as the forward resuscitation surgical group or the role 3 hospital depending on what happens. The balance you talk about is probably not worth the trouble or likely wrong application of such by the initial combat responder.

That and body armor saves lives (duh )


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Most recent conflicts have benefitted from much better battlefield medicine than tourniquets, which are after all, a fairly primitive form of hemostasis.

The topical cellulose / thrombin products and other hemostatic products that have been developed for the modern battlefield have begun to reduce the need for tourniquets, and I would attribute some of the improvement in recent stats to that exchange for a more benign approach to stopping exsanguination. It also helps that extraction from the field is typically much more prompt than in previous eras, and that tourniquet time is thereby decreased over previous eras. Still, I remain concerned for situations where definitive care is delayed and think that it is worth employing best practices when tourniquets must be used.

If a limb is completely mangled beyond the point of salvage, sure, a tourniquet is going to do more good than harm, because you don't have to worry about reperfusing an amputated arm or leg.

Full agreement on the body armor.

 

[DrMetal]

"In a controlled setting."

Use of tourniquets was once more indiscriminate. In mid 20th century first aid manuals, people in the general public were advised to use them even for minor injuries. When I was a kid, I had scouts manuals

And you can substitute 'corpsman' or 'medic' for scouts in your sentence above, because that's what they're teaching them in their dinky schools (liberal application of tourniquets to small distal wounds, in a stable patient). This is what I really fear the most.... usage of a Tourniquet in patient that clearly does not need one

 

[alpinism]

We used them all the time in South Africa, sometimes multiple times a night.

Tourniquets are absolutely lifesaving especially for massive arterial bleeds (femoral, popliteal, brachial, radial, etc....). If done properly it should cut off all bleeding except for some minor oozing from the wound which can be easily controlled. In many situations it just isn't possible to have someone hold direct pressure over the wound for long periods of time and regardless its nearly impossible to obtain local control of bleeding without a tourniquet in place. For most patients we would place temporary tourniquet as high as possible just in case there was internal damage that extended proximally along the extremity. This was immediately followed by local control with vascular clamps or figure eight stitches before taking down the tourniquet to check for hemostasis. Sometimes it was possible to just leave the tourniquet in place if a theatre was available but oftentimes this was not the case.

Now with that being said they should only be used for massive arterial bleeds. Not for blood oozing from a capillary or flowing from a vein. In those two situations randomly applying a tourniquet is unnecessary and probably even harmful. As for knowing when to apply one its usually pretty obvious since a fountain of blood will be spraying across the room. There's a reason why we only wore black scrubs when working in resuscitation.

 

[alpinism]

On a slightly related note its always a fun time watching a med student or resident seeing a massive arterial bleed for the first time...

"Calm down and put your finger on the wound."

 

[Homunculus]

Neurosurgeon? Dermatologist? Ophthalmologist? Radiologist?

Could be urologist

I think the above the neck guesses are closest.

As for another's suggestion that an 18 year old grunt may be difficult to teach to deploy a tourniquet close to a wound... these young people are entrusted with deadly weapons and taught to use them with skill and discretion under extreme stress. I believe they can learn best practice first aid with the same proficiency.

i don't want you to take this the wrong way but have you witnessed these 18 year olds who are taught to use deadly weapons will skill and discretion under extreme stress? half of them can't handle a sprained ankle. go to sick call sometime at your local infantry unit, you will be aghast.

from my personal experience, when the **** hits the fan everything becomes more complicated. doctors do the same with codes-- we have code teams to prevent a single person blindly focusing on one area at the expense of others, following the wrong protocol, or missing something. to expect a single medic to handle a patient dropped suddenly in his lap (and with IEDs it's often more than one) it's unreasonable to expect them to be functioning at 100%. it's why the new emphasis of care under fire was created. they don't have time to expose and precisely locate and place a tourniquet 2 inches above the wound and get it tight enough so it oozes but not too tight. or to try a pressure dressing and see if it would suffice instead of a tourniquet. if they do their initial assessment and see significant bleeding they slap it on, stop the bleeding, and evac the patient. almost all of their trauma training is (in my opinion) is correctly focused on initial stabilization and evac. it's why NTC has strict evac standards for died of wounds-- they hammer the evac aspect 10x more than whatever medical care is being provided because they've discovered what saves lives is getting the patient to the CSH where the surgeons are.

