.png?token=f37e6444bbb25b582e76e80d0c76db24)
.jpg?token=d1409d09466cbc1260b091ff86078c90)
The CPR of Trauma
Did You Know?
It takes only 3-5 minutes to bleed to death after sustaining severe physical trauma.
As a cardiac nurse, I fervently advocate for everyone learning CPR (Cardiopulmonary Resuscitation) and how to use an AED (Automated External Defibrillator). CPR and AEDs have been shown to increase survival of out-of-hospital cardiac arrest for over two decades. Public access defibrillators (PAD) and CPR training save countless lives.
As a military nurse, I’ll explore how and why another critical initiative is gaining momentum to save the lives of trauma victims.
During the latter part of the last century, the US military’s Joint Trauma System developed and implemented battlefield trauma training for its special forces and select medical personnel. This response resulted from high combat-related deaths from traumatic hemorrhage before a casualty arrived at a medical treatment facility.
Researchers later found, in an analysis of all US military casualties from October 2001 through December 2017 (Operation Iraqi Freedom, Operation Enduring Freedom), that survival among the most critically injured casualties increased 3-fold during those respective conflicts. Three critical interventions, tourniquets, blood transfusions, and prehospital transport within 60 minutes, were associated with a 44% mortality reduction.
Early bleeding control increases survival.
Today, that training, TCCC (Tactical Combat Casualty Care), has been extended to all military members. TCCC provides military personnel with the resources to facilitate implementing best medical practices in battlefield trauma care, thus further reducing battlefield mortality and bringing our troops home to their families.
Traumatic hemorrhage is responsible for about 2 million deaths globally each year. It is a leading cause of preventable death from trauma. According to the CDC, unintentional injuries are the leading cause of death for Americans aged 1-44.
Unfortunately, the mass casualty incidents in Newtown, CT, Parkland, FL, the Boston Marathon, and many others called upon civilians to become first responders.
But you don’t have to master tactical combat casualty care; another program prepares civilians to control life-threatening bleeding.
STOP THE BLEED® is a national awareness campaign and call-to-action implemented in 2017 by the White House in collaboration with the American College of Surgeons (ACS) and ACS Committee on Trauma. The STOP THE BLEED® program trains, equips, and empowers citizens to control bleeding until professional help arrives.
.jpg?token=ec9fa1be7de71c020a3853841e2bf9f1)
Our US military health system’s experience during conflicts in Iraq and Afghanistan provided the expertise, and the civilian population’s experience with mass casualty events generated the demand for this program. Through knowledge-sharing partnerships between the Department of Defense and the ACS, STOP THE BLEED® became a milestone achievement.
Following the tragedy at Sandy Hook Elementary School in 2012, a Connecticut trauma surgeon, Lenworth M. Jacobs, Jr., MD, FACS, Chair of the Connecticut State Committee on Trauma, organized a panel of national experts to evaluate the response to mass casualty events. The group developed expert recommendations for improving the survival of traumatic bleeding victims.
Because the group met in Hartford, CT, their recommendations became known as the Hartford Consensus. A national emergency response goal transpired, empowering citizens to administer lifesaving techniques to bleeding victims. STOP THE BLEED® became a national awareness campaign that continues a call to action for anyone to become an immediate responder.
Since its launch in 2017, STOP THE BLEED® trained over 3 million people and more than 117,230 instructors.
The American College of Surgeons (ACS) and the ACS Committee on Trauma aim to train every American in basic bleeding control techniques. They continue to work persistently, ensuring bleeding control kits are available in public venues such as schools, places of worship, and stadiums. They work to include the STOP THE BLEED program in Active Shooter protocols nationwide and globally.
Trauma is the number one cause of death among Americans between the ages of 1 and 44, costing the US healthcare system more than $670 billion annually.
Among those with severe trauma who make it to the hospital alive, many may survive if the bleeding and traumatic injuries are rapidly identified and treated in the field.
Traumatic injuries with severe blood loss can cause death within 3-5 minutes. Anyone can learn to identify life-threatening bleeding and how to control bleeding with direct pressure, packing, and tourniquets.
The chain of survival for patients with severe bleeding always begins with the goal of primary prevention. Primary prevention encompasses fostering programs for industry and community-based violence prevention, increasing workplace and motor vehicle safety, and compliance with safety gear such as seatbelts and helmets.
However, when the unthinkable happens, the focus shifts to prehospital hemorrhage control, where the STOP THE BLEED® initiative is concentrated.
You could be a bystander during a mass casualty event or a first responder for a severely injured victim. STOP THE BLEED® trains and prepares you to save a life.
The priorities for care during a traumatic event include:
- Personal safety of the first responder
- Minimizing further blood loss.
- Tourniquet application above the sites of bleeding in the extremities.
- Hemostatic dressing application to junctional locations (groin, axilla).
- Preventing hypothermia.
- Report/Document the time and location where the tourniquets are placed.
- Rapid transport to a facility that can provide definitive care.
After your safety, identifying and controlling the life-threatening bleeding are the immediate goals.
Tourniquets: Tourniquets are designed to stop all blood flow to a limb. They work by compressing an artery. There are several approved types of tourniquets with various features.
