EMS bleeding control and fluid resuscitation

1. Shaun Ford
Division Chief North Country EMS

3.  I am not a doctor
 Follow your protocols
 I am staying at Oxford Suites not the Holiday
Inn Express

8. CDC 2013, Final Death Tables
All injury deaths
 Number of deaths: 192,945
 Deaths per 100,000 population: 60.2
Motor vehicle traffic deaths
 Number of deaths: 33,804
 Deaths per 100,000 population: 10.7
All firearm deaths
 Number of deaths: 33,636 (11,208 assault)
 Deaths per 100,000 population: 10.6

9. Non-transport accidents: 92,619
 Falls: 30,208
 Accidental discharge of fire arm: 505
 Accidental drowning: 3,391
 Accidental poisoning: 38,851
Intentional self-harm: 41,149
Complications of medical and surgical
procedures: 2,768
Alcohol: 29,001

13.  Assess your agencies call types
 Assess your prevention programs
 Become great at your usual call
 Be ready for it all

14. Today we are going to discuss
“bleed·ing”
ˈblēdiNG/Adjective/BRITISH/informal
used for emphasis or to express
annoyance.

16. What does blood do?
 transport oxygen and nutrients to the lungs
and tissues
 form blood clots to prevent excess blood loss
 carrying cells and antibodies that fight
infection
 bring waste products to the kidneys and liver,
which filter and clean the blood
 regulate body temperature

17. We will discuss just two things
1) How to stop bleeding
2) How to best treat damage from blood
loss

18.  Tourniquets
 Pressure Dressings
 Wound Packing/Hemostatic Agents
 Clamps
 Fluid Resuscitation
 TXA

19. Indications
 Life threatening limb hemorrhage not
controlled by simple methods, such as
mangled with multiple bleeding points.
 Point of hemorrhage is not accessible due to
patient entrapment or access issues.
 MCI’s where personnel are not available to
maintain other means of bleeding control

20.  As distal as possible, but at least 5cm
proximal to the injury
 Avoid joints as much as possible
 Directly onto bare skin
 Effectiveness based on cessation of the
bleeding and not be presence or absence of
distal pulse

21.  If the tourniquet application is ineffective,
attempt to re-position or tighten.
 If still ineffective consider the placement of a
second tourniquet.
 Oozing may continue after successful
placement due to medullary blood flow.
Emerg Med J. 2007 Aug; 24(8): 584–587

22. Based on 13 studies reporting mortality
data for casualties treated with tourniquets,
prehospital tourniquets are an effective
treatment method for the prevention of death
due to exsanguination. The reported survival
rates for casualties treated with prehospital
tourniquets ranged from 87% to 100%.
Snyder D, Tsou A, Schoelles K. Efficacy of
Prehospital Application of Tourniquets and
Hemostatic Dressings to Control Traumatic
External Hemorrhage.
DOT HS 811 999b. Washington, DC: National
Highway Traffic Safety Administration. May
2014. Available at: www.ems.gov.

27. NO

28.  Improvised devices are not reliable
 Many commercial options
 Do your research and chose one that works
for your application
 Practice frequently
 Review often
 Store it in a readily accessible location

35.  Emergency Bandage
 Israeli Bandage
 Trauma Wound Dressing
 Hemorrhage Control Bandage
 ACE

36.  Bleeding controlled by direct pressure
 Needs constant pressure

40. Many Sizes Available

44. 20-30 mmHg

45.  Can’t or shouldn’t use tourniquet
 What do we do when pressure dressings don’t
control bleeding
 ALS level>Wound Packing?

46. Identify need for wound packing
a. Junctional wounds
b. Large wound cavity
Prepare Equipment
Open “Z” fold gauze & hold in support hand
Locate Bleeding Vessel
a. Visulize inside of wound or place fingers of gloved
hand into wound to find bleeding vessel
b. Tamponade vessel with fingers against wall of
wound


47. Inserting Gauze
a. Begin inserting gauze into wound, placing in
space between fingers & bleeding vessel.
b. Pack gauze into wound tightly until entire
wound cavity is packed
c. If arterial, hold steady, tight pressure over
wound with remaining gauze for three minutes
d. Wrap compression bandage over wound
e. Reassess

