Introduction

Control of hemorrhage resulting from vascular disruption has been the historical cornerstone of trauma care. Throughout the world, traumatic injury is the leading cause of mortality and morbidity for patients aged 1 to 59. In the United States, trauma is the leading cause of death in individuals aged 1 to 40, accounting for over 150,000 deaths per year. The goals of trauma management are to ensure survival and to optimize the patient’s potential for achieving and maintaining the best possible functional recovery.

A comprehensive overview of the prehospital care of the trauma patient has been provided for both the civilian and military settings. This chapter will focus more directly on two aspects of prehospital care—stopping the bleeding that results from vascular trauma and preventing and treating hemorrhagic shock.

* Note: The views, opinions, and assertions expressed in this chapter are those of the authors alone and do not necessarily reflect the views of the Department of the Army or the Department of Defense.

Preventable Death

Avoidance of preventable death is the most important outcome measure in battlefield trauma care. Every preventable death is a call to action. Every effort is also made to ensure that limbs are saved whenever possible and that other avoidable adverse outcomes from the trauma are minimized.

Understanding the incidence of death from potentially survivable injuries in combat requires examination of autopsy records from the Office of the Armed Forces Medical Examiner (AFME). Published reports of the incidence of death in casualties with potentially survivable injuries from the conflicts in Iraq and Afghanistan range from 15% to 28%. Hemorrhage is still the leading cause of death in combat casualties. The key to reducing preventable fatalities is to achieve rapid and definitive control of vascular disruption and subsequent hemorrhage.

It is useful to think of hemorrhage in the prehospital setting as being one of the following two types: compressible (either extremity hemorrhage or external hemorrhage not suitable for a tourniquet) or noncompressible (internal). The extremities are the most commonly injured anatomic region in the combat wounded, representing over 50% of all anatomic combat wounds. In polytrauma casualties (most commonly from fragments from explosive devices), 82% of combat wounded have an injury to at least one limb. Martin’s paper from Iraq, describing 151 in-hospital deaths, noted that the predominant causes of death were head injury (45%) and hemorrhage (32%). Improvements in diagnosing ongoing blood loss and resuscitation from shock (including efforts directed at maintaining coagulation status as close to normal as possible) offer the potential for improved survival in both categories ( Fig. 16-1 ).

Distribution of combat injuries: head, 30%; trunk, 15%; lower extremities, 25%; upper extremities, 30%.

(From Owens B, et al: Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 64:295–299, 2008.)

General Aspects of Care

Tactical Combat Casualty Care (TCCC) is a set of prehospital trauma care guidelines customized for use on the battlefield. TCCC recognizes the need to combine good medicine with good small-unit tactics while treating trauma on the battlefield. It focuses intensely on minimizing blood loss in injured warriors, and it has rapidly gained traction as an effective means of reducing combat death. In one study of a U.S. Army unit where TCCC training was instituted—before the start of the conflicts in Iraq and Afghanistan—the overall incidence of preventable deaths in 419 battle injury casualties was 3%, with no deaths due to lack of required prehospital interventions. TCCC has been recommended for all deploying U.S. combatants and physicians, is part of all U.S. military service combat medical training, is an integral component of the Army’s Combat Lifesaver course, and is mandatory for deploying Special Operations forces. TCCC has just been adopted as the standard of care by the ABCA (America, Britain, Canada, Australia, and New Zealand) Armies’ Program.

Prehospital Trauma Life Support (PHTLS) is the civilian counterpart to TCCC. It is designed primarily for use by nonphysicians in the prehospital setting and concentrates more on the management of blunt trauma than TCCC and, as such, reflects the nature of the epidemiology of civilian injury patterns. Implementation of a comprehensive PHTLS program has been shown to reduce mortality in trauma systems. The last 15 years has seen an increasingly close working relationship develop between the civilian and the military prehospital trauma care sectors, with an ongoing exchange of information and management concepts and copublication of both sets of management strategies in the seventh edition of the PHTLS manual.

Control of Extremity Hemorrhage: Tourniquets

Although tourniquets had been available for use in trauma patients for almost 500 years by the time of the Vietnam War, it is notable that exsanguination from extremity wounds was the leading cause of preventable death in the Vietnam conflict. In this respect, Maughon’s 1970 study on causes of death in U.S. combatants documented a 7.4% incidence of preventable death.

