Sage Journals: Discover world-class research

Abstract

Hemorrhage is the leading cause of preventable military and civilian trauma death. Damage control resuscitation with concomitant mechanical hemorrhage control has become the preferred in-hospital treatment of hemorrhagic shock. In particular, plasma-based resuscitation with decreased volumes of crystalloids and artificial colloids as part of damage control resuscitation has improved outcomes in the military and civilian sectors. However, translation of these principles and techniques to the prehospital, remote, and austere environments, known as remote damage control resuscitation, is challenging given the resource limitations in these settings. Rapid administration of tranexamic acid and reconstituted freeze-dried (lyophilized) plasma as early as the point of injury are feasible and likely beneficial, but comparative studies in the literature are lacking. Whole blood is likely the best fluid therapy for traumatic hemorrhagic shock, but logistical hurdles need to be addressed. Rapid control of external hemorrhage with hemostatic dressings and extremity tourniquets are proven therapies, but control of noncompressible hemorrhage (ie, torso hemorrhage) remains a significant challenge.

Keywords

remote damage control resuscitation hemorrhage hemorrhagic shock

Introduction

Exsanguination can occur rapidly¹^–3 and is the leading cause of potentially preventable civilian^4,5 and combat^6,7 trauma deaths. Optimization of prehospital hemorrhage control and resuscitation therefore are critical,^8,9 especially when transport to a facility capable of definitive hemorrhage control is delayed. “Remote” or “forward” has been proposed to define the prehospital phase of resuscitation, and “austere” or “far-forward” as “the environment where professional health care providers normally do not operate, and basic equipment and capabilities necessary for resuscitation are often not available.”¹⁰ The translation of hospital-based damage control resuscitation (DCR) techniques to remote and austere settings forms the crux of remote damage control resuscitation (RDCR).¹¹ RDCR is applicable in a wide range of settings: rural, frontier/wilderness, ships at sea, and mass casualty incidents. Given the inherent logistical and resource limitations in these settings, however, translation of DCR to RDCR is challenging.

DAMAGE CONTROL RESUSCITATION

Definition

DCR with concomitant effort to achieve definitive hemorrhage control is the preferred in-hospital treatment of traumatic hemorrhagic shock. Core principles of DCR include minimization of crystalloid, hemostatic (balanced) resuscitation, and permissive hypotension. Overall, the goal of DCR is to quickly perform maneuvers that promote hemostasis while minimizing (iatrogenic) insults that would exacerbate bleeding.

Implementation of DCR in Operation Iraqi Freedom and Operation Enduring Freedom

Prior to the advent of DCR, clinicians infused large volumes of crystalloid, artificial colloid, and red blood cells (RBCs) for resuscitation of hemorrhagic shock.^12,13 However, this changed after a retrospective study of 246 massively transfused patients treated at a combat support hospital in Iraq found that increasing the plasma:RBC ratio was associated with increased survival (odds ratio [OR], 8.6; 95% confidence interval [CI], 2.1−35.2), primarily by reduced risk of exsanguination.¹⁴

Based on these data, a subsequent Joint Trauma System clinical practice guideline recommended a 1:1 plasma:RBC ratio for any patient at risk for massive transfusion, which was soon revised to a 1:1:1 plasma:platelet:RBC ratio. A study of Operation Iraqi Freedom/Operation Enduring Freedom resuscitation practice between 2003 and 2012 found increasing survival over time despite increasing injury severity, which correlated with decreased crystalloid and artificial colloid use and increased plasma:RBC and platelet:RBC ratios.¹⁵

Lessons Learned: Evidence-based benefits of DCR in military and civilian sectors

In the civilian sector, the prospective, observational, multicenter, major trauma transfusion (PROMMTT) study found that plasma:RBC and platelet:RBC ratios varied significantly over time during active resuscitation of bleeding trauma patients and that increased plasma:RBC and platelet:RBC ratios were associated with decreased 6-hour mortality when risk of exsanguination was greatest.¹ After 6 hours, however, product ratios no longer correlated with mortality as competing risks (eg, traumatic brain injury [TBI]) became more important.

The multicenter pragmatic randomized optimal platelet and plasma ratios trial randomized 680 bleeding civilian trauma patients to resuscitation with 1:1:1 vs 1:1:2 plasma:platelet:RBC ratios.² Although 24-hour and 30-day mortality did not differ, the 1:1:1 group had a significantly decreased risk of exsanguination (9 vs 15%) and increased hemostasis (86 vs 78%).

A recent systematic review and meta-analysis that analyzed 5292 patients across 15 studies found that mortality was reduced significantly for patients who received a high (approaching 1:1) vs low (≤1:2) plasma:RBC ratio (31 vs 38%).¹⁶ The mechanism behind this benefit is unclear but likely involves plasma-mediated endothelial repair^17,18 in addition to replacement of volume and clotting factors. The same systematic review also found that mortality was reduced for 1607 patients across 4 studies who received a high vs low platelet:RBC ratio (28 vs 43%).¹⁶ Overall, this supports a 1:1:1 plasma:platelet:RBC ratio for resuscitation of hemorrhagic shock. Increasing volumes of crystalloid, on the other hand, are associated with inflammation (eg, acute respiratory distress syndrome),¹⁹ edema (eg, abdominal compartment syndrome),²⁰ and mortality.²¹

RDCR

Definition

Hospital-based DCR practices and mechanical hemorrhage control techniques translated into the prehospital, remote, and austere settings are the central tenets of RDCR. However, the resource limitations and logistical restraints inherent in these settings preclude direct application of all DCR principles.

Translation of DCR components to RDCR

Permissive hypotension

In an animal model of uncontrolled hemorrhage, fluid resuscitation induced reproducible rebleeding (“popping the clot”) when the mean arterial pressure was increased above 64±2 mm Hg.²² Several clinical studies have shown either improved outcome²³ or no difference^24,25 in civilian patients randomized to hypotensive vs normotensive resuscitation. However, these studies were performed in urban environments where prehospital transport times were relatively short. In remote and austere environments, permissive hypotension will undoubtedly lead to some accumulation of oxygen debt.