48.  Clear out pooled blood to find wound
 Make a ball in the end of the gauze and
place that on vessel wound
 Pile the gauze above the level of the skin
 Pressure dressing/bandage over the top of
wound

49. Gauze
WOUND
DEPARTMENT OF COMBAT MEDIC
TRAINING
C168W003

50.  Q: After packing a wound, how will you know if
the bleeding has NOT been controlled?
You may not know and should not
assume, always consider bleeding may still
continue internally.
A: Blood visible and spreading on
bandaging/dressing
Signs your casualty is entering or
progressing further into hemorrhagic
shock.
DEPARTMENT OF COMBAT MEDIC
TRAINING
C168W003

51.  Wound depth may affect how it is treated.
 Moderate and deep wounds may require
hemostatic agents and gauze packing.
 For superficial wounds, pressure bandages
may be all that is necessary.
DEPARTMENT OF COMBAT MEDIC
TRAINING
C168W003

52.  Impregnated polyester gauze
 Active agents are Kaolin or Chitin
 When kaolin contacts blood it immediately
initiates the clotting process by transforming
Factor XII to it’s activated form XIIa.
 Chitosan functions by adhering to tissue and
sealing wounds, it also possesses antimicrobial
properties
Comparison of novel hemostatic dressings with
QuickClot combat gauze in a standardized swine
model of uncontrolled hemorrhage
Journal of Trauma and Acute Surgery Care, August
2013, V75, Issue 2

54.  Swine models only
 Small study sizes
 High risk of bias
 Some tests not EMS relative, 30-45 second
bleeding time
 In the 3+ minute bleeding tests
◦ 0-17% survival rate with no treatment
◦ 33% with RDH lived
◦ 50-67% with standard gauze lived
◦ 75% with Hemcon Lived
◦ 90% of Quickclot granules lived
◦ 67% of TraumaDex lived

55. Product Agent
Celox Chitosan
HemCon,Chitoflex, Chito Guaze,
Guardacare
Chitosan
Quick Relief, PRO QR, StatSeal,
WoundSeal, TraumaSeal, BioSeal
hydrophilic, or water- loving,
polymer and potassium ferrate
Quikclot Combat Gauze, QuickClot
ACS
Kaolin
RDH, MRDH pGlcNAc fibers
Trauma Dex, Bleed-X, Hemaderm microporous polysaccharide
hemospheres
UltraClot, BallistiClot a proprietary hemostatic agent is
dissolved into the wound from the
UltraClot pouch

57. XSTAT

60. Based on what you see, does it appear bleeding
has been controlled? Why or why not?
DEPARTMENT OF COMBAT MEDIC
TRAINING
C168W003

62. http://www.innovativetraumacare.com/images/iTC-Case-Studies.pdf

65. Filips, D., Logsetty, S., Tan, J., Atkinson, I., & Mottet, K. (2013). The iTClamp
Controls Junctional Bleeding in a Lethal Swine Exsanguination Model.
Prehospital Emergency Care, 17(4), 526-532.
Proof of concept study for iTClamp Hemorrhage Control Device. Lethal
hemorrhagic injury to 20 swine found 100% of swine treated with iTClamp
survived whether the clamp was placed immediately or placement was delayed.
60% treated with packing with standard gauze survived v. 0% survival if the
wound was left untreated. The iTClamp was superior in terms of overall survival
(p <0.009), total blood loss (p=0.008) and survival time (p=0.003) to standard
gauze and the control. iTClamp is an effective temporary wound closure device.
Mottet, K., Filips, D., Logsetty, S., & Atkinson, I. (2014). Evaluation of the
iTClamp 50 in a human cadaver model of severe compressible bleeding. J
Trauma Acute Care Surg, 76(3), 791-797.
Laboratory cadaveric study testing effectiveness of iTClamp to control external
fluid loss from injuries to compressible areas, maintain this control despite
movement, as well as maintain distal perfusion. Wounds made to thigh, groin,
neck, and arm and sterile water was pumped through the arteries. iTClamp was
found to effectively stop fluid loss to all of these areas, the fluid used had no
clotting factors, movement had no effect on the hematoma formation or
maintenance and distal flow remained intact.

