الشكل من: Spahn ، DR ، Bouillon ، B. ، Cerny ، V. et al. الدليل الإرشادي الأوروبي لإدارة النزيف الشديد واعتلال التخثر بعد الصدمة: الطبعة الخامسة. Crit Care 23 ، 98 (2019). https://doi.org/10.1186/s13054-019-2347-3

النزف هو السبب الرئيسي للوفاة التي يمكن الوقاية منها بعد الصدمة ، وهو في حد ذاته سبب لما يصل إلى 40٪ من الوفيات في المرضى المصابين بصدمات نفسية. [1] [2] وفقًا لمركز السيطرة على الأمراض والوقاية منها (CDC) ، لقي 62٪ من الأشخاص الذين لقوا حتفهم بسبب الإصابات و 75٪ من إصابات أعيرة نارية حتفهم خارج المستشفى. [3] ستيوارد وآخرون. وجدت أن 53٪ من الوفيات التي تُعزى إلى الصدمة حدثت في أول 12 ساعة ، و 37٪ منها سببها النزف. [4] لا يستغرق الأمر سوى دقائق حتى ينزف المريض حتى الموت. يجب اتخاذ القرارات بشأن السيطرة على النزيف في غضون ثوان.

في المراكز الصحية الداخلية ، يتم تدريب أول المستجيبين (المسعفون ، وضباط الشرطة ، ورجال الإطفاء) على تقنيات التحكم في النزيف [5] [6]لكن هذا ليس الواقع الحالي في غواتيمالا ، التي تفتقر إلى نظام رسمي لنظام الإدارة البيئية. يتم توفير الرعاية الطارئة قبل دخول المستشفى لكامل دولة غواتيمالا من قبل ثلاث شركات منفصلة لمكافحة الحرائق. في المجموع ، تتكون هذه الشركات الثلاث من حوالي 8500 رجل إطفاء ، نصفهم على الأقل من المتطوعين. يهتم رجال الإطفاء في غواتيمالا بكل أنواع الطوارئ ، من الولادة إلى إطلاق النار إلى الكوارث الطبيعية. يعد التدريب الطبي لحضور حالات الطوارئ هذه أساسيًا ، حيث توفر واحدة فقط من الشركات الثلاث خيارًا لدورة EMT رسمية غير إلزامية. علاوة على ذلك ، تحدث العديد من الصدمات في المناطق الريفية حيث لا توجد مراكز للصدمات ، وقدرة بنك الدم نادرة ، وتتفاوت أوقات النقل في المستشفى بشكل كبير ويمكن أن تكون واسعة النطاق. لا يوجد في غواتيمالا نظام مركزي لبنك الدم لتوفير العلاج بنقل الدم للمرضى المحتاجين. لا يوجد سوى 3 بنوك دم عامة في مدينة غواتيمالا ، التي يبلغ عدد سكانها أكثر من 3 ملايين نسمة.[7] وهذا يبرز أهمية إدارة النزيف في مرضى الصدمات.

لماذا هذا مهم؟

Trauma injury

  • Is one of the 10 leading causes of death and disability in the world[8]
  • Major cause of death for people <45 years old [9]
  • Main cause is accidents
  • 5.8 million deaths per year, accounting for almost 10% of global annual mortality[8]
  • Injury accounts for 16% of the global burden of disease [10]
  • In the US, trauma is the fourth leading cause of death for all ages [11]
  • Road traffic crashes kill 1.3 million people annually around the world (3242 people a day) 90% of these deaths are in low or middle-income countries [12]
  • 50 million people are injured in road traffic every year
  • The risk of dying in a road traffic crash is more than 3 times higher in low-income countries than in high-income countries.[13]
  • Estimated annual cost of road injuries: $518 billion globally [14]
  • Multi-system trauma victims have a 50-58% return-to-work rate in 2 years, which is a measurement of economic burden for countries[15][16]

