Perspectives of solution to the problem of persistent intra-abdominal hemorrhage at the prehospital stage

Abstract

A post-hoc analysis of 338 casualties demonstrating persistent intra-abdominal hemorrhage has been carried out, the proportion of this group being 16.5% in overall casualty structure or 64% in the group of casualties with abdominal injuries. Lethal outcome rate in the studied group was 13%, the complication rate was 53.2%. Traumatic shock was found in 86% of casualties, the greatest proportion was accounted for by the first and second degree (59.1%). Lethality rate in the case of the third degree traumatic shock and terminal state was 34.4%. Injured parenchymal organs and abdominal major vessels showed the greatest blood loss — 2348 ± 250 ml. The time of arrival of casualties with persistent intra-abdominal hemorrhage to the advanced trauma management stage or definitive surgical care stage was virtually similar amounting to 2.6 ± 0.4 hr. Injuries to hollow organs (34.1%) were most commonly found, injuries to parenchymal organs (24.9%) occurred less frequently, the rate of combination of injuries to abdominal internal organs was approximately the same (24.9%). Major vessels injuries were diagnosed only in one casualty (0.3%), while those combined with internal organs injuries — in 37(11%)of casualties. As regards favorable prognosis this group was considered to be the least perspective owing to high rate of hemorrhage and inability to achieve effective hemostasis at the prehospital stage. Thus, persistent hemorrhage was not profuse, and the majority of casualties (88.7%) should be considered as perspective “recipients” to achieve temporary hemostasis at the prehospital stage. It is this approach based on the principles of early pathogenetic management that could reduce the rate of complications and lethality in casualties with persistent intra-abdominal hemorrhage.

Keywords

combat surgical trauma / abdominal injury / persistent hemorrhage / traumatic shock / endocavitary hemostasis / topical hemostatic (biodegradable) agent

References

[1] Samokhvalov IM, Goncharov AV, Chirskij VS, et al. «Potencial'no spasaemye» ranenye – rezerv snizheniya dogospital'noj letal'nosti pri raneniyah i travmah perspektivy. Skoraja medicinskaja pomosh. 2019;(3):10–16. (In Russ.)

[2] Самохвалов И.М., Гончаров А.В., Чирский В.С., и др. «Потенциально спасаемые» раненые – резерв снижения догоспитальной летальности при ранениях и травмах перспективы // Скорая медицинская помощь. 2019. № 3. С. 10–16.

[3] Samokhvalov IM, Golovko KP, Bojarincev VV, et al. Obosnovanie koncepcii rannego patogeneticheskogo lecheniya tyazhelyh ranenij i travm. Vestnik Rossijskoj Voenno-medicinskoj akademii. 2020;71(3):23–28. (In Russ.)

[4] Самохвалов И.М., Головко К.П., Бояринцев В.В., и др. Обоснование концепции раннего патогенетического лечения тяжелых ранений и травм // Вестник Российской военно-медицинской академии. 2020. № 3 (71). С. 23–28.

[5] Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg. 2011;146(12):1350–1358. doi: 10.1001/archsurg.2011.213

[6] Kotwal R.S., Montgomery H.R., Kotwal B.M. et al. Eliminating preventable death on the battlefield // Arch Surg. 2011. Vol. 46, No. 12. P. 1350–1358. doi: 10.1001/archsurg.2011.213

[7] Eastridge BJ, Stansbury LG, Stinger H, et al. Forward Surgical Teams provide comparable outcomes to combat support hospitals during support and stabilization operations on the battlefield. J Trauma. 2009;66(4 Suppl):S48–S50. doi: 10.1097/TA.0b013e31819ce315

[8] Eastridge B.J., Stansbury L.G., Stinger H., et al. Forward Surgical Teams provide comparable outcomes to combat support hospitals during support and stabilization operations on the battlefield // J Trauma. 2009. Vol. 66. 4 Suppl. P. S48–S50. doi: 10.1097/0TA.0b013e31819ce315

[9] Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004. Ann Surg. 2007;245(6):986–991. doi: 10.1097/01.sla.0000259433.03754.98

[10] Holcomb J.B., McMullin N.R., Pearse L., et al. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004 // Ann Surg. 2007. Vol. 245, No. 6. P. 986–991. doi: 10.1097/01.sla.0000259433.03754.98

[11] Krjukov EV, editor. Primenenie sredstv immobilizacii, ostanovki krovotechenija i jevakuacii pri okazanii pervoj i dovrachebnoj pomoshhi ranenym i postradavshim s povrezhdenijami oporno-dvigatel'noj sistemy Moscow; 2019. (In Russ).