that's different than maybe a role 1 (thought most go from point of injury to the CSH now which makes it more of a rarity) where there would be a PA or Doc who can consider the things you correctly are concerned about and can try the "hold pressure for X minutes" and reassess. but in the acute setting that i think you are asking about I'm still on the "the enemy of good is better" side of the fence and would defer any tourniquet manipulation to the CSH in a controlled environment. monkeying around with better placement if time allows may be ok, but the acute threat to their life based on probability is the injury not the reperfusion phenomenon.

Most recent conflicts have benefitted from much better battlefield medicine than tourniquets, which are after all, a fairly primitive form of hemostasis.

true. but if you look at the data early in OIF/OEF if I recall correctly preventable deaths were due to hemorrhage and tension pneumos. they are primitive but that has been the one philosophical change that has had the greatest impact in our historic survival rate. that and the rapid adaptation of point of injury to CSH instead of the old battle line conventional war model of POI -> role 1 -> role 2 -> CSH. the funny thing is the current equipment standard is still to this old model. which, in my opinion, leaves the role 2 with a lot of evac assets they never really use.

The topical cellulose / thrombin products and other hemostatic products that have been developed for the modern battlefield have begun to reduce the need for tourniquets, and I would attribute some of the improvement in recent stats to that exchange for a more benign approach to stopping exsanguination. It also helps that extraction from the field is typically much more prompt than in previous eras, and that tourniquet time is thereby decreased over previous eras. Still, I remain concerned for situations where definitive care is delayed and think that it is worth employing best practices when tourniquets must be used.

in my experience combat gauze and the like are very useful for certain injuries. but I would disagree the improvement in recent stats is due to it. I would argue the opposite-- that the continued emphasis on aggressively stopping the bleeding (even if overkill via a tourniquet), treating a tension pneumo if they have it and getting them to the CSH accounts for it.

again, this is not my primary MOS, and I guess if we have any trauma surgeons or general surgeons around they can comment as well. good discussion and I hope you don't take me disagreeing personally-- I think we just fall on different sides of the philosophical argument. In a perfect world (or even CONUS), I'd probably agree with you but deployed military settings are far away from being perfect.

--your friendly neighborhood seeing the malingering sick call horde caveman

 

[dpmd]

I think the pendulum is swinging towards tourniquet anytime you see any blood rather than having the medic take time to evaluate whether one is necessary. In the case of care under fire I suppose high and tight needs to be the mantra because you aren't even necessarily seeing the wounds. The problem is when there will be prolonged field care and people are so stuck on the high and tight doctrine that they don't reeval. When I was trained as a medic before going to med school, tourniquets were taught but not with the level of focus it sounds like they are given now. In time the pendulum may swing back away from tourniquets for all. In the meantime, teaching those you work with that while high and tight is the care under fire standard that when **** calms down, exposure and evaluation of the need for that tourniquet is important. Having controlled audible bleeding with just a well placed finger it is easy for me to have the confidence to take down a tourniquet others have applied. The trick is figuring out how to train others who haven't had that experience.

 

[Promethean]

Thank you all for this interesting discussion.

I agree that better is the enemy of good, and thank you for that reminder.

 

[d2305]

I cringed when I saw the medic trying to clamp off the femoral artery in Black Hawk Down. I'm glad that I never had to try. I think I was taught to loosen the tourniquet every 2 hours, and later changed to leave it on and write a "T" on his forehead.

 

[dpmd]

I cringed when I saw the medic trying to clamp off the femoral artery in Black Hawk Down. I'm glad that I never had to try. I think I was taught to loosen the tourniquet every 2 hours, and later changed to leave it on and write a "T" on his forehead.

In basic we were taught to mark a T on the forehead "blood, mud, or feces". Ah drill sgts, what a way you have with words.

 

[d2305]

Do they have whole blood at the battalion aid station?

 

[Atlas Shrugged]

Do they have whole blood at the battalion aid station?

Walking blood bank, if that. No stored blood products.