66. St John, A. E., Wang, X., Lim, E. B., Chien, D., Stern, S. A., & White, N. J. (2015).
Effects of rapid wound sealing on survival and blood loss in a swine model of
lethal junctional arterial hemorrhage. J Trauma Acute Care Surg,79(2), 256-262.
Laboratory study performed on 50 swine, 5-mm diameter femoral arteriotomy
was performed and 1 of 7 interventions was randomized and applied after 30
seconds of free bleeding: control, iTClamp, standard gauze packing, iTClamp
with standard gauze packing, compression, standard gauze packing with
compression and hemostatic gauze packing with compression. At 3:30 minutes
post arteriotomy all animals received one dose of Hextend (15mL/kg over
15 mins). Animals were monitored for 3 hours or until death. Survival rates were
as follows: control and compression 0%, standard gauze packing 12.5%,
iTClamp 62.5%, hemostatic gauze packing with compression 62.5%, standard
gauze packing with compression 87.5% and iTClamp with standard gauze
packing 100%. Proper wound packing was a key factor in this study and the
iTClamp is seen as a viable option for junctional hemorrhage.

67. You stopped the bleeding, now what?

69.  How much
 Metrics
 What fluid

70. We base it on Mean Arterial Pressure (M.A.P.)
MAP = SBP + 2 (DBP)/3
BP= 83/50
MAP = 83 +2 (50)/3
MAP = 83 +100/3
MAP = 183/3
MAP = 61 mm HG

71. “Resuscitating patients with the intent of maintaining a
target minimum MAP of 50 mm Hg, rather than 65 mm
Hg, significantly decreases postoperative coagulopathy
and lowers the risk of early postoperative death and
coagulopathy”.
50 is really low
Examples; BP 70/40 is a MAP of 50 mmHg
90/60 is a MAP of 70 mmHg
Hypotensive resuscitation strategy reduces transfusion
requirements and severe postoperative coagulopathy in
trauma patients with hemorrhagic shock: preliminary
results of a randomized controlled trial.
Morrison CA1, Carrick MM, Norman MA, Scott BG, Welsh FJ,
Tsai P, Liscum KR, Wall MJ Jr, Mattox KL.

72. In non-TBI patients we aim for a systolic of 90
Approximate MAP of 65
In TBI patients we aim for a systolic of 110
Approximate MAP of 90
Based on a Cerebral Perfusion Pressure of 50-70
CPP= MAP-ICP
Optimal ICP <20

73. Journal of Trauma and Acute Care Surgery:
April 2015 - Volume 78 - Issue 4 - p 687–697
A controlled resuscitation strategy is feasible and safe in
hypotensive trauma patients: Results of a prospective
randomized pilot trial
Schreiber, Martin A. MD; Meier, Eric N. MS; Tisherman, Samuel A. MD; Kerby,
Jeffrey D. MD, PhD; Newgard, Craig D. MD, MPH; Brasel, Karen MD; Egan, Debra
MSc, MPH; Witham, William MD; Williams, Carolyn RN; Daya, Mohamud MD;
Beeson, Jeff DO; McCully, Belinda H. PhD; Wheeler, Stephen MD; Kannas,
Delores RN, MS, MHA; May, Susanne PhD; McKnight, Barbara PhD; Hoyt, David B.
MD; the ROC Investigators

74. 192 Randomized Patients from 19 EMS Systems in
the Resuscitation Outcomes Consortium (97 CR, 95
SR)
Controlled Resuscitation (CR) patients received 250
mL of fluid if they had no radial pulse or an SBP
lower than 70 mm Hg and additional 250-mL
boluses to maintain a radial pulse or an SBP of 70
mm Hg or greater.
The Standard Resuscitation (SR) group patients
received 2 L initially and additional fluid as needed
to maintain an SBP of 110 mm Hg or greater.
The crystalloid protocol was maintained until
hemorrhage control or 2 hours after hospital
arrival.

