What kind of injury gives a true uncontrolled bleed?

[AZCEP]

I could be wrong, but I think the reports you mention are from battlefield injuries. Situations where cleaning the site, applying direct pressure, and carefully bandaging will end up getting you killed. Placing a tourniquet is much faster, and therefore safer for the providers.

Of course, this is the military, so we might see some of these ideas in the future.

[JPINFV]

*Drafting letter to PCP school regarding "crush syndrome"*

*Drafting letter to basic school requesting the addition of "crush syndrome"

[Ace844]

Hello Everyone,

Heres some related info from a recent trauma study...

Hope this helps,

ACE844

(Trauma Associated Severe Hemorrhage (TASH)-Score: Probability of Mass Transfusion as Surrogate for Life Threatening Hemorrhage after Multiple Trauma.

Original Articles

Journal of Trauma-Injury Infection & Critical Care. 60(6):1228-1237 @ June 2006.

Yucel, Nedim MD; Lefering, Rolf PhD; Maegele, Marc MD; Vorweg, Matthias MD; Tjardes, Thorsten MD; Ruchholtz, Steffen MD; Neugebauer, Edmund A. M. PhD; Wappler, Frank MD; Bouillon, Bertil MD; Rixen, Dieter MD; the "Polytrauma Study Group of the German Trauma Society)

Abstract:

Background: To develop a simple scoring system that allows an early and reliable estimation for the probability of mass transfusion (MT) as a surrogate for life threatening hemorrhage following multiple trauma.

Methods: Potential clinical and laboratory variables documented in the Trauma Registry of the German Trauma Society (DGU) (1993-2003; n = 17,200) were subjected to univariate and multivariate logistic regression analysis to predict the probability for MT.

Results: Clinical and laboratory variables available from data sets were screened for their association with mass transfusion. MT was defined by transfusion requirement of >=10 units of packed red blood cells from emergency room (ER) to intensive care unit admission. Seven independent variables were identified to be significantly correlated with an increased probability for MT: systolic blood pressure (<100 mm Hg = 4 pts, <120 mm Hg = 1 pt), hemoglobin (<7 g/dL = 8 pts, <9 g/dL = 6 pts, <10 g/dL = 4 pts, <11 g/dL = 3 pts, and <12 g/dL = 2 pts), intra-abdominal fluid (3 pts), complex long bone and/or pelvic fractures (AIS 3/4 = 3 pts and AIS 5 = 6 pts), heart rate (>120 = 2 pts), base excess (<-10 mmol/L = 4 pts, <-6 mmol/L = 3 pts, and <-2 mmol/L = 1 pt), and gender (male = 1 pt). These variables were incorporated into a risk score, the Trauma Associated Severe Hemorrhage Score (TASH-Score, 0-28 points). Performance of the score was tested with respect to discrimination, precision, and calibration. Increasing TASH-Score points were associated with an increasing probability for MT.

Conclusion: The TASH-Score is an easy-to-use scoring system that reliably predicts the probability for MT after multiple trauma. Taken as a surrogate for life threatening bleeding calculation may focus attention on relevant variables indicative for risk and impact strategies to stop bleeding and stabilize coagulation in acute trauma care.

(Reduced Heart Rate Variability: An Indicator of Cardiac Uncoupling and Diminished Physiologic Reserve in 1 @ 425 Trauma Patients.

Original Articles

Journal of Trauma-Injury Infection & Critical Care. 60(6):1165-1174, June 2006.

Morris, John A. Jr MD; Norris, Patrick R. MS; Ozdas, Asli PhD; Waitman, Lemuel R. PhD; Harrell, Frank E. Jr PhD; Williams, Anna E. BA; Cao, Hanqing PhD; Jenkins, Judith M. MS, RN)

Abstract:

Background: Measurements of a patient's physiologic reserve (age, injury severity, admission lactic acidosis, transfusion requirements, and coagulopathy) reflect robustness of response to surgical insult. We have previously shown that cardiac uncoupling (reduced heart rate variability, HRV) in the first 24 hours after injury correlates with mortality and autonomic nervous system failure. We hypothesized: Deteriorating physiologic reserve correlates with reduced HRV and cardiac uncoupling.

Methods: There were 1,425 trauma ICU patients that satisfied the inclusion criteria. Differences in mortality across categorical measurements of the domains of physiologic reserve were assessed using the [chi]2 test. The relationship of cardiac uncoupling and physiologic reserve was examined using multivariate logistic regression models for various levels of cardiac uncoupling (>0 through 28% reduced HRV in the first 24 hours).

Results: Of these, 797 (55.9%) patients exhibited cardiac uncoupling. Deteriorating measures of physiologic reserve reflected increased risk of death. Measures of acidosis (admission lactate, time to lactate normalization, and lactate deterioration over the first 24 hours), coagulopathy, age, and injury severity contributed significantly to the risk of cardiac uncoupling (area under receiver operator curve, ROC = 0.73). The association between deteriorating reserve and cardiac uncoupling increases with the threshold for uncoupling (ROC = 0.78).

Conclusions: Reduced heart rate variability is a new biomarker reflecting the loss of command and control of the heart (cardiac uncoupling). Risk of cardiac uncoupling increases significantly as a patient's phyiologic reserve deteriorates and physiologic exhaustion approaches. Cardiac uncoupling provides a noninvasive, overall measure of a patient's clinical trajectory over the first 24 hours of ICU stay.

[Just Plain Ruff]

I think a filet knife to the throat at the level of the carotid would do it. could bleed out really quickly.

[Richard]

I could be wrong, but I think the reports you mention are from battlefield injuries. Situations where cleaning the site, applying direct pressure, and carefully bandaging will end up getting you killed. Placing a tourniquet is much faster, and therefore safer for the providers.

Of course, this is the military, so we might see some of these ideas in the future.

Unfortunatly, good tactics is bad medicine and vice versa.

I've seen an idiot proof TQ issued to every soldier, and the last US Army medic I talked to told me airway management in Iraq is NPA straight to a cric.

Anyone heard anything different?

[chbare]

Richard, this is what I had been hearing before my ETS date a couple months ago. In our CLS classes we were emphasizing the use of NPA's. We also taught a modified CAB survey over the ABC survey to emphasize hemorrhage control in combat casualties. I have a buddy that was a medic with an MP unit who just got back from an 18 month deployment. I do not recall him emphasizing airway management in combat. He said all they did was stop the bleeding and EVAC. (that is truly all he had time for) He was in Baghdad, so EVAC times were pretty fast. Your techniques may change a little in the remote mountains of Afghanistan. You are right about the TQ thing, everybody is issued the CAT.

Take care,

chbare.