 

[SurfingDoctor]

Just curious... has REBOA made its way into operational use?
A Perspective on the Potential for Battlefield Resuscitative Endovascular Balloon Occlusion of the Aorta. - PubMed - NCBI

Last trauma meeting I when to, the military was spending all sorts of DoD funding in damage control devices. They made it sound like it was going to have operational use for large hemorrhagic bleeding in the field and was going to be placed by medics/corpsmen. Clearly, based on the above article, opinions vary.

As for blood products... DoD also is investing heavily in freeze dried blood products. I know they have plasma, not sure if it is employed.
ASBP: Freeze-dried Plasma Effort Seeks to Increase Battlefield Survival Rates

 

[d2305]

I don't think that plasma is much better than normal saline. I didn't have any "blood bags" on my ship. I guess carriers have O neg in the refer.

 

[Shikima]

POGs are just walking blood banks.

 

[Homunculus]

REBOA will be at Role I and POI in a few years. We need to develop a evidenced based algorithm and a sustainable training pathway. Both of which I'm interested in. As far as plasma, SOF has been using it since 2010 with several uses at the POI. HK Beecher noted in WWII, that plasma gives the more severely injured patient more time to get to a surgeon. Low titer Group O whole blood is moving extremely fast and hopefully will be available for Role I and II soon. I carried and transfused the first Group O low titer stored whole blood last year at the POI in AFG.

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re: REBOA- for the pointy end of the spear, maybe. otherwise it would be a flail. just doing a chest tube at a role 1 is challenging enough-- I can't imagine the complications and the rate of successfully placing a REBOA in a "typical" role 1 scenario. how many do you have to do to become proficient? most PROFIS docs are not ER, and asking them to do something like this is like playing the lottery. maybe once in awhile one would get lucky, but even the hard core SF folks could only manage this:

"REBOA may have a place in prehospital resuscitation but patient and provider selection are paramount. The procedure, although simple in description, is quite complicated and can cause major physiologic changes best dealt with by experienced providers. REBOA is incapable of extending the golden hour limiting the procedure's utility."

hardly a ringing endorsement. this won't be routinely available at role 1's for 5-10 years, if ever.

as far as blood products go-- they can only go as far as your refrigeration capacity. by doctrine, a role 1 does not have this-- though practically most do. the old linear battlefield everyone is still trained on and that is still taught is outdated and in need of a major overhaul. the newer model should have role 1's like cell towers, with role 2s as major nodes within them. injuries if possible should go POI->CSH or nearest FST. keep the trauma specialists with their high tech toys and skills consolidated and accessible. outcomes will be better and the role 1's can focus on perfecting basic trauma stabilization instead of pie in the sky hail mary interventions. at some point "good enough" has to be "good enough."

--your friendly neighborhood good idea fairy trapping caveman

 

[d2305]

Anyone know how to do a direct transfusion? From 100 years ago. "Various other devices for achieving the same result have been elaborated by other workers, and attention may be drawn to those of Elsberg and Bernheim, both of which are described in the book by the latter on " Blood Transfusion." During the war a simpler method was introduced by Colonel Andrew Fullerton, who, working at a Base Hospital in France, found that he could get good results by employing a thin rubber tube with a small silver cannula at either end. The apparatus was first coated on the inside with a thin layer of paraffin wax, in order to discourage clotting within the tube, and the cannula were introduced into the donor's artery and the recipient's vein respectively. The blood could then flow freely from one to the other. The fact that blood was being transmitted was taken to be proved by the visible pulsation of the thin rubber connecting-tube synchronously with the arterial pulsations. The disappearance of this was assumed to be evidence that clotting had occurred. This method was described by Colonel Fullerton to the surgeons working at the Casualty Clearing Stations, where blood transfusion was likely to be of most service, but it was never used extensively. The coating of the inside of the tube with paraffin is in itself an operation of some difficulty. Under conditions in which any loss of time could not be permitted, success by this method was not attained with sufficient certainty, and it, was shortly afterwards replaced by the more satisfactory methods described below. The most recent work on direct transfusion has been done by J. M. Graham at Edinburgh, who has however reached the conclusion that the. technique is always more difficult than that of indirect transfusion."