[12] Применение средств иммобилизации, остановки кровотечения и эвакуации при оказании первой и доврачебной помощи раненым и пострадавшим с повреждениями опорно-двигательной системы: учебное пособие / под ред. Е.В. Крюкова. М., 2019.

[13] Smith S, White J, Nashat Wanis K, et al. The effectiveness of junctional tourniquets: A systematic review and meta-analysis. Meta-Analysis. J Trauma Acute Care Surg. 2019;86(3):532–539. doi: 10.1097/TA.0000000000002159

[14] Smith S., White J., Nashat Wanis K., et al. The effectiveness of junctional tourniquets: A systematic review and meta-analysis. Meta-Analysis // J Trauma Acute Care Surg. 2019. Vol. 86, No. 3. P. 532–539. doi: 10.1097/TA.0000000000002159

[15] Rago AP, Duggan MJ, Hannett P, 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. doi: 10.1097/TA.0000000000000571

[16] Rago A.P., Duggan M.J., Hannett P., et al. Chronic safety assessment of hemostatic self-expanding foam: 90-day survival study and intramuscular biocompatibility // J Trauma Acute Care Surg. 2015. Vol. 79, 4 Suppl 2. P. S78–S84. doi: 10.1097/TA.0000000000000571

[17] Rappold JF, Bochicchio GV. Surgical adjuncts to noncompressible torso hemorrhage as tools for patient blood management. Transfusion. 2016;56 Suppl 2:S203–S207. doi: 10.1111/trf.13585

[18] Rappold J.F., Bochicchio G.V. Surgical adjuncts to noncompressible torso hemorrhage as tools for patient blood management // Transfusion. 2016. Vol. 56. Suppl 2. P. S203–S207. doi: 10.1111/trf.13585

[19] Benov A, Shkolnik I, Glassberg E, et al. Prehospital trauma experience of the Israel defense forces on the Syrian border 2013–2017. J Trauma Acute Care Surg. 2019;87(1S Suppl 1):S165–S171. doi: 10.1097/TA.0000000000002217

[20] Benov A., Shkolnik I., Glassberg E., et al. Prehospital trauma experience of the Israel defense forces on the Syrian border 2013-2017 // J Trauma Acute Care Surg. 2019. Vol. 87, 1S Suppl 1. P. 165–S171. doi: 10.1097/TA.0000000000002217

[21] CRASH-2 trial collaborators, Shakur H, Roberts I, 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(9734):23–32. doi: 10.1016/S0140-6736(10)60835-5

[22] CRASH-2 trial collaborators, Shakur H., Roberts I., 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. Vol. 376, No. 9734. P. 23–32. doi: 10.1016/S0140-6736(10)60835-5

[23] Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012;147(2):113–119. doi: 10.1001/archsurg.2011.287

[24] Morrison J.J., Dubose J.J., Rasmussen T.E., et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study // Arch Surg. 2012. Vol. 147, No. 2. P. 113–119. doi: 10.1001/archsurg.2011.287

[25] Kotwal RS, Butler FK Jr. Junctional Hemorrhage Control for Tactical Combat Casualty Care. Wilderness Environ Med. 2017;28(2S):S33–S38. doi: 10.1016/j.wem.2016.11.007

[26] Kotwal R.S., Butler F.K. Jr. Junctional Hemorrhage Control for Tactical Combat Casualty Care // Wilderness Environ Med. 2017. Vol. 28. 2S. P. S33–S38. doi: 10.1016/j.wem.2016.11.007

[27] Brännström A, Rocksén D, Hartman J, et al. Abdominal Aortic and Junctional Tourniquet release after 240 minutes is survivable and associated with small intestine and liver ischemia after porcine class II hemorrhage. J Trauma Acute Care Surg. 2018;85(4):717–724. doi: 10.1097/TA.0000000000002013

[28] Brännström A., Rocksén D., Hartman J., et al. Abdominal Aortic and Junctional Tourniquet release after 240 minutes is survivable and associated with small intestine and liver ischemia after porcine class II hemorrhage // J Trauma Acute Care Surg. 2018. Vol. 85, No. 4. P. 717–724. doi: 10.1097/TA.0000000000002013

[29] Rall JM, Ross JD, Clemens MS, et al. Hemodynamic effects of the Abdominal Aortic and Junctional Tourniquet in a hemorrhagic swine model. J Surg Res. 2017;212:159–166. doi: 10.1016/j.jss.2017.01.020

[30] Rall J.M., Ross J.D., Clemens M.S., et al. Hemodynamic effects of the Abdominal Aortic and Junctional Tourniquet in a hemorrhagic swine model // J Surg Res. 2017. No. 212. P. 159–166. doi: 10.1016/j.jss.2017.01.020

[31] Anonymous. Abdominal aortic tourniquet? Use in Аfghanistan. J Spec Oper Med. 2013;13(2):1–2.