In LMICs

  • Road traffic injuries cost between 1-2% of the gross national product – more than the total development aid received by these countries
  • Traffic-related injuries represent between 30% and 86% of all trauma admissions in many LMICs
  • Estimated annual cost of road injuries in LICs: $65 billion[17]
  • The burden of death and disability from injury is especially notable: 90% of the total burden of injury (approximately 90%)
  • The mortality rate for serious injuries (both pre-hospital and in-hospital ) ranges from 35% in HICs to 55% in LMICs, to 63% in a LICs.
  • For moderate injuries, the mortality in a rural hospital in an LIC is 6x higher than in a HIC: 36% vs 6%.[10]
  • Exsanguination is the main cause of death among patients dead upon the arrival of emergency medical services
  • Hemorrhage accounts for 50% of hospital deaths within 24 hours; 80% of operating room deaths after major trauma and the largest proportion of mortality within the first hour in emergency services care[18]

Hemorrhagic Shock

  • Is the main preventable cause of death worldwide [19]
  • Up to 29% of all trauma deaths are considered preventable, and uncontrolled bleeding accounts for 64% of all of these deaths[20]
  • On the battlefield, 91% of deaths are from hemorrhage [21]
  • Is responsible for 30 to 40% of trauma mortality
  • 33 to 56% of hemorrhage-related deaths occur during the prehospital period
  • 25% of central nervous system injuries are complicated by shock[18]

Providing early,[22] effective[23] triage and control of external bleeding increases the chances of survival of victims – which shows the need for well-trained first responders. Because of the survival benefit, prehospital providers should be prepared to address urgent situations.

In the military, protocols to deal with trauma and hemorrhage in extreme conditions are well established, with the use of evidence-based protocols. Military experience and research show that the leading cause of preventable death for penetrating trauma victims is bleeding. The Tactical Combat Casualty Care (TCCC) program has significantly reduced the number of preventable deaths, by recommending early use of tourniquets and pressure dressings to control bleeding.[24]

The Hartford consensus

The Hartford Consensus took place in the US in 2015, because of an increasing number of active shootings since 2012, which caused a rise in trauma and hemorrhage in the country. The directive wanted to include recommendations for national preparedness, planning, prevention, and protection of communities. This committee was led by the American College of Surgeons, using supporting evidence from the U.S. Department of Homeland Security, the Federal Emergency Management Agency, and the U.S. Fire Administration.[25]

This consensus highlighted the importance of the incorporation of tourniquets and hemostatic agents as a part of bleeding control by first responders and general population, as well as guidance of pearls and pitfalls of tourniquet application. You can find more information about the tourniquet use recommendations here.

THREAT

Threat is an acronym created at the event with the steps to achieve hemorrhage control. They are:

T - Threat suppression

H - Hemorrhage control

RE - Rapid Extrication to safety

A - Assessment by medical providers

T - Transport to definitive care

This acronym supports the evidence that bleeding control is very important in patients with active bleeding, and should be done even before the assessment by medical providers, since it has been demonstrated to have a profound increase in survival rates in patients with severe trauma. All medical and non-medical personnel were advised to the competent in tourniquet use to stop the bleeding.[25]

كيف يموت الناس من النزيف؟

Uncontrolled post-traumatic bleeding remains the leading cause of potentially preventable death in injured patients, and one-third of bleeding trauma patients show signs of coagulation dysfunction on admission.

These patients develop multiple organ failure and experience death more frequently than patients with other diseases with similar injury pattern in the absence of coagulopathy.

Early acute coagulopathy associated with traumatic injury has recently been defined as a multi-factor condition, by the combination of shock caused by bleeding, upregulation of thrombomodulin related to tissue damage, generation of thrombin-thrombomodulin complex, and activation of anticoagulation and fibrinolytic pathways.[26]

Table 1: Hemorrhagic Shock Classification [27]
Class IClass IIClass IIIClass IV
Blood loss (mL)<750760-15001500-2000>2000
Blood loss (%)15%15-30%30-40%40%
Pulse rate (beats/min)<100>100>120>140
Blood pressureNormalDecreasedDecreasedDecreased
Respiration rate (breaths/min)14-2020-3030-3535-40
Urine Output (mL/h)>3020-305-15Negligible
Mental statusNormalAnxiousConfusedLethargic

It is not known the exact amount of time it takes for a human to exsanguinate, but there are some factors associated with it, such as type of injury, location and whether it is an arterial hemorrhage.