Noting the implications of Maughon’s study and further writings from Ron Bellamy, the originators of TCCC established this course in 1996—some 5 years before the onset of Operation Enduring Freedom (OEF) in Afghanistan—and made an appeal for aggressive use of tourniquets to control life-threatening extremity hemorrhage. This call was contrary to what was taught in civilian trauma courses and centers, but further evidence was provided by Mabry’s analysis of extremity hemorrhage among U.S. Special Operations casualties sustained in Mogadishu. Further data of the significance of extremity hemorrhage as a cause of preventable death continued to accrue from the Iraq and Afghanistan wars. Kelly’s paper from 2008, which reviewed fatalities occurring up to December 2006, documented a 7.8% death rate from extremity hemorrhage with 77 deaths resulting from failure to use a tourniquet. To restate, even in 2006, the death rate from extremity hemorrhage in U.S. forces in Iraq and Afghanistan was essentially the same as that observed in Vietnam.

Contrast this experience with the aforementioned Kotwal study that documented the Ranger experience with TCCC. The Rangers are one of only three groups in the U.S. military to have implemented TCCC protocols and training throughout their combatant force and to have done so before 2001, and they were the only group to publish their experience. Every Ranger went to war in Iraq and Afghanistan equipped with a tourniquet and trained in its use. Preventable deaths from failure to obtain prehospital control of extremity hemorrhage throughout the recent decade of conflict have been zero.

Two publications were instrumental in bringing about the widespread adoption of tourniquets to control extremity hemorrhage from vascular trauma by the U.S. military. Firstly, Holcomb’s 2007 analysis of a small cohort of Special Operations fatalities from OEF revealed that, several years into the war, extremity hemorrhage was still a leading cause of preventable death. Secondly, a report from the U.S. Army Institute of Surgical Research describing the laboratory evaluation of commercially available tourniquets made specific recommendations about which tourniquet would best suit troops for use on the battlefield. The three tourniquets that were found to meet this requirement were the Combat Application Tourniquet (CAT), the Special Operations Forces Tactical Tourniquet (SOFTT), and the Emergency Medical Tourniquet (EMT) ( Fig. 16-2, A-C ). The EMT is a pneumatic tourniquet and is susceptible to ballistic damage (bullets or shrapnel strikes) that may render the tourniquet nonfunctional. The CAT was fielded by both Special Operations forces and subsequently by the Army in 2005, although the SOFTT is preferred by some individual units. The CAT® and SOFTT are both windlass-type devices that are lightweight and relatively inexpensive. These tourniquets can be readily applied to one’s own or another’s extremity and are rugged, reliable, and small enough to be easily carried. The CAT has been designated as an item of individual issue to ground combatants in all services and has proven effective and reliable in the current conflicts. (See Fig. 16-2, A-C ). Evaluation and testing of updated models continues in the quest to refine tourniquet design.

A, Combat Application Tourniquet (CAT). B, Special Operations Forces Tactical Tourniquet (SOFTT). C, Emergency and Military Tourniquet (EMT).

The relevance of vascular trauma throughout the TCCC Guidelines is readily apparent. Specifically, these guidelines, last updated in October 2014, call for tourniquet use in the Care Under Fire Phase of Care (that phase of battlefield trauma care carried out in the presence of effective incoming fire) as follows :

• 7.
  

  Stop life-threatening external hemorrhage if tactically feasible:

  
  
  
  
  • •
    

    Direct casualty to control hemorrhage by self-aid if able.

    
    
  • •
    

    Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.

    
    
  • •
    

    Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover.

  
  
  
  

  When effective incoming fire is not an immediate threat to life, that phase of care is referred to as Tactical Field Care (TFC) and tourniquet guidelines are as follows:

  
  

  Bleeding

  
  
  
  
  • a.
    

    Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the wound. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.

    
    
  • b.
    

    For compressible hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze and ChitoGauze may also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

    
    
  • c.
    

    Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above wound. Ensure that bleeding is stopped. When possible, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse.

    
    
  • d.
    

    Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available.

    
    
  • e.
    

    Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

  
  

Additional recommendations regarding tourniquet use to control vascular injury with bleeding have been adopted by both the Army and TCCC and are shown in Box 16-1 .

When tourniquets are used in the prehospital setting, they have been documented to be remarkably effective at decreasing preventable deaths due to extremity hemorrhage. In order to be most effective, the tourniquet must be applied to the bleeding limb before the casualty has lost enough blood to suffer hypovolemic (Class III) shock. Complications are few if the correct TCCC guidelines are followed. There were no otherwise-preventable incidences of limb loss occurring as a result of tourniquet ischemia in Kragh’s case series of 232 patients with tourniquets on 309 extremities.

Since 2005, TCCC and the use of tourniquets have gained increasing acceptance within the U.S. military. Over the first 5 years of the wars in Afghanistan and Iraq, 7 out of every 100 combat fatalities were due to hemorrhage from extremity wounds. (9) There was no reduction in preventable deaths from this type of injury since the Vietnam war, despite 40 years of elapsed time. The Eastridge report notes that by the end of the war—after TCCC had been implemented in much of the military—deaths from extremity hemorrhage had dropped to 2.6%. (10) The use of prehospital tourniquets remains one of the major lessons learned from the recent conflicts in Iraq and Afghanistan.

Control of External Nonextremity Hemorrhage

Hemostatic Agents

Some anatomic areas such as the neck, the groin, and the axilla contain large vascular structures that are not amenable to tourniquet placement. Bleeding from these areas is often termed junctional hemorrhage as it arises from vascular structures in the transition area between the torso and the extremities. A broader description of junctional hemorrhage is provided in the following section; but for the combat casualty, once care has entered the tactical field phase, better security and more time mean that additional hemorrhage control options become available. For junctional hemorrhage, these options often include a form of topical hemostatic agents and dressings.

The HemCon dressing and the granular agent QuikClot were the initial hemostatic agents to be utilized by TCCC protocols, on the basis of their efficacy of controlling severe bleeding in animal models. These agents were found to work effectively, although some casualties were reported to suffer cutaneous burns with QuikClot use. These hemostatic agents were also found to perform well when used in civilian trauma settings.

Newer hemostatic agents have since become available and have been tested at both the U.S. Army Institute for Surgical Research (USAISR) and the Naval Medical Research Center (NMRC). Both laboratories found that the new agents Combat Gauze and Woundstat were consistently more effective than HemCon and QuikClot. In one ISR study, which used a 6-mm femoral arteriotomy model, only 2 of the 6 animals treated with placebo gauze survived, whereas 8 of the 10 Combat Gauze animals survived. No significant exothermic reaction was noted with either Combat Gauze or Woundstat. Celox was also found to perform better than HemCon and QuikClot ( Fig. 16-3 ). Survival time analysis and a summary of the characteristics of the various hemostatic agents are shown in Figure 16-3 and Table 16-1 .

Survival time analysis. ACS, Advanced Clotting Sponge Plus; CG, Combat Gauze; HC, HemCon; WS, WoundStat.

(Courtesy Dr. Bijan Kheirabadi.)

Table 16-1

Hemostatic Agent Comparison

Courtesy Dr. Bijan Kheirabadi.

	QC ACS +	HemCon	Celox	WoundStat	Combat Gauze
Hemostatic efficacy	+	+	+++	++++	++++
Side effect	None	None	Unknown	Yes	None
Ready to use	√	√	√	√	√
Training requirement	+	+	+	+++	++
Lightweight and durable	++	+++	+++	++	+++
2 years shelf life	√	√	√	√	√
Stable in extreme condition	√	√	√	√	√
FDA approved	√	√	√	√	√
Biodegradable	No	No	Yes	No	No
Cost ($)	∼30	∼75	∼25	30-35	∼25

 

Based on the ISR and NMRC testing results, the TCCC guidelines were changed; and Combat Gauze ( Fig. 16-4 ) is presently recommended as the first line treatment for life-threatening hemorrhage that is not amenable to tourniquet placement. Note that although WoundStat was also effective, subsequent studies at USAISR demonstrated that WoundStat use resulted in occlusive thrombi in injured vessels and resulted in evidence of toxicity to the endothelial cells. Concern about thromboembolic complications resulted in a decision not to recommend this agent in TCCC.