The question of how low and how long hypotension may be allowed to persist remains unresolved but is likely contingent on a number of factors, including baseline health status and injury acuity. Real-time monitoring modalities are limited in the prehospital setting, which has been identified as a critical technological gap.²⁶ Closing this critical knowledge gap would enable resuscitation to be titrated both to reduce risk of rebleeding and optimize tissue perfusion. Although no such technology currently exists, advances in computer-generated decision support tools utilizing continuous vital sign measures, tissue oxygen saturation monitoring,²⁷ and serial lactate measurements²⁸ all have demonstrated promising early results.

Balanced (hemostatic) resuscitation

Plasma is used as the primary volume expander in DCR. Storage conditions and therefore immediate availability of plasma products differ with implications for RDCR.²⁹ Fresh frozen plasma and thawed plasma are ill suited for RDCR; liquid plasma has fewer constraints, enabling wider use (Table 1).

Table 1

Characteristics of plasma products

Product	Fresh frozen plasma	Thawed plasma	Liquid plasma	Freeze-dried plasmas
Product	Fresh frozen plasma	Thawed plasma	Liquid plasma	French lyophilized plasma (French Red Cross)	LyoPlas n-w (German Red Cross)	Bioplasma freeze-dried plasmas (National Biomedical Institute, Pinetown, South Africa)
Source	Single donor	Single donor	Single donor	“Mini-pools” (≤10 donors), mixed ABO type	Single donor	Pooled, mixed ABO type
Pathogen inactivation	Screening only	Screening only	Screening only	Amotosalen ultraviolet light method	Screening only (includes 4-month quarantine period)	Solvent-detergent method
Storage	–18°C	1–6°C	1–6°C	Room temperature	2–25°C	<25°C
Shelf life	1 year	5 days	Up to 40 days	2 years	15 months	Not specified
Notes	Can be relabeled and stored as thawed plasma after thawing			ABO-universal		ABO-universal

Freeze-dried (lyophilized) plasma (FDP) has been “rediscovered” as a more suitable plasma product for RDCR. FDP was used extensively during World War II, but production was stopped in the United States due to heightened risk of disease transmission.³⁰ Currently, FDP is manufactured by updated processes in France,³¹ Germany,³² and South Africa.³³ The French product has been in continuous production since World War II, albeit in small quantities. Advantages of FDP include its long shelf life (up to 2 years), room temperature storage, rapid reconstitution within minutes, and relative stability at temperature extremes.³⁰^–32 The French and South African products are produced from pooled plasma. The advantages of pooling include uniform factor concentrations and universal ABO compatibility,³² while transmissible disease risk is minimized by pathogen inactivation.^30,32 Currently, no FDP product is approved for general use in the United States, although one product has completed phase I trials (LyP, HemCon Medical Technologies, Portland, OR). Additionally, there is limited use of French FDP by some US Special Operations Forces under a US Food & Drug Administration (FDA) Investigational New Drug protocol.

Platelets are an important part of hemostatic resuscitation, but logistical constraints (constant agitation at room temperature and 5-day shelf life) make platelets essentially unavailable in remote and austere settings.^34,35 Cold storage of platelets, which appears to preserve hemostatic function better than room temperature storage without the need for agitation, appears viable.³⁶ Another hemostatic resuscitation option when platelets are unavailable is whole blood, including fresh whole blood (FWB) obtained as needed from the “walking blood bank.” FWB has greater hematocrit, clotting factor activity, platelet count, and fibrinogen content compared with component therapy (Table 2).³⁷ Being fresh, the well-described “storage lesion” of aged RBCs³⁸ and platelets³⁹ is avoided. Transfusion of 1 bag of FWB in lieu of 3 to 4 bags of components is logistically simpler (reducing risk of administrative error) and reduces donor exposure (lowering the risk of disease transmission). The Committee on Tactical Combat Casualty Care (CoTCCC) now recommends whole blood as the preferred fluid for resuscitation of casualties in hemorrhagic shock.⁴⁰ During the Vietnam War, low anti-A/B (titer <1:256) type O whole blood was transfused universally with an acceptably low incidence of major hemolytic transfusion reactions (1 per 9600 units transfused),⁴¹ and this strategy appears viable for modern use.⁴²

Table 2

Calculated parameters of fresh whole blood (450 mL donor blood with 63 mL anticoagulant) compared with component therapy with 1 unit packed red blood cells (hematocrit 55% in 335 mL), 1 unit fresh frozen plasma (80% coagulation factor activity, 250 mL), and 1 unit platelet (5.5 × 10¹⁰ platelets in 50 mL)

	Fresh whole blood	1 to 1 to 1 component therapy
Dilution factor	12%	35%
Hematocrit	33–43%	29%
Clotting factor activity	86%	65%
Platelets	130–350 × 10⁹/L	88 × 10⁹/L
Fibrinogen content	675–1800 mg	400–500 mg
Bags of product (donor exposure)	1	3–4

Pathogen inactivation⁴³ is one promising solution for negating the potentially increased transmissible disease risk of FWB.⁴⁴ Additionally, pathogen inactivation by riboflavin/ultraviolet light followed by cold storage at 21 days was found to minimally affect the hemostatic potential of whole blood.⁴⁵ The Mayo Clinic, which provides prehospital whole blood transfusions by helicopter, has published their experience in establishing a universal whole blood donor group.⁴⁶

Tranexamic acid

Tranexamic acid (TXA) inhibits tissue plasminogen activator and fibrinolysis (clot breakdown), potentially making it an important DCR adjunct. The multinational Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) study randomized >20,000 trauma patients at risk for hemorrhage to TXA vs placebo and found that TXA reduced all-cause mortality (14.5 vs 16%) and exsanguination-associated mortality (4.9 vs 5.7%).⁴⁷ An exploratory post hoc analysis identified a time-dependent effect: exsanguination risk was most reduced when TXA was given within 1 hour of injury (5.3 vs 7.7%) with a lesser effect when given between 1 and 3 hours (4.8 vs 6.1%) and an increased risk of exsanguination when given after 3 hours (4.4 vs 3.1%).⁴⁸ The retrospective military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study also found that TXA was independently associated with improved survival (OR, 7.2; 95% CI, 3.0–17.3) in 231 massively transfused (≥10 RBC units in 24 hours) combat casualties.⁴⁹ The American College of Surgeons Committee on Trauma,⁵⁰ European Task Force for Advanced Bleeding Care in Trauma,⁵¹ and UK National Institute for Health and Care Excellence⁵² all recommend administering TXA to hospitalized trauma patients as soon as possible if within 3 hours of injury. Of note, trauma is not an FDA-approved indication for TXA and is considered off-label use.