- CAT- Combat Application Tourniquet
- TX2 & TX3
- XT
- SOF
The windlass design CAT tourniquet (Combat Application Tourniquet) is one of the most widely used tourniquets. It allows for rapid application, is one of the safest in that it is less likely to cause additional damage, and offers various features that adequately control extremity bleeding. There are multiple types of tourniquets and ways to improvise. It’s essential to learn how to use them correctly.
.jpg?token=123a30511b1aca94820a47698fe58ce1)
Hemostatic dressings: Hemostatic dressings are used when the source of bleeding is not amenable to a tourniquet, such as the groin and axilla. Hemostatic dressings contain kaolin, a clay mineral that activates the clotting cascade to rapidly control bleeding.
Some hemostatic dressings are :
- Quick Clot
- Celox
- Omni-STAT
- ChitoSam
- BleedStop
It’s essential to understand the why behind the how. If you can understand advanced concepts, you will have a greater sense of urgency while administering lifesaving care to a bleeding trauma victim. You will know why it is so essential to stop the bleeding.
Advanced prehospital interventions may include:
- Pelvic binder application for pelvic ring fracture
- Permissive hypotension and restrictive fluid administration.
- Early airway control
- Blood product infusion
- Tranexamic acid infusion.
Pelvic ring fractures may be life-threatening and are not part of STOP THE BLEED® training. A pelvic binder is used to reduce bleeding from fracture sites.
Specialist expertise is required for the identification and treatment of life-threatening pelvic fractures. Still, you should know that severe pelvic fractures can result in life-threatening blood loss.
A lower-than-normal blood pressure is maintained until active bleeding is controlled. The rationale is that peripheral vasoconstriction, an intrinsic action of a shock state, forces blood to the major organs, thus prolonging the onset of impending coagulopathy or abnormal blood clotting.
Administration of large amounts of fluid contributes to and exacerbates the lethal triad by diluting blood and dislodging clot formations that are necessary to stop bleeding.
Severe blood loss will inevitably lead to difficulty breathing- think about the oxygen-carrying capacity of blood; therefore, airway control is a priority function in managing a trauma victim.
Prehospital whole blood infusions to replace lost blood is a practice adapted from military medicine and is used when transport to a hospital is prolonged. Ideally, immediate transport is optimal; however, it is only sometimes possible.
.jpg?token=84a7c598d1db2f5a254b884c91948b45)
Urban and rural parts of the country are adapting prehospital damage control resuscitation protocols for areas with extended transport times.
Damage Control Resuscitation (DCR) centers around plasma-based resuscitation, decreased crystalloids, and artificial colloid volumes. DCR showed improved outcomes in military and civilian cohorts.
Tranexamic acid (TXA) is a class of drugs known as anti-fibrinolytic, inhibiting blood clots’ breakdown. It must be carefully considered and given within 3 hours of injury. Studies show that TXA reduces mortality. However, studies are ongoing.
The Lethal Triad
In hemorrhagic shock, organs and tissues are not getting the oxygen-rich blood needed to function. Therefore, the result is acidosis or too much acid in the blood, leading to lactate generation. Lactic acid is a substance made by muscle tissue and red blood cells.
Too much lactate results in oxygen depletion in body tissues. Lack of oxygen causes tissue death or ischemia. Tissue ischemia contributes to hypothermia and the inability to maintain core temperature.
If the body cannot maintain core temperature, blood becomes more acidic, thus deteriorating further with continued bleeding- coagulopathy (abnormal blood clotting). It’s a deadly cycle you can impede by controlling bleeding and keeping the victim warm. In healthcare, we call this the lethal triad—metabolic acidosis, hypothermia, and coagulopathy.
For this reason, after bleeding is controlled, strong emphasis is placed on hypothermia prevention. Wrap the victim in anything you have. Some STOP THE BLEED® kits may contain a hypothermia blanket. It’s not an actual blanket; it is mylar material, just like what is used for marathon runners.
Blood loss causes hypothermia, even in a warm climate. During bleeding, the body tries to compensate for this loss by constricting blood vessels in the extremities, causing skin to become cool and pale. When bleeding bodies become cold, they lose the ability to form clots.
Hypothermia is associated with poor outcomes and higher mortality in trauma patients. This is why we emphasize the importance of keeping a bleeding victim warm after you stop the life-threatening bleeding.
The STOP THE BLEED® initiative is a vital program in today’s environment. It is well received and sought after by schools, law enforcement agencies, industries, and even other countries. By teaching everyone the challenges of uncontrollable hemorrhage and the basic principles of stopping bleeding, many senseless deaths are avoided, and lives saved.
STOP THE BLEED® is the CPR of TRAUMA!
You can help save a bleeding victim’s life.
Enroll today! There is no charge for the STOP THE BLEED® Course.
More information on how to enroll in a STOP THE BLEED® course can be found at:
For information about setting up a group course for your organization, email: stopthebleed@facs.org
References
JAMA Network. Association of Tranexamic Acid With Mortality and Thromboembolic Events on Patients With Traumatic Injury. Published, March 1, 2022. Accessed, 6 September 2023.
National Library of Medicine. Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan Iraq Conflict 2001-2017 Published, March 27, 2019. Accessed, 6 September 2023.
Pub Med Central. Prognostic model for traumatic death due to bleeding: cross-sectional international study. Published, May 28, 2019. Accessed, 6 September 2023.
National Library of Medicine. Traumatic Hemmorhage and Chain of Survival. Published, May 24, 2023. Accessed 6 September 2023.