Improving time to hemostasis for injured patients with advanced resuscitative care

Oct. 03, 2023

"Trauma is a serious foe, but time is our mortal enemy."

— Daniel R. Gerard, MS, RN, NREMT-P

Though military and civilian medicine have made great strides in addressing four of five causes of prehospital death, one cause has remained elusive: noncompressible torso hemorrhage (NCTH). In a paper by Dr. Morrison in Critical Care Clinics in 2017, NCTH is "… defined by high-grade injury present in one or more of the following anatomic domains: pulmonary, solid abdominal organ, major vascular or pelvic trauma; plus hemodynamic instability or the need for immediate hemorrhage control."

The challenge with NCTH is its location in the body and medical professionals' inability to use techniques known to successfully stop hemorrhage in injuries to other anatomical locations, such as compression. According to Dr. Alarhayem and colleagues in a 2016 paper in American Journal of Surgery, NCTH has led to substantial mortality for civilians and military personnel. The current approach to NCTH has simply prolonged crucial time to hemostasis, according to Jeffrey D. Kerby, M.D., Ph.D., FACS, the Mayo Clinic Trauma Center Mucha Lecture speaker on August 18, 2023. Dr. Kerby chairs Trauma and Acute Care Surgery at the University of Alabama at Birmingham (UAB) and chairs the American College of Surgeons Committee on Trauma.

Thus, he says a new approach is needed. What Dr. Kerby deems can make an impact in NCTH is advanced resuscitative care (ARC).

Hemostasis: A race against time

ARC involves whole blood transfusion combined with use of a resuscitative endovascular balloon occlusion of the aorta (REBOA) to stem blood loss in the abdominal and pelvic regions and replenish lost blood. Specially trained teams who meet the patient in the field — at the scene of the injury — perform these treatments.

ARC provides highly specialized care for patients with NCTH. Also, these patients are treated in half the time it takes for EMTs to reach the scene and then transport the patients to the hospital, where a trauma surgeon can bring the patients to hemostasis. Bringing advanced procedures to the field is significant, as getting a patient with NCTH to hemostasis is literally a race against time, according to Dr. Kerby.

"Time saved is a life saved," says Dr. Kerby. "Advanced resuscitative care is an opportunity for patients to reach hemostasis earlier, impacting preventable mortality."

Dr. Kerby says the average time to hemostasis in an OR for patients who have experienced NCTH is 2 hours and 8 minutes. He indicates that in less than 30 minutes post-injury, a precipitous rise in mortality occurs, especially before the patient arrives at the hospital.

"There is no golden hour for internal hemorrhage," says Dr. Kerby.

A publication by Dr. Chang and colleagues in a 2019 issue of The Journal of Trauma and Acute Care Surgery underlines what Dr. Kerby stated about hemostasis and mortality. This study proved an independent association between earlier time to hemostasis and lower 30-day mortality rates.

Researchers have looked at numerous other factors that influence a patient's time to hemostasis, such as:

Mode of transport. Dr. Bulger and colleagues investigated the time impact of patient mode of transport — air versus ground — to determine whether this affected mortality. According to findings published in a 2012 issue of Journal of Trauma and Acute Care Surgery, they did not discern a difference.

Time spent in emergency department (ED). In a study of patients who were hypotensive and experienced abdominal trauma, investigators found probability of death increased 1% for every three minutes a patient spent in the ED. Dr. Clarke and colleagues published these results in a 2002 issue of Journal of Trauma and Acute Care Surgery.

Experience and data behind ARC. The experience of leading U.S. trauma centers and clinical trial findings underline the potential for ARC and its use of whole blood and REBOA to save patients' lives.

"Time saved is a life saved."

— Jeffrey D. Kerby, M.D., Ph.D., FACS

Dr. Kerby notes that Donald H. Jenkins, M.D., FACS, former Mayo Clinic Trauma Center adult medical director who now is vice chair for quality at UT Health San Antonio, advocated for prehospital whole blood use in his region. This implementation positively impacted shock indexes and reduced massive transfusion protocol activation and crystalloid use for patients experiencing traumatic injury.

The PPOWER prospective, randomized pilot trial found that prehospital low-titer group O whole blood is safe and assists in bringing a patient with traumatic injury to hemostasis. The Journal of Trauma and Acute Care Surgery published these results by Dr. Guyette and colleagues in 2022. Two ongoing clinical trials, Type O Whole Blood and Assessment of Age During Prehospital Resuscitation (TOWAR) trial and Trauma Resuscitation With Low-Titer Group O Whole Blood or Products (TROOP) trial are assessing 30-day and 6-hour mortality, respectively, in patients experiencing hemorrhagic shock who would typically need massive blood transfusion.

The other major aspect of advanced resuscitative care, REBOA use, has been used since the Korean War, says Dr. Kerby. However, in 2011, Todd E. Rasmussen, M.D., FACS, associate dean for research at Uniformed Services University who later became a vascular surgeon at Mayo Clinic's campus in Minnesota, along with a U.S. Air Force colonel, brought back REBOA use, says Dr. Kerby. REBOA is quick to insert, reduces blood loss, and increases cerebral and myocardial perfusion, he says. Dr. Kerby explains that the first-ever Department of Defense REBOA use occurred during Operation Inherent Resolve in 2016. In seven weeks, this operation's medical services saw 757 patients, including 414 gunshot wounds or blasting injuries.

A 2017 paper in Journal of Special Operations Medicine by Dr. Manley and colleagues outlines a case series of patients who were war-injured and treated 5 to 10 minutes' transport from the scene of injury. This paper presented REBOA catheter use and REBOA's feasibility and effectiveness in current combat casualty care. A 2018 paper in Journal of Trauma and Acute Care Surgery echoed these results with the largest single case series of REBOA use in severe combat casualties. This paper indicated REBOA's utility and lifesaving capability. It also showed use of whole blood, rather than component therapy, along with REBOA, significantly impacted outcomes for patients with NCTH and hemodynamic instability. All 20 patients in this study remained alive during transport to another care level.

Putting advanced resuscitative care into action for civilian trauma care

Calls are now going out for putting prehospital ARC into practice for patients with NCTH.

In a 2018 paper in Critical Care Medicine, Dr. Holcomb calls for advanced field care for military and for civilians, bringing treatment to patients who are injured in the field. Dr. Kerby explains that in a similar vein, UAB enacted an at-the-scene care team for civilian injury, named Surgical forWard Intervention for Trauma (SWIFT) team, in 2019. Similarly, he would like to see advanced resuscitative care teams trained and deployed for trauma medicine across the U.S.

"We must improve care on the battlefield — prehospital," says Dr. Kerby. "Forty percent of injured patients could be saved with advanced resuscitative care."