Evidence-based benefits of RDCR in military and civilian sectors

Given the time course of hemorrhage, initiating balanced resuscitation as soon as possible is paramount. Making ready-to-transfuse universal-donor plasma and RBCs available on civilian prehospital transport was associated with less deranged patient physiology on admission and decreased 6-hour mortality in the most critically ill patients.⁵³ In the military sector, decreased mortality was observed after implementation of several prehospital interventions, including blood product transfusions and faster transport time.⁵⁴

Several groups have published their experiences with FDP, although these are currently limited to noncomparative observational studies.⁵⁵^–57 Nevertheless, compelling common themes include its observed clinical efficacy, ease of reconstitution and administration, rapid availability, and no adverse events. The Israeli Defense Force (IDF) have reported successful administration of FDP (and TXA) at the point of injury,⁵⁶ similar to how FDP was used in World War II. Two studies have found that FWB was associated with improved survival compared with resuscitation with plasma and RBCs (platelets not available) in combat casualties treated at a combat field hospital³⁴ by forward surgical teams.³⁵ In the civilian sector, pilot trials have reported successful use of crossmatched modified whole blood (leukoreduced, platelets removed)⁵⁸ and uncrossmatched cold-stored whole blood (leukoreduced, containing platelets)⁵⁹ in the initial resuscitation of civilian trauma patients. Norwegian Naval Special Operations have published their simplified protocol for whole blood “buddy” transfusions in the field,⁶⁰ and a similar protocol for US forces has been proposed.⁶¹

The optimal use of TXA after trauma remains controversial. Although some advocate its empiric use in all trauma patients within 3 hours of injury,⁶² others argue that an antifibrinolytic should be reserved for patients who demonstrate hyperfibrinolysis on coagulation testing,⁶³ although no prehospital assays for hyperfibrinolysis currently are available.

In the elective surgical setting, TXA reduces blood loss without increased risk of venous thromboembolism (VTE).⁶⁴ The TXA-related VTE risk in trauma is less clear, however. CRASH-2 reported no difference in VTE risk between the TXA and placebo groups, although the overall VTE incidence was unusually low (1.7 vs 2.0%),⁴⁷ and the adequacy of patient follow-up has been questioned.⁶⁵ The MATTERs study reported that patients who received TXA had greater VTE incidence on univariate analysis, but TXA was not an independent predictor of VTE on multivariable regression.⁴⁹ Nevertheless, the likely clinical efficacy and probable low risk suggest that prehospital administration of TXA (ideally at the point of injury) is justifiable.⁶³ Prehospital TXA is given by several military and civilian aeromedical transport services, and the IDF administers TXA (and FDP) at the point of injury, so far with no apparent increase in adverse events.⁶⁶ A recent matched-cohort study found that prehospital TXA was associated with reduced 24-hour mortality (5.8 vs 12.4%) in 516 patients transported by the German Air Rescue Service without increased VTE incidence.⁶⁷

Mechanical hemorrhage control

Broadly speaking, hemorrhage can be classified as compressible (controllable with external pressure) or noncompressible (torso hemorrhage). A review of 4596 combat casualties in Afghanistan and Iraq from 2001 to 2011 found that 24% of prehospital battlefield deaths were potentially survivable and primarily linked to uncontrolled hemorrhage.⁶ Source of lethal hemorrhage was 67% truncal (noncompressible), 19% junctional, and 14% extremity. One of the greatest successes in modern combat casualty care is the widespread adoption of tourniquets, which has substantially reduced exsanguination from extremity hemorrhage. However, the prehospital management of noncompressible hemorrhage still presents a major challenge.

Hemostatic dressings

For millennia, plain gauze was used to pack wounds and tamponade bleeding. Modern products are impregnated with hemostatic agents for additional efficacy. Current TCCC Guidelines recommend kaolin-impregnated QuikClot Combat Gauze (Z-Medica LLC, Wallingford, CT) as first-line therapy for external hemorrhage not amenable to tourniquet application.⁶⁸ Combat Gauze should be applied with at least 3 minutes of direct pressure. Two chitosan-impregnated gauzes, Celox (Medtrade Products Ltd., Crewe, UK) and ChitoGauze (HemCon Medical Technologies), were found to be equally efficacious compared with Combat Gauze in large-animal models of hemorrhage and are recommended as second-line therapy if Combat Gauze is unavailable. All 3 products are FDA approved.

Extremity tourniquet

Tourniquet use was discouraged until the late 1990s because of the prevailing sentiment that tourniquet application resulted in limb ischemia and possible limb loss. Improvised tourniquets were used successfully in Somalia in 1993, and a report analyzing causes of combat death in Iraq and Afghanistan from 2003 to 2006 found that extremity hemorrhage accounted for 7.8% of all combat deaths (similar to the Vietnam era⁶⁹) but one-third of potentially preventable combat deaths.⁷⁰ Subsequently, several commercially available tourniquets were evaluated, with selection of the FDA-approved Combat Application Tourniquet (C-A-T, North American Rescue LLC, Greer, SC) and Special Operations Forces Tactical Tourniquets (SOFTT, Tactical Medical Solutions, Anderson, South Carolina) for deployment. Widespread adoption by the US military was evident by 2007.⁷¹ Tourniquets were consistently demonstrated to save lives, especially when applied early (before onset of shock).^72,73 One of the landmark achievements of this initiative has been the reduction of death from extremity hemorrhage from 23.3 per year before 2006 to 3.5 per year after 2007.⁶

Given the effectiveness of tourniquets in controlling extremity hemorrhage, the 2015 Hartford Consensus emphasized the need for civilian preparedness in responding to mass casualty incidents, a major component of which is rapid hemorrhage control with the appropriate use of tourniquets and hemostatic dressings by professional first responders.⁷⁴ Emerging data suggest that tourniquet application reduces blood loss and shock⁷⁵ with a low risk of ischemic limb loss in civilian trauma patients.⁷⁶^–78 In a single-center retrospective review of 326 tourniquets placed on 306 patients for extremity injuries, delayed tourniquet placement (in the trauma center) was associated with an increased likelihood of exsanguination (OR, 8.5; 95% CI, 1.1–68.9) compared with prehospital tourniquet placement.⁷⁷ However, in the austere environment where definitive hemorrhage control is delayed, prolonged tourniquet application could result in detrimental limb ischemia. A study using porcine models found that neuromuscular recovery was well preserved when tourniquet application was ≤3 hours but significantly diminished at 6 hours.⁷⁹