 

[mimelim]

Just curious... has REBOA made its way into operational use?
A Perspective on the Potential for Battlefield Resuscitative Endovascular Balloon Occlusion of the Aorta. - PubMed - NCBI

Last trauma meeting I when to, the military was spending all sorts of DoD funding in damage control devices. They made it sound like it was going to have operational use for large hemorrhagic bleeding in the field and was going to be placed by medics/corpsmen. Clearly, based on the above article, opinions vary.

As for blood products... DoD also is investing heavily in freeze dried blood products. I know they have plasma, not sure if it is employed.
ASBP: Freeze-dried Plasma Effort Seeks to Increase Battlefield Survival Rates

re: REBOA- for the pointy end of the spear, maybe. otherwise it would be a flail. just doing a chest tube at a role 1 is challenging enough-- I can't imagine the complications and the rate of successfully placing a REBOA in a "typical" role 1 scenario. how many do you have to do to become proficient? most PROFIS docs are not ER, and asking them to do something like this is like playing the lottery. maybe once in awhile one would get lucky, but even the hard core SF folks could only manage this:

"REBOA may have a place in prehospital resuscitation but patient and provider selection are paramount. The procedure, although simple in description, is quite complicated and can cause major physiologic changes best dealt with by experienced providers. REBOA is incapable of extending the golden hour limiting the procedure's utility."

hardly a ringing endorsement. this won't be routinely available at role 1's for 5-10 years, if ever.

as far as blood products go-- they can only go as far as your refrigeration capacity. by doctrine, a role 1 does not have this-- though practically most do. the old linear battlefield everyone is still trained on and that is still taught is outdated and in need of a major overhaul. the newer model should have role 1's like cell towers, with role 2s as major nodes within them. injuries if possible should go POI->CSH or nearest FST. keep the trauma specialists with their high tech toys and skills consolidated and accessible. outcomes will be better and the role 1's can focus on perfecting basic trauma stabilization instead of pie in the sky hail mary interventions. at some point "good enough" has to be "good enough."

--your friendly neighborhood good idea fairy trapping caveman

REBOA in a major trauma center with is hard enough, I can only imagine how difficult it would be to sort out in an even less controlled setting. I have done 3 REBOA, seen maybe half a dozen more and have reviewed a major trauma center's experience. The access complication rate is absurdly high among non-vascular trained personal. Never mind surgically trained or even interventionally trained.

Just a little background... Access site complications from percutaneous interventional procedures is incredibly under reported. My guess is that in elective, uncomplicated patients, the rate is somewhere in the 2-5% range, depending on the provider, the use of ultrasound and the patient population in question. And that is among people that do a dozen or more cases a week. Never mind putting this in the hands of someone who doesn't really do percutaneous access on a regular basis, is under the stress of an emergency procedure and is in far from optimal conditions. You are talking about 50%+ problems without trying hard.

I wouldn't want someone someone doing this on me. I would want someone to crack my chest and cross clamp my aorta. I obviously say that as a civilian and experience only in major trauma centers, but I also say that as someone who lives and breathes vascular surgery with a strong interest in trauma. In the absence of the capabilities to do that, I can imagine 50% complication rate is okay if the rest of the system can get figured out so that the success rate is reasonable. But, I can not imagine a world where it would make sense to attempt REBOA outside of very controlled, specific environments.

 

[SurfingDoctor]

REBOA in a major trauma center with is hard enough, I can only imagine how difficult it would be to sort out in an even less controlled setting. I have done 3 REBOA, seen maybe half a dozen more and have reviewed a major trauma center's experience. The access complication rate is absurdly high among non-vascular trained personal. Never mind surgically trained or even interventionally trained.

Just a little background... Access site complications from percutaneous interventional procedures is incredibly under reported. My guess is that in elective, uncomplicated patients, the rate is somewhere in the 2-5% range, depending on the provider, the use of ultrasound and the patient population in question. And that is among people that do a dozen or more cases a week. Never mind putting this in the hands of someone who doesn't really do percutaneous access on a regular basis, is under the stress of an emergency procedure and is in far from optimal conditions. You are talking about 50%+ problems without trying hard.

