1. Pre-hospital haemorrhage control `then and now`
A #FOAMed article for Critical Care in Pre-hospital Practice @CCinPP
Matt Green PGDip MCPara
@MLG1611
When I was a fresh IHCD Trainee Ambulance Technician, an old hand of 44 years’ service remarked
that the public always expect an ambulance person to have a bandage to hand. He reasoned not
having other equipment would go unnoticed by the general public, but a bandage should always be
within arms’ reach as part of good patient care, and to ward off complaints.
In those days, haemorrhage control was limited to simple dressings whose design had been
unchanged for decades and raising a wound before popping the patient to the nearest Emergency
Department. In some cases, copious IV fluids were given before leaving scene `to make up for what
the patient had lost` and rapid infusions continued on route to hospital. In an era before widespread
reconfiguration of emergency departments and hospital downgrades, a receiving facility was rarely
more than a few short minutes’ drive away, where it was blindly assumed expert care was
immediately available from all clinical grades.
It was the year 2007.
Since then, haemorrhage control techniques used in pre-hospital medicine have swelled. The dogma
of opening the airway before controlling massive bleeding has crumbled, and there is now a choice
of traditional bandage or specialised pressure dressing or arterial tourniquet or haemostatic gauze or
tranexamic acid which can be mixed and matched to the specific situation. There is intraosseous
access for carefully titrated infusion of saline where IV access is impossible or insufficient, and the
use of pre-hospital blood transfusion is expanding and being tested by the RePHILL trial
(Birmingham.ac.uk/RePHILL) to ensure efficacy. Specialist paramedics offer sutures, steri-strips, glue
or staples for wound care and novel solutions such as the iTCLAMP (innovativetraumacare.com) and
REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) are been reported to conference
audiences who lap up the promise of saving more lives. The flagship network of consultant-led
major trauma centres are available nationwide 24 hours a day, with an integral role for damage-
control surgery and secondary transfer from local trauma units where indicated. For patients with
haemorrhagic shock in cardiac arrest, there are now standardised Resuscitation Council UK
traumatic cardiac arrest guidelines and a more clearly defined role for resuscitative thoracotomy
than has been seen previously.
The net effect is that we certainly save more people than we used to; there are even suggestions
that making haemostatic gauze and arterial tourniquets available to untrained members of the
public might help reduce life-threatening haemorrhage in the first few minutes before trained
personnel arrive, following a similar model as public access defibrillation. An idea which probably
needs to be examined much more closely before any rollout.
While the future is bright for saving those who are bleeding to death, it should be remembered that
in accessing trauma networks, ambulance clinicians are managing traumatised people for up to 60
minutes’ drive time (plus on-scene time); longer distances and durations than ever demanded
before and unanticipated in many colleagues’ initial training. As such, there is a need for continued
profession-wide unity to ensure pre-hospital practitioners have the education, medications,
equipment and autonomy to make this a reality and to avoid patients suffering in ambulances miles
from definitive care with ambulance staff unable to meet the patient’s clinical needs.