Current TCCC Guidelines recommend reassessing every 2 hours and converting the tourniquet to a hemostatic or compression dressing if the following criteria are met: 1) patient is not in shock, 2) limb was not amputated, and 3) it is possible to monitor the wound closely for bleeding.⁸⁰ Periodic loosening of the tourniquet to reperfuse the limb results in increased blood loss without any benefit (possibly worsening ischemia-reperfusion injury)⁸¹ and should be avoided. Because of the risk of reperfusion syndrome, removal of a tourniquet that has been applied for ≥6 hours should be done only when close monitoring and laboratory capability are available.⁸⁰

Junctional tourniquet

The extremity tourniquet is ineffective at controlling hemorrhage from “junctional” regions, such as the axillae and groins, because it cannot be applied proximal to the region of injury. The CoTCCC recommends 3 FDA-approved junctional tourniquet devices for bleeding control in these regions (Table 3).⁸² These devices differ somewhat in the body regions in which they can be used, but they were equally effective at eliminating distal blood flow to the lower extremities in healthy volunteers.⁸³ In a porcine model of groin hemorrhage, 2-hour inguinal application of the Combat Ready Clamp to control common femoral artery inflow resulted in mild and reversible ischemic injury, but 2-hour umbilical application for aortic inflow control resulted in extensive lumbar muscle necrosis and severe disability.⁸⁴

Table 3

Comparison of junctional tourniquets

	Combat Ready Clamp (CRoC, Combat Medical Systems, LLC)	Junctional Emergency Treatment Tool (JETT, North American Rescue, LLC)	SAM Junctional Tourniquet (SJT, SAM Medical Products)
Mechanism	Mechanical	Mechanical	Pneumatic
FDA-approved regions of application	Delto-pectoral grove	Groin^*	Delto-pectoral groove
	Groin (unilateral)		Groin^*
	Neck (as a “last resort” for significant carotid artery bleeding)
	Umbilicus (as a “last resort” for significant bilateral bleeding or unilateral bleeding not controllable by another method)
Vessel occluded	Axillary artery	Common femoral artery	Axillary artery
	Axillary artery		Common femoral artery
	Common femoral artery
	Carotid artery
	Aortic bifurcation
Notes	Unilateral use	Bilateral use (for groins)	Bilateral use (for groin)
Notes	Unilateral use	Literature supports use as pelvic stabilizer⁹⁹	FDA approved as pelvic stabilizer

FDA, US Food & Drug Administration.

⁎

Device allows for concurrent bilateral occlusion of bleeding from both groins.

Abdominal aortic and junctional tourniquet

The abdominal aortic and junctional tourniquet (AAJT) is FDA approved for occlusion of the aortic bifurcation at the umbilicus and axillary artery at the delto-pectoral groove.⁸⁵ It can effectively control bleeding distal to its application (eg, pelvic hemorrhage) but will exacerbate any proximal bleeding and should not be used in patients with known or suspected proximal injuries. A single-center retrospective study of 402 patients who required emergent trauma laparotomy for intra-abdominal hemorrhage control found that only 9% had isolated hemorrhage originating distal to the aortic bifurcation and would have potentially benefitted from the AAJT.⁸⁶ To our knowledge, there is no evidence in the literature of improved outcomes from comparative studies of junctional tourniquets or the AAJT.

Nonabsorbable, expandable, injectable hemostatic sponge (XStat)

XStat (RevMedx, Wilsonville, OR) is a novel device consisting of approximately 92 discoid chitosan-coated sponges loaded into a syringe. When injected into a wound cavity, the sponges expand from 4.5 mm disks to 40 mm tubes after coming into contact with blood, thus tamponading bleeding.⁸⁷ Sponges have radiopaque markers to facilitate retrieval. XStat is FDA approved for junctional wounds in the axillae and groin not amenable to tourniquet application. It is particularly suitable for penetrating injuries in which the bleeding vessel is in a deep, narrow wound tract. In porcine models of subclavian vessel transection, XStat took significantly less time to apply, did not require continuous external compression after application, and significantly reduced blood loss compared with QuikClot Combat Gauze.^87,88 Current TCCC Guidelines recommend XStat as a second-line therapy (in the same category as Celox and ChitoGauze) to external hemorrhage not amenable to extremity tourniquet application when Combat Gauze is not available.⁸⁹ To our knowledge, there are no comparative studies of XStat and junctional tourniquets and no clinical studies of XStat in patients.

Resuscitative endovascular balloon occlusion of the aorta

The new FDA-approved ER-resuscitative endovascular balloon occlusion of the aorta (REBOA) device (Prytime Medical, San Antonio, TX) can be introduced through a 7-French sheath by percutaneous access to the common femoral artery without the aid of a guidewire.⁹⁰ Balloon inflation in the supraceliac aorta (zone 1) functions similar to an aortic cross-clamp placed during resuscitative thoracotomy and should be limited to 45 to 60 minutes to prevent necrosis of all intra-abdominal contents. Alternatively, the balloon can be inflated in the infrarenal abdominal aorta (zone 3) to control pelvic bleeding for longer periods of time. REBOA should not be used for patients with thoracic bleeding because balloon inflation will increase blood loss.

Currently, REBOA use in level 1 trauma centers is safe⁹¹ and may offer improved survival compared with resuscitative thoracotomy.⁹² However, the prehospital use of REBOA in its current design raises important safety concerns and is controversial secondary to the requisite prolonged inflation time. The arterial cannulation procedure is beyond the scope of many prehospital providers, and prolonged zone 1 aortic balloon occlusion inevitably will induce irreversible ischemia of abdominal contents. Zone 3 occlusion in select patients⁹³ will likely be better tolerated; however, the difficulty of this approach (and of AAJT use) is identifying the patient with isolated pelvic bleeding in the prehospital setting. Encouraging animal studies of partial zone 1 occlusion allowing some distal flow prolongs the exsanguination process,⁹⁴ but human data are lacking.