I wouldn't want someone someone doing this on me. I would want someone to crack my chest and cross clamp my aorta. I obviously say that as a civilian and experience only in major trauma centers, but I also say that as someone who lives and breathes vascular surgery with a strong interest in trauma. In the absence of the capabilities to do that, I can imagine 50% complication rate is okay if the rest of the system can get figured out so that the success rate is reasonable. But, I can not imagine a world where it would make sense to attempt REBOA outside of very controlled, specific environments.

Yes, I suspect the technique is easier said than done and has a not insignificant complication rate, even in trained hand. However, I think it was to be used when external compression was unable to achieve adequate hemorrhage control. Last stats I saw stated 75% of causalities died from hemorrhage. Needless to say there's all sorts of arteries and major viens that could be cause of that and REBOA only works in the lower extremities/lower abdomen from my understanding. And I don't know what percent of the 75% would account for those types of injuries, but I think the purpose (from my understanding) was salvage therapy when extraction wasn't readily available. Again, I don't what the causality rate specific to that scenario is, but it didn't seem insignificant.

 

[Homunculus]

I appreciate the skepticism, it's the only way to progress in a manner than has the best results. I'm not saying putting skills like REBOA at the POI/Role I is going to be easy, but I believe, programs will be of benefit. Not done by medics per se, but by a team (PA/Doc with medics). The REBOA gurus feel it can be done, and I understand Knight's concerns, they are legitimate. However, putting state of the art medicine as close to the POI will undoubtedly lead to more lives saved. I don't know how many times you need to do it to be proficient, but we will never know if we do not at least evaluate the capability.

I'm skeptical because I think we come from different parts of field medicine. you (im guessing given your research) work with and train with highly functioning highly motivated people. go visit a local role 1 downrange. it might be staffed by any random assortment of specialties and medics with various levels of experience. they may hav a doc and PA or they may be split up, or may simply not have one or the other. they aren't doing SF medicine day in day out-- they're doing sick call and basic trauma resuscitations/stabilizations. sure a 1 week crash course like the TCMC course might familiarize people with it, but 6 months later would that suffice? could it be a hail mary that may work? sure. but at what expense? the injury requiring this intervention is likely to never make it to the role 1 door. in looking at the indications, it appears that imaging is recommended before placement. would the military standard just be to forego all that and "just do it" in the hopes it works? what zone do you place it in? how do you confirm placement?

True, by doctrine, Role I does not have the capability to store blood, but we rarely do anything by doctrine, and nothing says doctrine is the right approach.

in the SF world, yes. in the rest of the army, no. we are staffed and equipped based on Vietnam era thought processes. my CAV unit legit has 113's for evac assets. that's what they train with. I just can't see how any HHC company commander is going to justify a generator, fridge, the medical maintenance and monitoring of said fridge and planning for how to haul it around. what happens when it breaks?

a role 1 should not be relied on for ultrasound, xrays, refrigeration or labs. are there role 1s that have this? sure, in mature theaters. but in new environments (syria, Iraq v2.0) it's not as common. the second you rely on this being the standard you will find some tailgate medicine style role 1 setup.

I wholeheartedly agree, that cax should get to a surgeon as soon as possible. Kotwal et al. also demonstrated that any advanced procedure or treatment in the prehospital setting may decrease mortality. Putting advanced care where the cax are injured or may even be evacuated too is not ignoring that they need a surgeon, it is giving them some extra time. Again, absolutely agree that POI to a surgeon is optimal and no cax should have delayed evacuation to surgical care, but POI/Role I does not always allow for it.

I agree. I think we're of the same thought process that this might be useful, but I'm seeing it more pragmatically from the plug and play PROFIS side of the house. at some point they should just bite the bullet and upgrade the role 1's to role 2's, since that's what people seem to expect nowadays.

--your friendly neighborhood jack of all trades master of none PROFIS caveman

 

[pgg]

However, putting state of the art medicine as close to the POI will undoubtedly lead to more lives saved.

That's a bold statement.

 

[pgg]

Yes, I suspect the technique is easier said than done and has a not insignificant complication rate, even in trained hand.

Every day I watch trained cardiac surgeons get femoral access. It's not always easy. And these are ideal conditions in normovolemic patients.