تشريح ووظائف الأوعية الدموية / الأطراف

ANATOMY

- Upper and lower limbs

- Blood supply

PHYSIOLOGY

  • A hemorrhagic shock may lead to hemodynamic instability, followed by decreased tissue perfusion, organ damage, and ultimately death. (14). To avoid this, the 2 main goals are: 1) stopping the bleeding; 2) restoring circulating volume (15). For this, first responders have to be trained to triage and act in a timely manner.

The severity of clotting disorders is affected by the environment and treatment leads to acidemia, hypothermia, dilution, hypoperfusion, and coagulation factor consumption. In addition, coagulation dysfunction is affected by trauma-related factors (such as brain injury) and individual patient-related factors (including age, genetic background, comorbidities, inflammation, and medications taken before the injury, especially oral anticoagulants and prehospital infusions.[26]

 
Figure from: Spahn, D.R., Bouillon, B., Cerny, V. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 23, 98 (2019). https://doi.org/10.1186/s13054-019-2347-3

TYPES OF HEMORRHAGE

Arterial:

  • Bright red blood - more oxygen and more hemoglobin
  • Pulsating fashion
  • Arterial blood is lost at an increased speed compared to others, so it is usually the most dangerous.

Venous:

  • Darker red blood - less oxygen
  • Blood flow is homogeneous, and less strong

Capillary:

  • Very slow blood loss
  • Most common, the least dangerous

External vs internal bleeding

There can also be differences in the source of bleeding. When one can see it outside the body, it is considered external, and this is the subject of our study with the simulator. However, someone can bleed internally after a trauma, which is usually not visible, but can be as or more threatening to life, for example, if there is a complication called compartment syndrome. The major source of internal bleeding is the spleen.

Signs, symptoms

The patient can present pale, with cold skin, dizziness, difficulty breathing (tachypnea), difficulty speaking (diaphoretic), sticky skin, thirsty, yawning. The pulse can either be very fast or on the other hand, weak and difficult to palpate. The patient might show one or many signs, and you always have to suspect internal or external bleeding in traumatic injuries.

بروتوكول ATLS

  • Assessment of Bleeding/Circulation

ATLS, or the Advanced Trauma Life Support protocol, is a methodology for recognizing, triaging, and managing life-threatening traumatic injuries.  It was developed by trauma care providers at the American College of Surgeons Committee on Trauma and has been implemented at many sites around the world.[28] 

One of the core components of this systematic approach to the traumatically injured patient is the assessment and control of life-threatening problems with circulation. In a trauma patient, this generally means bleeding. After quickly assessing the patient's airway and breathing, practitioners are encouraged to assess the patient's circulation by obtaining vital signs, if possible, and also assessing if there are major sources of bleeding.

أمراض النزيف

While patients can bleed from anywhere they are injured, there are a few primary locations where blood loss can be a life-threatening problem. These locations are - the chest, inside the abdomen, in the pelvis or retroperitoneum, and notably for our training module, into the femurs/thighs or outside the body.  While pressure, packing, tourniquets, and foleys may not be very useful for bleeding that is happening inside the chest, abdomen, or pelvis, they can certainly help stop or temporize bleeding that is happening from extremities or joints that can lead to life-threatening bleeding outside the body or into the femurs.  As you recall from the previous section about the anatomy of blood vessels, there are very large and important blood vessels in the neck, arms, groins, and legs that, if injured, can cause a lot of blood loss very quickly. The techniques you will learn in this module can help you prevent morbidity and mortality from injuries in these types of places.