Intra-abdominal self-expanding foam

Intra-abdominal self-expanding foam (ResQ Foam, Arsenal Medical, Boston, MA; not FDA approved) is one of the first products that shows promise in prehospital control of noncompressible abdominal hemorrhage. Polyol and isocyanate solutions are delivered into the peritoneal cavity through a small anterior abdominal incision. When combined in situ, they polymerize into a self-expanding poly(urea)urethane polymer, tamponading intra-abdominal bleeding.⁹⁵ The foam is removed en bloc at the time of laparotomy. In porcine models, it was left in situ for 3 hours before explantation and was highly successful in rescuing animals from lethal hemorrhagic shock after grade V hepatoportal venous injury⁹⁶ and iliac artery injury.⁹⁷ Focal bowel injuries caused by foam expansion were repaired during laparotomy. In a long-term survival study, 90% of animals survived to the end point of 28 or 90 days without clinically significant complications.⁹⁸ At the time of this writing, no clinical use of this product has been reported, although studies in trauma patients are under discussion with the FDA.

Implications for RDCR in civilian austere sectors

Prehospital providers and lay persons are being trained in the control of external hemorrhage with hemostatic gauzes and extremity tourniquets under the Hartford Consensus Stop the Bleed Program.⁷⁴ However, there is little comparative evidence to guide the use of junctional tourniquets, the AAJT, XStat, or prehospital REBOA for civilian RDCR. Currently, the best resuscitation fluid reliably available in austere settings is FDP. However, there is still a minimum of several years before an FDP product will be FDA approved for general use in the United States. Some US prehospital providers in austere settings currently have access to blood products, but others may be faced with a difficult choice for bleeding patients: crystalloid, artificial colloid, or no fluid at all? Unfortunately, we do not think there is enough evidence to make a recommendation in this situation. Finally, TXA is likely safe to be administered in the field, although confirmatory studies are needed. Our evidence-based recommendations for RDCR are summarized in Table 4.

Table 4

Recommendations for RDCR

Rapidly identify patient with significant hemorrhage.

As soon as possible (ideally at point of injury): obtain mechanical hemorrhage control with hemostatic gauzes and/or extremity tourniquet, and commence resuscitation with reconstituted FDP and administer TXA (if available).

Transition to (in order of preference): whole blood, 1:1:1 plasma:RBCs:platelets, 1:1 plasma:RBC.

Reassess limb tourniquet every 2 hours and convert to a hemostatic or pressure dressing, if able.

Minimize use of crystalloids and artificial colloids.

Do not administer TXA >3 hours after injury.

For patients without TBI and minimal expected prehospital transport time, permissive hypotension is safe. However, there is insufficient data for a recommendation for patients with TBI or expected transport delay.

FDP, freeze dried plasma; RDCR, remote damage control resuscitation; RBCs, red blood cells; TXA, tranexamic acid; TBI, traumatic brain injury.

Conclusions

Several gaps in knowledge and technology preclude optimal RDCR implementation and require further study (Table 5). Although the prehospital treatment of hemorrhagic shock remains a major challenge, this is an area where even small incremental improvements will improve outcomes of injured patients.

Table 5

Topics needing additional investigation in prehospital hemorrhage control

Improved monitoring capability of oxygen debt accumulation.

Improved control of noncompressible hemorrhage.

Role for prehospital REBOA.

Role of permissive hypotension with prolonged prehospital time.

Prehospital resuscitation end points and goals.

Shelf life of cold-stored platelets and cold-stored whole blood.

Technology to minimize transmissible disease risk of whole blood transfusion.

Methods to store whole blood at ambient temperature.

Optimal balance between permissive hypotension and TBI after polytrauma.

REBOA, resuscitative endovascular balloon occlusion of the aorta; TBI, traumatic brain injury.

Disclosures: RC is supported by a T32 fellowship (grant no. 5T32GM008792) from the National Institute of General Medical Sciences. BJE reports no disclosures. JBH is the co-inventor of the junctional emergency treatment tool.

Footnotes

☆

Presented at the Tactical Combat Casualty Care: Transitioning Battlefield Lessons Learned to Other Austere Environments Preconference to the Seventh World Congress of Mountain & Wilderness Medicine, Telluride, Colorado, July 30–31, 2016.

References

Holcomb

J.B.

del Junco

D.J.

Fox

E.E.

et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013; 148, 127–136.

Holcomb

J.B.

Tilley

B.C.

Baraniuk

et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015; 313, 471–482.

Oyeniyi

B.T.

Fox

E.E.

Scerbo

Tomasek

J.S.

Wade

C.E.

Holcomb

J.B.

Trends in 1029 trauma deaths at a level 1 trauma center: impact of a bleeding control bundle of care. Injury. 2017; 48, 5–12.

Sauaia

Moore

F.A.

Moore

E.E.

et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995; 38, 185–193.

Tien

H.C.

Spencer

Tremblay

L.N.

et al. Preventable deaths from hemorrhage at a level I Canadian trauma center. J Trauma. 2007; 62, 142–146.

Eastridge

B.J.

Mabry

R.L.

Seguin

et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012; 73(Suppl 5), S431–S437.

Kotwal

R.S.

Montgomery

H.R.

Kotwal

B.M.

et al. Eliminating preventable death on the battlefield. Arch Surg. 2011; 146, 1350–1358.

Holcomb

J.B.

Methods for improved hemorrhage control. Crit Care. 2004; 8(Suppl 2), S57–S60.

Holcomb

J.B.

Pusateri

A.E.

MacPhee

M.J.

Hess

J.R.

New technologies for hemorrhage control. Curr Opin Crit Care. 1997; 3, 488–493.

10.

Jenkins

D.H.

Rappold

J.F.

Badloe

J.F.

et al. Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps. Shock. 2014; 41(Suppl 1), 3–12.

11.

Gerhardt

R.T.

Strandenes

Cap

A.P.

et al. Remote damage control resuscitation and the Solstrand Conference: defining the need, the language, and a way forward. Transfusion. 2013; 53(Suppl 1), 9S–16S.

12.

Johansson

P.I.

Stensballe

Oliveri

Wade

C.E.