[32] Anonymous. Abdominal aortic tourniquet? Use in Аfghanistan // J Spec Oper Med. 2013. Vol. 13, No. 2. P. 1–2.

[33] Tovmassian RV, Kragh JF Jr, Dubick MA, et al. Combat ready clamp medic technique. J Spec Oper Med. 2012;12(4):72–78.

[34] Tovmassian R.V., Kragh J.F. Jr, Dubick M.A., et al. Combat ready clamp medic technique // J Spec Oper Med. 2012. Vol. 12, No. 4. P. 72–78.

[35] Brown SR, Reed DH, Thomas P, et al. Successful Placement of REBOA in a Rotary Wing Platform Within a Combat Theater: Novel Indication for Partial Aortic Occlusion. J Spec Oper Med. 2020;20(1):34–36.

[36] Brown S.R., Reed D.H., Thomas P., et al. Successful Placement of REBOA in a Rotary Wing Platform Within a Combat Theater: Novel Indication for Partial Aortic Occlusion // J Spec Oper Med. 2020. Vol. 20, No. 1. P. 34–36.

[37] Manley JD, Mitchell BJ, DuBose JJ, et al. A Modern Case Series of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Out-of-Hospital, Combat Casualty Care Setting. J Spec Oper Med. 2017;17(1):1–8.

[38] Manley J.D., Mitchell B.J., DuBose J.J., et al. A Modern Case Series of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Out-of-Hospital, Combat Casualty Care Setting // J Spec Oper Med. 2017. Vol. 17, No. 1. P. 1–8.

[39] Reva VA, Petrov AN, Samokhvalov IM. Pervyj otechestvennyj opyt primeneniya endovaskulyarnoj ballonnoj okklyuzii aorty v zone boevyh dejstvij. Angiologija i sosudistaja hirurgija. 2020;26(2):61–75. (In Russ.)

[40] Рева В.А., Петров А.Н., Самохвалов И.М. Первый отечественный опыт применения эндоваскулярной баллонной окклюзии аорты в зоне боевых действий // Ангиология и сосудистая хирургия. 2020. Т. 26, № 2. С. 61–75.

[41] Fisher AD, Teeter WA, Cordova CB, et al. The Role I Resuscitation Team and Resuscitative Endovascular Balloon Occlusion of the Aorta. J Spec Oper Med. 2017;17(2):65–73.

[42] Fisher A.D., Teeter W.A., Cordova C.B., et al. The Role I Resuscitation Team and Resuscitative Endovascular Balloon Occlusion of the Aorta // J Spec Oper Med. 2017. Vol. 17, No. 2. P. 65–73.

[43] Cantle PM, Hurley MJ, Swartz MD, et al. Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit. J Spec Oper Med. 2018;18(2):98–104.

[44] Cantle PM, Hurley MJ, Swartz MD, et al. Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit // J Spec Oper Med. 2018. Vol. 18, No. 2. P. 98–104.

[45] Gumanenko E.K. Voenno-polevaja hirurgija: uchebnik. Moscow: GEOTAR-Media, 2008. Prilozhenie 1. (In Russ.)

[46] Гуманенко Е.К. Военно-полевая хирургия: учебник. М.: ГЭОТАР-Медиа, 2008. 768 с. Приложение 1.

[47] Lewis KM, Li Q, Jones DS, et al. Development and validation of an intraoperative bleeding severity scale for use in clinical studies of hemostatic agents. Surgery. 2017;161(3):771–781. doi: 10.1016/j.surg.2016.09.022

[48] Lewis K.M., Li Q., Jones D.S., et al. Development and validation of an intraoperative bleeding severity scale for use in clinical studies of hemostatic agents // Surgery. 2017. Vol. 161, No. 3. P. 771–781. doi: 10.1016/j.surg.2016.09.022

RIGHTS & PERMISSIONS

Golovko K.P., Samokhvalov I.M., Grishin M.S., Suprun T.Y., Nosov A.M., Dmitrieva E.V., Kovalevsky A.Y.