Prehospital Guidelines for External Hemorrhage


CarolinaFireJournal - By James Winslow
By James Winslow MD
01/12/2016 -

Clinical Care related to current events: I thought that with the current tragic events involving active assailants that it would be a good moment to review the Evidenced-based Prehospital Guidelines for external hemorrhage that were published in 2014 by the American College of Surgeons Committee on Trauma.  These guidelines can be found in the April/June 2014 issue of Prehospital Emergency Care (vol 18, # 24). The recommendations address the use of tourniquets and topical hemostatic agents. The first recommendation involved the use of tourniquets.

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The American College of Surgeons also gave training recommendations. The college stated that tourniquets and hemostatic agents should be used under clear practice guidelines.

The guidelines strongly recommend the use of tourniquets. The panel felt that survival was improved when used to treat severe extremity hemorrhage.  The comment was also made that direct pressure may be ineffective when there is bleeding from a major artery and impractical in many settings. The document also addressed the best types of tourniquets.  It found that commercially made devices using windlass, pneumatic, or ratcheting type components were best. There was a recommendation against tourniquets using elastic materials. Improvised tourniquets should not be used unless there is no other option.

The guidelines also stated that tourniquets should not be released until arrival at definitive care unless there were long transport times or other factors that might limit timely evacuation. The guidelines stated that topical hemostatic agents are indicated along with direct pressure for areas of external hemorrhage not amenable to tourniquets. The guidelines stated that the hemostatic agents should be delivered via impregnated gauze.  The quality of evidence for these recommendations was low.

The American College of Surgeons also gave training recommendations. The college stated that tourniquets and hemostatic agents should be used under clear practice guidelines. In addition, prehospital personnel should be taught proper wound packing and how to deliver direct pressure to wounds. Lastly, the college stated that all prehospital personnel should be trained in the use of tourniquets and topical hemostatic agents.

Active EMS Research Project

I would also like to bring to your attention to some very innovative research being done by the University of North Carolina at Chapel Hill. They need more EMS participation! The Sudden Unexplained Death Registry (SUDDEN) study is looking at sudden death of patients. They hope to identify causal factors of sudden death. There is limited research in this area and some of the best research on this is currently taking place in North and South Carolina. There is no other study like this in the world that is looking across different states, cities and different demographic areas. The registry needs EMS agencies to sign up and participate. There is very little that EMS agencies will need to do, but they will receive quarterly reports on trends in patient sudden deaths in their service areas. The focus of the project is to identify causal factors of Out of Hospital Sudden Unexpected Death (OHSUD) and develop focused prevention strategies.

Potential OHSUD victims are identified by county EMS — monthly automated clinical software report — and transmitted to SUDDEN researchers via secure email. Quarterly reports (OHSUD incidence, location, clinical profile, etc) are provided to EMS and a county level, EMS directed, prevention program can be developed that focuses on OHSUD “hotspots” and recommended interventions.

SUDDEN senior investigators include, Ross J. Simpson, Jr., MD, PhD, Principal Investigator, J Paul Mounsey, MD, PhD, Co-Principal Investigator, and Irion W Pursell, Jr., RN, BSN, Co-Principal Investigator. Any EMS agency interested in participating may contact Irion W Pursell at [email protected]. SUDDEN senior investigators include, Ross J. Simpson, Jr., MD, PhD, Principal Investigator, J Paul Mounsey, MD, PhD, Co-Principal Investigator, and Irion W Pursell, Jr., RN, BSN, Co-Principal Investigator. Any EMS agency interested in participating may contact Irion W Pursell at [email protected].

Dr. Winslow graduated from Emergency Medicine residency from UNC-Chapel Hill in 2002 and completed his EMS Fellowship in 2003. He has worked at Baptist Hospital in Winston-Salem for the past 11 years. He was appointed as the Medical Director of the NC Office of EMS in 2011. This document contains all protocol, procedures, and policies for all EMS agencies in North Carolina.
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