This is going to get done in the dark and the dirt, with poor exposure, in a tactical situation, by less trained people, after the balloon itself gets stepped on and flopped and dragged across non-sterile bits of clothing and gear ... I can't roll my eyes hard enough.

I gotta admit, this POI REBOA idea had me bursting with laughter when I first read it upthread. For every successful placement under battlefield conditions I bet two end up in the IVC and nine just poke holes in the femoral artery and vein before ending up on the floor when they just say **** it.

 

[SurfingDoctor]

Every day I watch trained cardiac surgeons get femoral access. It's not always easy. And these are ideal conditions in normovolemic patients.

This is going to get done in the dark and the dirt, with poor exposure, in a tactical situation, by less trained people, after the balloon itself gets stepped on and flopped and dragged across non-sterile bits of clothing and gear ... I can't roll my eyes hard enough.

I gotta admit, this POI REBOA idea had me bursting with laughter when I first read it upthread. For every successful placement under battlefield conditions I bet two end up in the IVC and nine just poke holes in the femoral artery and vein before ending up on the floor when they just say **** it.

Yes, there are likely to be complications and unsuccessful attempts, though I wonder how that is different than any other situation where a less skilled first responder is attempting to intervene in a patient who likely won't survive without emergent intervention? I've seen paramedics/EMTs, even adult ERs physicians, make all sorts of errors and mistakes. Some it caused harm, some it helped, some it didn't make a difference. I'm not suggesting it's a good or bad idea, but the situation you described, non-experts intervening in critically ill/injured patients, happens all the time.

I didn't get the idea that it was meant to replace a tourniquet or a pressure dressing and if that is how they are selling the idea, that is terribly misguided. Anyway, I'll be interested to see how much traction device-mediated salvage therapy gets.

 

[pgg]

Yes, there are likely to be complications and unsuccessful attempts, though I wonder how that is different than any other situation where a less skilled first responder is attempting to intervene in a patient who likely won't survive without emergent intervention?

It's different because it involves screwing around with the femoral vessels and a giant device with major capacity for harm, in an environment that doesn't have the kind of diagnostic tools (xray, FAST) to position the device properly, and people who aren't doctors who (despite a couple hours of instruction and a weekend workshop and an inkjet printer Certificate Of Awesome Competence) don't have the training or experience to safely access the femoral artery under ideal conditions, much less austere ones.

The whole idea of doing this at POI is absolutely pants-on-head, clown-shoes, special-kid-should-be-wearing-a-helmet, nuclear grade ******ed.

This is literally the dumbest idea for hooo-ah forward POI high speed low drag care I've read since ... I don't know. It's been a while.

 

[Homunculus]

The whole idea of doing this at POI is absolutely pants-on-head, clown-shoes, special-kid-should-be-wearing-a-helmet, nuclear grade ******ed.

omg. literally lol'd at this line.

as an aside-- I wonder what the impact factor of the special forces medical journal is?

--your friendly neighborhood forgot to renew his JAMA- Military Medicine journal subscription

 

[d2305]

Reboa too hard, but artificial blood that doesn't require refrigeration would save lives. Not related, but I was amazed to find out the SF (not medics) extract teeth in Central America.

 

[SurfingDoctor]

It's different because it involves screwing around with the femoral vessels and a giant device with major capacity for harm, in an environment that doesn't have the kind of diagnostic tools (xray, FAST) to position the device properly, and people who aren't doctors who (despite a couple hours of instruction and a weekend workshop and an inkjet printer Certificate Of Awesome Competence) don't have the training or experience to safely access the femoral artery under ideal conditions, much less austere ones.

I won't speak to battlefield medicine and I suspect it situation provides unique challenges, but what you described here also could apply to any out of hospital intubation for respiratory failure. I suppose there would be an argument for EMT and paramedics not intubating someone with ineffective breathing after being ejected from a car because they don't have enough skill or immediate resources (e.g. X-ray), but I bet you could also find a number of people who think they should in certain situations.