Ostrowski

S.R.

Holcomb

J.B.

How I treat patients with massive hemorrhage. Blood. 2014; 124, 3052–3058.

13.

Butler

F.K.

Jr Blackbourne

L.H.

Battlefield trauma care then and now: a decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012; 73(6 Suppl 5), S395–S402.

14.

Borgman

M.A.

Spinella

P.C.

Perkins

J.G.

Grathet

The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007; 63, 805–813.

15.

Pidcoke

H.F.

Aden

J.K.

Mora

A.G.

et al. Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: increased plasma and platelet use correlates with improved survival. J Trauma Acute Care Surg. 2012; 73(6 Suppl 5), S445–S452.

16.

Cannon

J.W.

Khan

M.A.

Raja

A.S.

et al. Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 82, 605–617.

17.

Peng

Pati

Potter

et al. Fresh frozen plasma lessens pulmonary endothelial inflammation and hyperpermeability after hemorrhagic shock and is associated with loss of syndecan 1. Shock. 2013; 40, 195–202.

18.

Kozar

R.A.

Peng

Zhang

et al. Plasma restoration of endothelial glycocalyx in a rodent model of hemorrhagic shock. Anesth Analg. 2011; 112, 1289–1295.

19.

Robinson

B.R.

Cotton

B.A.

Pritts

T.A.

et al. Application of the Berlin definition in PROMMTT patients: the impact of resuscitation on the incidence of hypoxemia. J Trauma Acute Care Surg. 2013; 75(1 Suppl 1), S61–S67.

20.

Balogh

McKinley

B.A.

Cocanour

C.S.

et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch Surg. 2003; 138, 637–642.

21.

Joseph

Azim

Zangbar

et al. Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg 2017; 82, 328–333.

22.

Sondeen

J.L.

Coppes

V.G.

Holcomb

J.B.

Blood pressure at which rebleeding occurs after resuscitation in a swine with aortic injury. J Trauma. 2003; 54(5 Suppl), S110–S117.

23.

Bickell

W.H.

Wall

M.J.

Jr Pepe

P.E.

et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994; 331, 1105–1109.

24.

Dutton

R.P.

Mackenzie

C.F.

Scalea

T.M.

Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002; 52, 1141–1146.

25.

Schreiber

M.A.

Meier

E.N.

Tisherman

S.A.

et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial. J Trauma Acute Care Surg. 2015; 78, 687–695.

26.

Hooper

T.J.

De Pasquale

Strandenes

et al. Challenges and possibilities in forward resuscitation. Shock. 2014; 41(Suppl 1), 13–20.

27.

Sagraves

S.G.

Newell

M.A.

Bard

M.R.

et al. Tissue oxygenation monitoring in the field: a new EMS vital sign. J Trauma. 2009; 67, 441–444.

28.

Brown

J.B.

Lerner

E.B.

Sperry

J.L.

et al. Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level. J Trauma Acute Care Surg. 2016; 81, 445–452.

29.

Dunbar

N.M.

Chapter 9: Hospital storage, monitoring, pretransfusion processing, distribution, and inventory management of blood components

Technical Manual . 18th ed. Bethesda, MD: American Association of Blood Banks, 2014, 213–229.

30.

Kendrick

D.B.

Chapter 11: The plasma program

Blood Program in World War II. , Washington, DC: Office of the Surgeon General, Department of the Army, 1989, 265–319 Available at: http://history.amedd.army.mil/booksdocs/wwii/blood/chapter11.htm. Accessed May 23, 2016.

31.

Martinaud

Civadier

Ausset

et al. In vitro hemostatic properties of French lyophilized plasma. Anesthesiology 2012; 117, 339–346.

32.

Bux

Dickhörner

Scheel

Quality of freeze-dried (lyophilized) quarantined single-donor plasma. Transfusion. 2013; 53, 3203–3209.

33.

Solheim

B.G.

Chetty

Flesland

Indications for use and cost-effectiveness of pathogen-reduced ABO-universal plasma. Curr Opin Hematol. 2008; 15, 612–617.

34.

Spinella

P.C.

Perkins

J.G.

Grathwohl

K.W.

et al. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009; 66(4 Suppl), S69–S76.

35.

Nessen

S.C.

Eastridge

B.J.

Cronk

et al. Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets. Transfusion. 2013; 53(Suppl 1), 107S–113S.

36.

Reddoch

K.M.

Pidcoke

H.F.

Montgomery

R.K.

et al. Hemostatic function of apheresis platelets stored at 4°C and 22°C. Shock. 2014; 41(Suppl), 54–61.

37.

Ponschab

Schöchl

Gabriel

et al. Haemostatic profile of reconstituted blood in a proposed 1:1:1 ratio of packed red blood cells, platelet concentrate and four different plasma preparations. Anaesthesia. 2015; 70, 528–536.

38.

Hess

J.R.

Red cell changes during storage. Transfus Apher Sci. 2010; 43, 51–59.

39.

Devine

D.V.

Serrano

The platelet storage lesion. Clin Lab Med. 2010; 30, 475–487.

40.

Butler

F.K.

Holcomb

J.B.

Schreiber

M.A.

et al. Fluid resuscitation for hemorrhagic shock in Tactical Combat Casualty Care: TCCC guidelines change 14-01--2 June 2014. J Spec Oper Med. 2014; 14, 13–38.

41.

Neel

Chapter 9: The military blood program. in: Vietnam Studies: Medical Support of the US Army in Vietnam 1965-1970 . Washington, DC: Office of the Surgeon General, Department of the Army, 1991: 114–126 Available at: http://history.amedd.army.mil/booksdocs/vietnam/medicalsupport/chapter9.html. Accessed June 28, 2016.

42.

Strandenes

Berséus

Cap

A.P.

et al. Low titer group O whole blood in emergency situations. Shock. 2014; 41(Suppl 1), 70–75.

43.

Allain

J.P.

Owusu-Ofori

A.K.

Assennato

S.M.

et al. Effect of Plasmodium inactivation in whole blood on the incidence of blood transfusion-transmitted malaria in endemic regions: the African Investigation of the Mirasol System (AIMS) randomised controlled trial. Lancet. 2016; 387, 1753–1761.

44.

Hakre

Peel

S.A.