References

  1. Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute management of  trauma hemorrhage: a systematic review of randomized controlled trials. Crit Care.  2011;15(2):R92. doi:10.1186/cc10096
  2. Rhee P, Joseph B, Pandit V, et al. . Increasing trauma deaths in the United States. Ann Surg.  2014;260(1):13-21.
  3. CDC. Quickstats: Percentage of Injury Deaths for Which Deathwas Pronounced Outside the Hospital. Morb Mortal Wkly Rep2008;57:1130.
  4. Stewart RM, Myers JG, Dent DL, et al. Seven hundred fifty-threeconsecutive deaths in a level I trauma center: the argument forinjury prevention. J Trauma 2003;54:66-70 discussion −1.
  5. American College of Surgeons BleedingControl.org—about us.  http://www.bleedingcontrol.org/about-bc.
  6. Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK,  Fallat M, Taillac P, White L, Salomone JP, Seifarth W, Betzner MJ, Johannigman J, McSwain N  Jr. An evidence-based prehospital guideline for external hemorrhage control: American  College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014 Apr-Jun;18(2):163- 73. doi: 10.3109/10903127.2014.896962. PMID: 24641269.
  7. https://www.censopoblacion.gt/explo/TabA5.xlsx
  8. 8.0 8.1 G. B. D. Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1151–210.
  9. CDC: Web-based Injury Statistics Query and Reporting System (WISQARS). In: U.S. Department of Health and Human Services, CDC, National Center for Injury Prevention and Control. 2018.
  10. 10.0 10.1 Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. Guidelines for essential trauma care. Geneva, World Health Organization, 2004
  11. https://www.aast.org/resources/trauma-facts
  12. https://www.who.int/publications/i/item/guidelines-for-essential-trauma-care
  13. https://www.who.int/news-room/facts-in-pictures/detail/road-safety
  14. https://www.aast.org/resources/trauma-facts
  15. Holbrook TL, Anderson JP, Sieber WJ, Browner D, Hoyt DB. Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project. J Trauma. 1999, 46:765– 771; discussion 771–763.
  16. Vazquez Mata G, Rivera Fernandez R, Perez Aragon A, Gonzalez Carmona A, Fernandez Mondejar E, Navarrete Navarro P. Analysis of quality of life in polytraumatized patients two years after discharge from an intensive care unit. J Trauma. 1996;41:326 –332.
  17. World Health Organization., & Peden, M. M. (2004). World report on road traffic injury prevention. Geneva: World Health Organization
  18. 18.0 18.1 Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006 Jun;60(6 Suppl):S3-11. doi: 10.1097/01.ta.0000199961.02677.19. PMID: 16763478.
  19. Johansson PI, Ostrowski SR, Secher NH. Management of major blood loss: an update. Acta Anaesthesiol Scand. 2010 Oct;54(9):1039-49. doi: 10.1111/j.1399-6576.2010.02265.x. Epub 2010 Jul 6. PMID: 20626354.
  20. Davis JS, Satahoo SS, Butler FK, Dermer H, Naranjo D, Julien K, Van Haren RM, Namias N, Blackbourne LH, Schulman CI. An analysis of prehospital deaths: Who can we save? J Trauma Acute Care Surg. 2014 Aug;77(2):213-8. doi: 10.1097/TA.0000000000000292. PMID: 25058244.
  21. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen TE, Butler FK, Kotwal RS, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L, Blackbourne LH. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S431-7.
  22. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009 Jan;249(1):1-7. doi: 10.1097/SLA.0b013e31818842ba. PMID: 19106667.
  23. Kragh JF Jr, O'Neill ML, Walters TJ, Dubick MA, Baer DG, Wade CE, Holcomb JB, Blackbourne LH. The military emergency tourniquet program's lessons learned with devices and designs. Mil Med. 2011 Oct;176(10):1144-52. doi: 10.7205/milmed-d-11-00114. PMID: 22128650.
  24. Montgomery HR, Hammesfahr R, Fisher AD, Cain JS, Greydanus DJ, Butler FK Jr, Goolsby C, Eastman AL. 2019 Recommended Limb Tourniquets in Tactical Combat Casualty Care. J Spec Oper Med. 2019 Winter;19(4):27-50. PMID: 31910470.
  25. 25.0 25.1 https://www.facs.org/about-acs/hartford-consensus
  26. 26.0 26.1 Spahn, D.R., Bouillon, B., Cerny, V. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 23, 98 (2019). https://doi.org/10.1186/s13054-019-2347-3
  27. Gutierrez, G., Reines, H. & Wulf-Gutierrez, M.E. Clinical review: Hemorrhagic shock. Crit Care 8, 373 (2004). https://doi.org/10.1186/cc2851
  28. https://www.facs.org/quality-programs/trauma/atls
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