75. Mean volume given in CR group was 1.0L
Mean volume given in the SR group was 2.0L
Intensive care unit–free days, ventilator-free days,
renal injury, and renal failure did not differ
between the groups.
At 24 hours after admission, there were 5 deaths
(5%) in the CR group and 14 (15%) in the SR group
Among patients with blunt trauma, 24-hour
mortality was 3% (CR) and 18% (SR)
There was no difference among patients with
penetrating trauma 9% each
“Prehospital Volume Therapy as an Independent Risk
Factor after Trauma”

76. Group 0-
500ml
501-1L 1-1.5L 1.5-2L >2L Total
Pre-Hosp.
BP
Mean,SD
133.8
34.5
122
34.7
115.4
32.9
109.7
32.3
100.3
34.4
117.6
35.6
BP at
admission
Mean, SD
130.3
29.7
124.2
29.8
117.8
30.2
116.4
29.5
110.6
21.2
120.7
30.8
Age 52.6 46.3 43.4 40.1 39.9 45
“Prehospital Volume Therapy as an Independent
Risk Factor after Trauma”

77. Group 0-500 501-1L 1001-1500 1501-2000 >2000
Days of
Intubation
6.6
10.8
7.8
11.7
9.3
13.3
10.2
12.7
11
13.1
Days in ICU 10.9
13
12.1
13.5
13.7
15.5
14.7
14.2
15.3
15
Days in
Hospital
21.9
20.1
25.6
23.4
27.8
25.7
28.5
25.9
29.7
27.2
Sepsis % 8.6 8.9 10.8 13.7 14.6
Organ
Failure %
46.5 49.4 56.1 58.1 61.3
Multiorgan
failure %
29.4 31.5 37.3 40.9 43.3
Death % 18.3 16.8 16.9 18.7 24
Death
within 24H
7.2 7.7 8.9 10.7 13.4

78. Bjoern Hussmann, Matthias Heuer, Rolf Lefering, et al.,
“Prehospital Volume Therapy as an Independent Risk Factor
after Trauma,” BioMed Research International, vol. 2015,
Article ID 354367, 9 pages, 2015.
doi:10.1155/2015/354367

79. Patients seen between 2002 and 2010 were selected for
this study according to the following criteria:
(1) Primary admission to the hospital (no transfers).
(2) Injury Severity Score (ISS) ≥16.
(3) Age ≥16 years.
(4) Data available for prehospital and hospital volume
therapy and packed red blood cell administration,
Glasgow Coma Scale (GCS), hemoglobin concentration,
base excess, one coagulation parameter (e.g.,
prothrombin time), blood pressure at the accident
site, blunt trauma, therapeutic measures (resuscitation,
intubation, insertion of chest tube), and prehospital
time.

80. Conclusions: Prehospital volume therapy in
patients without severe TBI represents an
independent risk factor for mortality. In such cases,
respiratory and circulatory conditions should be
stabilized during permissive hypotension, and
patient transfer should not be delayed.

81. Albumin
Dextran 40
Dextran 70
5% Dextrose (D5W)
Hydroxyethyl starch (HES)
Lactated Ringer’s (LR)
0.9% NaCl (NS)
3% NaCl
Blood products
HBOC (PolyHeme)

82. Investigators in Australia and New Zealand
conducted the Saline versus Albumin Fluid
Evaluation (SAFE) study
The study showed no significant difference
between albumin and saline with respect to
the rate of death

83. Among injured patients with hypovolemic
shock, initial resuscitation fluid treatment
with either HS or HSD compared with NS, did
not result in superior 28-day survival.
**TBI
Out-of-hospital Hypertonic Resuscitation After Traumatic Hypovolemic
Shock A Randomized, Placebo Controlled Trial
Eileen M. Bulger, MD,* Susanne May, PhD,* Jeffery D. Kerby, MD, PhD,†
Scott Emerson, MD, PhD,* Ian G. Stiell, MD,‡ Martin A. Schreiber, MD,§
Karen J. Brasel, MD, MPH,‖ Samuel A. Tisherman, MD,¶ Raul Coimbra,
MD, PhD,# Sandro Rizoli, MD, PhD,** Joseph P. Minei, MD,†† J. Steven
Hata, MD,‡‡ George Sopko, MD, MPH,§§ David C. Evans, MD,‖‖ and
David B. Hoyt, MD¶¶, for the ROC investigators