Combat Gauze.

(Courtesy Z-Medica.)

Combat Gauze also has the advantage of being a gauze-type agent rather than a granular one. Based on their field experience, combat medics, corpsmen, and pararescuemen on the Committee on Tactical Combat Casualty Care expressed a preference for gauze over a granular agent. They noted that powder or granular agents do not work well in wounds where the bleeding vessel is at the bottom of a narrow tract. Gauze-type hemostatic agents were believed to be more effective in this setting. Granular agents also present an ocular hazard when used in high wind conditions (caused by transport in or downdraft from evacuation helicopters) and may be problematic to remove from wounds during subsequent operations.

Combat Gauze should be applied with 3 minutes of sustained direct pressure over the bleeding site in order to be effective. Simply applying the Combat Gauze without maintaining pressure is not adequate. After 3 minutes of direct manual pressure, a pressure dressing may be applied to cover the wound and the agent to maintain a degree of pressure. Note that wound geography and contour may impact on the efficacy; Littlejohn found that Combat Gauze did not work well in an animal bleeding model where the bleeding vessel was located at the bottom of a narrow wound tract. Combat Gauze was also found to be no different from standard gauze when the two agents were used without application of direct manual pressure.

The first report of Combat Gauze use in combat operations was published by Ran et al from Israeli Defense Force operations in Gaza. This case series of 14 uses noted a success rate of 79%. Most dressings were applied in anatomic locations where tourniquets could not be used and no significant adverse events were reported. More advanced hemostatic agents may become available in the future, and it is useful to have a standardized bleeding model with which to evaluate these agents. The model currently used by USAISR and NMRC is a 6-mm femoral arteriotomy model designed to have high lethality when the wound is left untreated or packed using a standard gauze dressing. New agents should be tested using this standardized model so that their relative efficacy to Combat Gauze may be objectively evaluated. A key design feature of next generation hemostatic dressings over present-day agents will be the ability to stem hemorrhage in coagulopathic bleeding models.

Hemostatic Agents

Some anatomic areas such as the neck, the groin, and the axilla contain large vascular structures that are not amenable to tourniquet placement. Bleeding from these areas is often termed junctional hemorrhage as it arises from vascular structures in the transition area between the torso and the extremities. A broader description of junctional hemorrhage is provided in the following section; but for the combat casualty, once care has entered the tactical field phase, better security and more time mean that additional hemorrhage control options become available. For junctional hemorrhage, these options often include a form of topical hemostatic agents and dressings.

The HemCon dressing and the granular agent QuikClot were the initial hemostatic agents to be utilized by TCCC protocols, on the basis of their efficacy of controlling severe bleeding in animal models. These agents were found to work effectively, although some casualties were reported to suffer cutaneous burns with QuikClot use. These hemostatic agents were also found to perform well when used in civilian trauma settings.

Newer hemostatic agents have since become available and have been tested at both the U.S. Army Institute for Surgical Research (USAISR) and the Naval Medical Research Center (NMRC). Both laboratories found that the new agents Combat Gauze and Woundstat were consistently more effective than HemCon and QuikClot. In one ISR study, which used a 6-mm femoral arteriotomy model, only 2 of the 6 animals treated with placebo gauze survived, whereas 8 of the 10 Combat Gauze animals survived. No significant exothermic reaction was noted with either Combat Gauze or Woundstat. Celox was also found to perform better than HemCon and QuikClot ( Fig. 16-3 ). Survival time analysis and a summary of the characteristics of the various hemostatic agents are shown in Figure 16-3 and Table 16-1 .

Survival time analysis. ACS, Advanced Clotting Sponge Plus; CG, Combat Gauze; HC, HemCon; WS, WoundStat.

(Courtesy Dr. Bijan Kheirabadi.)

Based on the ISR and NMRC testing results, the TCCC guidelines were changed; and Combat Gauze ( Fig. 16-4 ) is presently recommended as the first line treatment for life-threatening hemorrhage that is not amenable to tourniquet placement. Note that although WoundStat was also effective, subsequent studies at USAISR demonstrated that WoundStat use resulted in occlusive thrombi in injured vessels and resulted in evidence of toxicity to the endothelial cells. Concern about thromboembolic complications resulted in a decision not to recommend this agent in TCCC.