 

[pgg]

I won't speak to battlefield medicine and I suspect it situation provides unique challenges, but what you described here also could apply to any out of hospital intubation for respiratory failure. I suppose there would be an argument for EMT and paramedics not intubating someone with ineffective breathing after being ejected from a car because they don't have enough skill or immediate resources (e.g. X-ray), but I bet you could also find a number of people who think they should in certain situations.

Intubation doesn't require an xray; all you need are a tube, laryngoscope, disposable CO2 detector, and an ambubag. And training. EMTs and paramedics have a big truck to haul a bunch of stuff around. They also respond to different problems. They get mostly medical (non-trauma) calls that require airway support often enough to maintain the skills. They work in pairs, typically new guys get an experienced partner and OJT is significant. None of these things are generally true of .mil Corpsmen and medics.

Intubation is actually an excellent example of something our Corpsmen and medics really aren't good at.

Setting aside the important logistic issue of carrying tubes, a laryngoscope, and an ambu-bag (you'd be surprised how many of my Corpsmen neglected to include that bulky third item when stocking their aid bags!) ... the basic problem is that intubation is not a skill that they have.

And like this silly REBOA POI concept, it's a procedure that carries real risk - an esophageal intubation is more or less a clean kill.

Intubation is a skill that needs more than a rep or two on a mannequin to get right. I'm an anesthesiologist - we often have non-anesthesia interns and residents rotate with us for airway experience. Under ideal conditions such as a well lit OR, table at a good height, a preoxygenated patient, an anesthetized and paralyzed patient, no real fear or responsibility, and an expert walking them through every step ... doctors still can't get the airway about half the time. Even the easy ones. After a week or so and a dozen reps on humans, most will be able to get the easy airways. Most.

Never ever have I ever seen a Corpsman or medic rotate through our ORs to get intubation experience. And that's OK, because they don't need it.

Your average trauma patient still has respiratory drive and an oro or nasopharyngeal airway is sufficient. If he doesn't, it's probably because at least part of his brainstem is extracranial. Endotracheal tubes in the hands of Corpsmen and medics at POI are a real danger with little need or benefit.

Ain't no way no how, never ever, nope, are they going to be putting balloons in aortas.

 

[SurfingDoctor]

Intubation doesn't require an xray; all you need are a tube, laryngoscope, disposable CO2 detector, and an ambubag. And training. EMTs and paramedics have a big truck to haul a bunch of stuff around. They also respond to different problems. They get mostly medical (non-trauma) calls that require airway support often enough to maintain the skills. They work in pairs, typically new guys get an experienced partner and OJT is significant. None of these things are generally true of .mil Corpsmen and medics.

Intubation is actually an excellent example of something our Corpsmen and medics really aren't good at.

Setting aside the important logistic issue of carrying tubes, a laryngoscope, and an ambu-bag (you'd be surprised how many of my Corpsmen neglected to include that bulky third item when stocking their aid bags!) ... the basic problem is that intubation is not a skill that they have.

And like this silly REBOA POI concept, it's a procedure that carries real risk - an esophageal intubation is more or less a clean kill.

Intubation is a skill that needs more than a rep or two on a mannequin to get right. I'm an anesthesiologist - we often have non-anesthesia interns and residents rotate with us for airway experience. Under ideal conditions such as a well lit OR, table at a good height, a preoxygenated patient, an anesthetized and paralyzed patient, no real fear or responsibility, and an expert walking them through every step ... doctors still can't get the airway about half the time. Even the easy ones. After a week or so and a dozen reps on humans, most will be able to get the easy airways. Most.

Never ever have I ever seen a Corpsman or medic rotate through our ORs to get intubation experience. And that's OK, because they don't need it.

Your average trauma patient still has respiratory drive and an oro or nasopharyngeal airway is sufficient. If he doesn't, it's probably because at least part of his brainstem is extracranial. Endotracheal tubes in the hands of Corpsmen and medics at POI are a real danger with little need or benefit.

Ain't no way no how, never ever, nope, are they going to be putting balloons in aortas.

No ambu, that does seem rather problematic.

Anyway, like I said, I don't treat battlefield injuries, and I have seen enough clusters in the US from first responders to surmise that applications of those techniques at POI and in theater could be more problematic. That being said, I doubt people will abandon the idea of device-mediated hemorrhage control beyond a tourniquet. I'm sure it will undergo many interations and I'm curious to see where it leads. Maybe no where, but I don't know. Transfusions were considered "research" in World War I field hospitals, we've come quite a bit away from that notion.