84. Human Polymerized Hemoglobin for the Treatment of
Hemorrhagic Shock when Blood Is Unavailable: The USA
Multicenter Trial Abstract presented at the American College of
Surgeons 93rd Annual Clinical Congress, New Orleans, LA,
October 2007.
Ernest E. Moore, MD, FACSa, , Frederick A. Moore, MD, FACSb,
Timothy C. Fabian, MD, FACSc, Andrew C. Bernard, MD, FACSd,
Gerard J. Fulda, MD, FACSe, David B. Hoyt, MD, FACSf, Therese
M. Duane, MD, FACSg, Leonard J. Weireter Jr, MD, FACSh,
Gerardo A. Gomez, MD, FACSi, Mark D. Cipolle, MD, FACSj,
George H. Rodman Jr, MD, FACSk, Mark A. Malangoni, MD,
FACSl, George A. Hides, BAm, Laurel A. Omert, MDn, Steven A.
Gould, MD, FACSn, o, PolyHeme Study Group

85. Patients resuscitated with PolyHeme, without
stored blood for up to 6 U in 12 hours
postinjury, had outcomes comparable with
those for the standard of care. Although
there were more adverse events in the
PolyHeme group, the benefit-to-risk ratio of
PolyHeme is favorable when blood is needed
but not available.

86. FDA has not approved any Hemoglobin Based
Oxygen Carriers for use in the United States,
and the regulatory agencies of most other
countries also have not approved HBOCs.

87.  pH of 6.5 compared to 5.0 of NS
 Less acidity dose not cause vasodilatation
 Base excess is recovered by LR not NS
 Electrolyte content is most closely related to
blood serum
A hypercoagulable state can result when
Lactated Ringers is given to resuscitate
patients experiencing shock; this state may
prove to be a positive protective symptom but
could result in thrombolytic complication

88.  Isotonic fluid
 Cheap
 Readily available
 Small doses equals small harm

89.  Tranexamic acid (TXA) was originally
developed for the treatment of hemophilia
and to reduce bleeding in patients
undergoing oral surgery

90.  TXA is a synthetic amino acid (lysine) that
blocks plasminogen from being converted to
the enzyme plasmin.
 Plasmin works to break down already-formed
blood clots in the human body by attacking
and breaking down fibrin, destroying clots in
a process known as fibrinolysis
 TXA is widely used by hospitals in Europe and
other countries for severely injured trauma
patients

91.  CRASH-2 study, undertaken in 274 hospitals
in 40 countries and published in 2010
 TXA, when administered within one hour of
significant trauma, greatly reduced patient
mortality (over 30%) when used in
conjunction with blood transfusions.
 When TXA was used alone, patient mortality
was reduced by over 20%

92.  MATTERs was a retrospective observational
study of 893 consecutive admissions of
combat-injured persons in a role 3 surgical
hospital (equivalent to a U.S. level 2 trauma
center) in southern Afghanistan.
 Authors measured patient mortality at 24
hours, 48 hours and 30 days, as well as the
influence of TXA administration on
postoperative coagulopathy and the rate of
thromboembolic complications.

93.  MATTERs studies showed a decrease in the
unadjusted mortality of patients who received
TXA (vs. placebo) within the first three hours of
injury (17.4% vs. 23.9%)
 Patients who received TXA (vs. placebo) with
associated blood transfusion within one hour of
injury had an even greater decrease in mortality
(14.4% vs. 28.1%).
 TXA administered more than three hours after
injury, however, appears to increase the risk of
death due to bleeding, to 4.4% compared with
3.1% for the placebo group

94.  TXA may not be beneficial if it greatly delays
scene time to prepare and initiate the initial
1-gram dose and establish an IV.
 TXA would be ideal for situations including
prolonged extrication, extended transport
times due to heavy traffic or other conditions,
and mass-casualty incidents.
 If TXA is administered after three hours,
mortality rates have shown to increase.

95.  In the United States the cost is approximately
$10 per gram

96.  The recommended procedure for
administering TXA is 1 gram in 100 mL of
0.9% normal saline or Ringer’s lactate given
by IV infusion over 10 minutes, followed by 1
gram in 500 mL of 0.9% NS or LR infused over
eight hours

97.  It is recommended that TXA not be mixed
with colloid fluid, (e.g., Hextend or Hespan,
plasma or any other blood components), nor
with solutions containing penicillin, and/or
piggybacked into any IV line delivering blood.

98.  Still new
 Higher incidents of DVT’s in MATTER’s study
 Patients is MATTER’s also had worse injuries

99.  Get the right tools
 Practice with the tools
 Make educated decisions before additions
s.ford@northcountryems.org
https://www.youtube.com/user/NCEMStraining