O’Connell

R.J.

et al. Transfusion-transmissible viral infections among US military recipients of whole blood and platelets during Operation Enduring Freedom and Operation Iraqi Freedom. Transfusion. 2011; 51, 473–485.

45.

Strandenes

Austlid

Apelseth

T.O.

et al. Coagulation function of stored whole blood is preserved for 14 days in austere conditions: a ROTEM feasibility study during a Norwegian antipiracy mission and comparison to equal ratio reconstituted blood. J Trauma Acute Care Surg. 2015; 78(6 Suppl 1), S31–S38.

46.

Stubbs

J.R.

Zielinski

M.D.

Jenkins

The state of the science of whole blood: lessons learned at Mayo Clinic. Transfusion. 2016; 56(Suppl 2), S173–S181.

47.

CRASH-2 Trial Collaborators Shakur

Roberts

et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010; 376, 23–32.

48.

CRASH-2 Collaborators Roberts

Shakur

et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011; 377, 1096–1101.

49.

Morrison

J.J.

Dubose

J.J.

Rasmussen

T.E.

Midwinter

M.J.

Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012; 147, 113–139.

50.

Committee on Trauma of the American College of Surgeons

ACS TQIP massive transfusion in trauma guidelines . Chicago, IL, 2014: Available at: https://www.facs.org/∼/media/files/quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma%20guildelines.ashx. Accessed April 12, 2017.

51.

Rossaint

Bouillon

Cerny

et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016; 20, 100.

52.

National Institute for Health and Care Excellence. Major trauma: assessment and initial management. February 17, 2016. London, UK: 2016. https://www.nice.org.uk/guidance/ng39/resources/major-trauma-assessment-and-initial-management-1837400761285. Accessed January 15, 2016..

53.

Holcomb

J.B.

Donathan

D.P.

Cotton

B.A.

et al. Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care. 2015; 19, 1–9.

54.

O’Reilly

D.J.

Morrison

J.J.

Jansen

J.O.

Apodaca

A.N.

Rasmussen

T.E.

Midwinter

M.J.

Prehospital blood transfusion in the en route management of severe combat trauma: a matched cohort study. J Trauma Acute Care Surg. 2014; 77(3 Suppl 2), S114–S120.

55.

Martinaud

Ausset

Deshayes

A.V.

et al. Use of freeze-dried plasma in French intensive care unit in Afghanistan. J Trauma. 2011; 71, 1761–1764.

56.

Glassberg

Nadler

Gendler

et al. Freeze-dried plasma at the point of injury: from concept to doctrine. Shock. 2013; 40, 444–450.

57.

Sunde

G.A.

Vikenes

Strandenes

et al. Freeze dried plasma and fresh red blood cells for civilian prehospital hemorrhagic shock resuscitation. J Trauma Acute Care Surg. 2015; 78(6 Suppl 1), S26–S30.

58.

Cotton

B.A.

Podbielski

Camp

et al. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg. 2013; 258, 527–532.

59.

Yazer

M.H.

Jackson

Sperry

J.L.

et al. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg. 2016; 81, 21–26.

60.

Strandenes

De Pasquale

Cap

A.P.

et al. Emergency whole-blood use in the field: a simplified protocol for collection and transfusion. Shock. 2014; 41(Suppl 1), 76–83.

61.

Fisher

A.D.

Miles

E.A.

Cap

A.P.

Strandenes

Kane

S.F.

Tactical damage control resuscitation. Mil Med. 2015; 180, 869–875.

62.

Roberts

Fibrinolytic shutdown: fascinating theory but randomized controlled trial data are needed. Transfusion. 2016; 56(Suppl 2), S115–S118.

63.

Moore

E.E.

Moore

H.B.

Gonzalez

Sauaia

Banerjee

Silliman

C.C.

Rationale for the selective administration of tranexamic acid to inhibit fibrinolysis in the severely injured patient. Transfusion. 2016; 56(Suppl 2), S110–S114.

64.

Ausset

Glassberg

Nadler

et al. Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: a critical appraisal of the medical literature and available alternatives. J Trauma Acute Care Surg. 2015; 78(6 Suppl 1), S70–S75.

65.

Napolitano

L.M.

Cohen

M.J.

Cotton

B.A.

Schreiber

M.A.

Moore

E.E.

Tranexamic acid in trauma: how should we use it?. J Trauma Acute Care Surg. 2013; 74, 1575–1586.

66.

Nadler

Gendler

Benov

Strugo

Abramovich

Glassberg

Tranexamic acid at the point of injury: the Israeli combined civilian and military experience. J Trauma Acute Care Surg. 2014; 77(3 Suppl 2), S146–S150.

67.

Wafaisade

Lefering

Bouillon

et al. Prehospital administration of tranexamic acid in trauma patients. Crit Care. 2016; 20, 143.

68.

Bennett

B.L.

Littlejohn

L.F.

Kheirabadi

B.S.

et al. Management of external hemorrhage in tactical combat casualty care: chitosan-based hemostatic gauze dressings—TCCC Guidelines-Change 13-05. J Spec Oper Med. 2014; 14, 40–57.

69.

Maughon

J.S.

An inquiry into the nature of wounds resulting in killed in action in Vietnam. Milit Med. 1970; 135, 8–13.

70.

Kelly

J.F.

Ritenour

A.E.

McLaughlin

D.F.

et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma. 2008; 64(Suppl 2), S21–S26.

71.

Kragh

J.F.

Burrows

Wasner

et al. Analysis of recovered tourniquets from casualties of Operation Enduring Freedom and Operation New Dawn. Mil Med. 2013; 178, 806–810.

72.

Kragh

J.F.

Jr Walters

T.J.

Baer

D.G.

et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009; 249, 1–7.

73.

Kragh

J.F.

Jr Littrel

M.L.

Jones

J.A.

et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med. 2011; 41, 590–597.

74.

Jacobs

L.M.

Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events

The Hartford Consensus III: implementation of bleeding control: if you see something do something. Bull Am Coll Surg. 2015; 100(Suppl 1), 40–46.

75.

Ode

Studnek

Seymour

et al. Emergency tourniquets for civilians: can military lessons in extremity hemorrhage be translated?. J Trauma Acute Care Surg. 2015; 79, 586–591.

76.