 

[NotAnOperator]

And you can substitute 'corpsman' or 'medic' for scouts in your sentence above, because that's what they're teaching them in their dinky schools (liberal application of tourniquets to small distal wounds, in a stable patient). This is what I really fear the most.... usage of a Tourniquet in patient that clearly does not need one

This is false. 68W/18D/corpsmen/PJs/4Ns are taught to only apply tourniquets when pressure dressing and combat gauze fails to stop gross bleeding because then your patient's "C" in CAB/ABC is compromised. This is the way I was initially trained years ago and it is the way I currently train my students as a cadre in one of the "dinky schools" recognized by the NREMT and AHA.

If the corpsmen you work with say they were taught to "liberally apply tourniquets to small distal wounds in a stable patient," you need to tell their leadership they need remedial training as they are below the standard.

 

[d2305]

I had a laryngoscope and ET tubes on my ship, but never had an opportunity (or training) to use it. I did use O2 on a MI patient once (he survived). I had MAST kit under my exam table which probably would have caused more harm to the patient.

 

[Ziehl-Neelsen]

Ahh blood talk. Now we're in my wheelhouse.

As for blood products... DoD also is investing heavily in freeze dried blood products. I know they have plasma, not sure if it is employed.

Lyophilized plasma is already in use in Ranger Bats and other SF groups. We currently get our supply from the French, who use the technology we developed in Korea for lyophilized plasma. The US discontinued the lyophilized plasma program in the Korea-Vietnam era due to a number of viral hepatitis infections, but the French experience with lyophilized plasma brought it back into vogue. DoD has already name a US supplier to manufacture our own lyophilized plasma for use at the POI.
Vascular Solutions Announces IND Submission for RePlas™ Freeze-Dried Plasma

Anyone know how to do a direct transfusion? From 100 years ago. "Various other devices for achieving the same result have been elaborated by other workers, and attention may be drawn to those of Elsberg and Bernheim, both of which are described in the book by the latter on " Blood Transfusion." During the war a simpler method was introduced by Colonel Andrew Fullerton, who, working at a Base Hospital in France, found that he could get good results by employing a thin rubber tube with a small silver cannula at either end. The apparatus was first coated on the inside with a thin layer of paraffin wax, in order to discourage clotting within the tube, and the cannula were introduced into the donor's artery and the recipient's vein respectively. The blood could then flow freely from one to the other. The fact that blood was being transmitted was taken to be proved by the visible pulsation of the thin rubber connecting-tube synchronously with the arterial pulsations. The disappearance of this was assumed to be evidence that clotting had occurred. This method was described by Colonel Fullerton to the surgeons working at the Casualty Clearing Stations, where blood transfusion was likely to be of most service, but it was never used extensively. The coating of the inside of the tube with paraffin is in itself an operation of some difficulty. Under conditions in which any loss of time could not be permitted, success by this method was not attained with sufficient certainty, and it, was shortly afterwards replaced by the more satisfactory methods described below. The most recent work on direct transfusion has been done by J. M. Graham at Edinburgh, who has however reached the conclusion that the. technique is always more difficult than that of indirect transfusion."

There is no need to perform a direct transfusion in theatre. Transfusion of fresh warm whole blood involves drawing from a donor into a prepackaged blood donation bag that is already filled with anticoagulant. These bags can be immediately hung for transfusion to the exsanguinating patient. The advantage of this method is the obvious--that you don't take the risk of clotting off the circuit--and the less obvious: you can collect from multiple donors at once for a massively bleeding patient; the blood can be stored for 4 hours in the anticoagulated bag for when the patient requires it and be moved with the patient; the donor can immediately reassume other responsibilities instead of being tethered to the patient; closer monitoring of the blood volume drawn from donors as to not significantly compromise the aerobic function of the donor by drawing an excessive amount of whole blood.

See the following for a description of warm fresh whole blood transfused at the POI:
Fresh whole blood transfusion for a combat casualty in austere combat environment. - PubMed - NCBI