Combat Gauze.

(Courtesy Z-Medica.)

Combat Gauze also has the advantage of being a gauze-type agent rather than a granular one. Based on their field experience, combat medics, corpsmen, and pararescuemen on the Committee on Tactical Combat Casualty Care expressed a preference for gauze over a granular agent. They noted that powder or granular agents do not work well in wounds where the bleeding vessel is at the bottom of a narrow tract. Gauze-type hemostatic agents were believed to be more effective in this setting. Granular agents also present an ocular hazard when used in high wind conditions (caused by transport in or downdraft from evacuation helicopters) and may be problematic to remove from wounds during subsequent operations.

Combat Gauze should be applied with 3 minutes of sustained direct pressure over the bleeding site in order to be effective. Simply applying the Combat Gauze without maintaining pressure is not adequate. After 3 minutes of direct manual pressure, a pressure dressing may be applied to cover the wound and the agent to maintain a degree of pressure. Note that wound geography and contour may impact on the efficacy; Littlejohn found that Combat Gauze did not work well in an animal bleeding model where the bleeding vessel was located at the bottom of a narrow wound tract. Combat Gauze was also found to be no different from standard gauze when the two agents were used without application of direct manual pressure.

The first report of Combat Gauze use in combat operations was published by Ran et al from Israeli Defense Force operations in Gaza. This case series of 14 uses noted a success rate of 79%. Most dressings were applied in anatomic locations where tourniquets could not be used and no significant adverse events were reported. More advanced hemostatic agents may become available in the future, and it is useful to have a standardized bleeding model with which to evaluate these agents. The model currently used by USAISR and NMRC is a 6-mm femoral arteriotomy model designed to have high lethality when the wound is left untreated or packed using a standard gauze dressing. New agents should be tested using this standardized model so that their relative efficacy to Combat Gauze may be objectively evaluated. A key design feature of next generation hemostatic dressings over present-day agents will be the ability to stem hemorrhage in coagulopathic bleeding models.

Junctional Bleeding

“Junctional bleeding” refers to a specific type of vascular trauma and external hemorrhage in dismounted military casualties injured by improvised-explosive-device (IED) weapons. Dismounted complex blast injury ( DCBI) casualties ( Fig. 16-5 ) are often noted to have life-threatening bleeding from vessels in the groin or very proximal lower extremity regions, where a tourniquet is difficult or impossible to apply. The vasculature considered as “junctional” involves the axillary, proximal femoral/distal iliac, and carotid arteries. Casualties with injuries to these areas account for approximately 20% of potentially survivable deaths on the battlefield. These junctional vasculature injuries have been termed “compressible but nontourniquetable” to differentiate these injuries from extremity wounds that can be addressed by tourniquets and from penetrating truncal vasculature injuries considered “noncompressible.” Eastridge and his coauthors reviewed all of the 4596 U.S. combat fatalities that occurred over a 10-year period in Iraq and Afghanistan and found that junctional hemorrhage had surpassed extremity hemorrhage as the leading cause of potentially preventable death from compressible hemorrhag; many of these junctional hemorrhage deaths occurred in DCBI casualties from Afghanistan.

Dismounted complex blast injury.

Although anecdotal reports suggest that Combat Gauze works well for most of these casualties, a backup means of hemorrhage control is needed for cases where tourniquets and/or Combat Gauze are not effective. USAISR has evaluated a junctional hemostatic device, the Combat Ready Clamp (CRoC) and has found it to be a promising technology for controlling hemorrhage in junctional regions such as the groin and the axilla. At the level of the groin, this device stops junctional hemorrhage by applying direct pressure on the external iliac artery at the inguinal ligament ( Fig. 16-6, A and B ). The compressing surface is tightened with a screw mechanism, and counterpressure is exerted from the portion of the clamp that is applied to the posterior surface of the body. The CRoC was presented to the CoTCCC in August 2011 and recommended for inclusion into the TCCC Guidelines. This recommendation was approved by the Defense Health Board in August of 2011. More recently, the Junctional Emergency Treatment Tool and the SAM Junctional Tourniquet have also been recommended for use by the CoTCCC as junctional hemorrhage control devices.

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