Inaba

Siboni

Resnick

et al. Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015; 79, 232–237.

77.

Scerbo MH, Holcomb JBm Gates K, et al. The trauma center is too late: severe extremity injuries without a pre-hospital tourniquet have increased death from hemorrhage. [abstract]. In: Proceedings from the 75th Annual Meeting of the American Association for the Surgery of Trauma. 2016 Sep 14–17; Waikoloa, HI. Chicago IL: AAST; 2016. Poster #49..

78.

Leonard

Zietlow

Morris

et al. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma. J Trauma Acute Care Surg. 2016; 81, 441–444.

79.

Burkhardt

G.E.

Gifford

S.M.

Propper

et al. The impact of ischemic intervals on neuromuscular recovery in a porcine (Sus scrofa) survival model of extremity vascular injury. J Vasc Surg. 2011; 53, 165–173.

80.

Shackelford

S.A.

Butler

F.K.

Jr Kragh

J.F.

et al. Optimizing the use of limb tourniquets in tactical combat casualty care: TCCC guidelines change 14-02. J Spec Oper Med. 2015; 15, 17–31.

81.

Klenerman

The Tourniquet Manual—Principles and Practice. . London, UK: Springer Verlag, 2003 44–46.

82.

Kotwal

R.S.

Butler

F.K.

Gross

K.R.

et al. Management of junctional hemorrhage in combat casualty care: TCCC guidelines—proposed change 13-03. J Spec Oper Med. 2013; 13, 85–93.

83.

Kragh

J.F.

Kotwal

R.S.

Cap

A.P.

et al. Performance of junctional tourniquets in normal human volunteers. Prehosp Emerg Care. 2015; 19, 391–398.

84.

Kheirabadi

B.S.

Terrazas

I.B.

Miranda

et al. Long-term effects of Combat Ready clamp application to control junctional hemorrhage in swine. J Trauma Acute Care Surg. 2014; 77(3 Suppl 2), S101–S118.

85.

Greenfield

E.M.

McManus

Cooke

W.H.

et al. Safety and efficacy of a novel abdominal aortic tourniquet device for the control of pelvic and lower extremity hemorrhage. Ann Emerg Med. 2009; 54(Suppl 3), S62.

86.

Hurley MJ, Holcomb JB. Three potential methods for prehospital treatment of abdominal hemorrhage [abstract]. In: Proceedings of the 11th Academic Surgical Congress. Academic Surgical Congress 11th Annual Meeting February 2–4. Jacksonville, FL. Association for Academic Surgery; 2016. Abstract#76.01..

87.

Mueller

G.R.

Pineda

T.J.

Xie

H.X.

et al. A novel sponge-based wound stasis dressing to treat lethal noncompressible hemorrhage. J Trauma Acute Care Surg. 2012; 73(2 Suppl 1), S134–S139.

88.

Cestero

R.F.

Song

B.K.

The effect of hemostatic dressings in a subclavian artery and vein transection porcine model. Technical Report 2013-012 . San Antonio, TX: Naval Medical Research Unit San Antonio, 2013.

89.

Sims

Montgomery

H.R.

Dituro

et al. Management of external hemorrhage in tactical combat casualty care: the adjunctive use of XStat™ compressed hemostatic sponges: TCCC guidelines change 15-03. J Spec Oper Med. 2016; 16, 19–28.

90.

US Food & Drug Administration

510(k) approval for K151821 ER-REBOA Catheter . Washington DC: Department of Health and Human Services, 2015: Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf15/K151821.pdf. Accessed August 12, 2016.

91.

Moore

L.J.

Brenner

Kozar

R.A.

et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015; 79, 523–530.

92.

DuBose

J.J.

Scalea

T.M.

Brenner

et al. The AAST Prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016; 81, 409–419.

93.

Chaudery

Clark

Morrison

J.J.

et al. Can contrast-enhanced ultrasonography improve Zone III REBOA placement for prehospital care?. J Trauma Acute Care Surg. 2016; 80, 89–94.

94.

Russo

R.M.

Williams

T.K.

Grayson

J.K.

et al. Extending the golden hour: partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg. 2016; 80, 372–378.

95.

Duggan

Rago

Sharma

et al. Self-expanding polyurethane polymer improves survival in a model of noncompressible massive abdominal hemorrhage. J Trauma Acute Care Surg. 2013; 74, 1462–1467.

96.

Peev

M.P.

Rago

Hwabejire

J.O.

Self-expanding foam for prehospital treatment of severe intra-abdominal hemorrhage: dose finding study. J Trauma Acute Care Surg. 2014; 76, 619–623.

97.

Rago

Duggan

M.J.

Marini

et al. Self-expanding foam improves survival following a lethal, exsanguinating iliac artery injury. J Trauma Acute Care Surg. 2014; 77, 73–77.

98.

Rago

A.P.

Duggan

M.J.

Hannett

et al. Chronic safety assessment of hemostatic self-expanding foam: 90-day survival study and intramuscular biocompatibility. J Trauma Acute Care Surg. 2015; 79(4 Suppl 2), S78–S84.

99.

Gary

J.L.

Kumaravel

Gates

et al. Imaging comparison of pelvic ring disruption and injury reduction with use of the junctional emergency treatment tool for preinjury and postinjury pelvic dimensions: a cadaveric study with computed tomography. J Spec Oper Med. 2014; 14, 30–34.

Remote Damage Control Resuscitation in Austere Environments

Abstract

Keywords

Introduction

DAMAGE CONTROL RESUSCITATION

Definition

Implementation of DCR in Operation Iraqi Freedom and Operation Enduring Freedom

Lessons Learned: Evidence-based benefits of DCR in military and civilian sectors

RDCR

Definition

Translation of DCR components to RDCR

Permissive hypotension

Balanced (hemostatic) resuscitation

Tranexamic acid

Evidence-based benefits of RDCR in military and civilian sectors

Mechanical hemorrhage control

Hemostatic dressings

Extremity tourniquet

Junctional tourniquet

Abdominal aortic and junctional tourniquet

Nonabsorbable, expandable, injectable hemostatic sponge (XStat)

Resuscitative endovascular balloon occlusion of the aorta

Intra-abdominal self-expanding foam

Implications for RDCR in civilian austere sectors

Conclusions

Footnotes

☆

References