Thank you, Dr. Christmas. Our next speaker this morning is Dr. Kaufman. Thank you, Tim. Good morning. Thanks to the Education Committee for the opportunity to present regarding tourniquets. I look at that as a sine qua non for hemorrhage control, so I think the tourniquet talk would be five minutes, and since I have 25, I thought I'd say a few more things than tourniquets are good. They are. They didn't used to be, but they are now. I'm the acute care surgery medical director at Grand Strand Medical Center, a level one trauma center in Myrtle Beach, South Carolina. I've only been there about six months. Before that, I was in Pittsburgh for six years building a level two trauma center, and I have one slide about Pittsburgh that I think I'd like to share with you all, and that's why I bring that up. I'm a new board member of TCAA, so a privilege to be here, and thank you all for being here and getting up early. These are some of the important topics I'm not going to speak about during this presentation. I think these are all important, but 25 minutes is really short. It's nice because you can usually listen to somebody for 25 minutes without falling asleep, and so I appreciate the short opportunity to present one or two things that maybe you haven't heard before or heard presented in this way before. TXA is important. PCC is critical in our elderly trauma population, as is reversal of anticoagulants, and so that's becoming more and more our daily work. The other things you see here, vascular access, controlled resuscitation, hemostatic resuscitation, massive transfusion protocol, all of these are important and not something that is easily talked about given the other more important things that we can stop bleeding, and that's my reason for speaking is, again, about stopping bleeding. So the bleeding spectrum, if you look at the very basic cut your finger in the kitchen that, if you're a doctor or nurse, your mom would call you up and say, oh, I just have a horrible wound that I sustained, and you'd tell her maybe put a Band-Aid on it and you'll be fine. The ones that are a little bit worse than that, we can activate our EMS system, so we have our medics, we have our ground folks come and take a look, and we may need to activate the EMS system, and they might need to trip to the emergency department for getting their bleeding controlled. Down at the lower left is an old-timey operating room, and sometimes we do need the surgeons, the OR, the trauma system to respond in order to save lives, to stop people's bleeding, and then the last remaining picture is when nothing really works, and I'm not sure if that was a surgeon mark or a coroner mark, or is it from a scary movie? I don't know, but I like it, so I put it here. Anyway, hemorrhage is the second leading cause of trauma death after brain injury. That's an epidemiologic fact, and if you look it up time after time in our country, that is the fact. Hemorrhage is responsible for 30 percent of trauma mortality, and of those deaths, a third to a half occur during the pre-hospital period. In red, I have among those who reach hospital care, early mortality is caused by continued hemorrhage, coagulopathy, and incomplete resuscitation. That's what Dr. Christmas does. That's what I do. We're the folks in the trauma center, ready, spending our lives there just for that patient that's going to come up, and any minute or two may make a difference in success for a patient being able to survive their injuries. I think all of us over the years wish we'd had about five more minutes with a lot of our patients and think maybe we could have made a difference if we just had the opportunity to get to them sooner. The continuum of trauma, care, and resuscitation has been learned through military experience, and now finally, in recent conflicts, we've had the opportunity to aggregate those data and record them and hope that we don't have to relearn lessons, as has happened for the last hundreds of years, that each war in a global scale has resulted in relearning of old lessons. I stuck a picture of me in the first Gulf War triaging a little girl who'd been shot in Iraq, and that was my brief experience for seven months being in that environment. And there are a lot more people in this room, Dr. Schreiber among others, who have spent years now deployed in the military, and thank you for doing that. Hemorrhage in the hospital. It's a leading cause of death in the first hour, responsible for more than 80 percent of operating room deaths for trauma patients, and nearly 50 percent of deaths in the first 24 hours. Here's what we do at trauma centers. We mop up blood. It's not really what we want to be doing, but that's really what we do. The patients come in bleeding, and we're like trying to stop it, and we're cleaning up blood. What would we like to do? We talk about the spectrum of trauma system care and trauma systems, and we should be prevention experts. We try to be, and we try to turn off the flow of trauma, but we're not really successful at it to this point. So we want to be tap turners, not mopper uppers, if you will. And so I think most trauma talks, if you have the opportunity, you should mention something about prevention. And there's certainly lots of opportunity for prevention as regards hemorrhage control. The ABCs not only organize the way that we approach trauma patients, but they're a way that we can teach it and share and communicate, and ATLS serves as a common language for trauma care around the world. This is the way it's been taught forever and ever since the 1970s, and circulation now today has taken primacy maybe even among airway and breathing, because you can do something immediately. You can put your finger and stop the bleeding while you're maybe assessing airway and circulation. And certainly in military circumstances, in the field, if a medic is trying to take care of someone or a buddy's trying to take care of his partner, if there's an airway and a breathing problem from a penetrating injury, that's likely to be lethal, and you can't fix it quickly as you could if there was a circulation problem you can put your finger or a tourniquet on, as I'm going to talk about for most of the rest of my time. So stopping the bleeding is critical. It's what we're all about. It's what the organization of the trauma system is regarding stopping bleeding as much as anything else. If we could teach the folks in our country this as part of the BCON course, I think we would be way ahead, that the fate of the wounded lies in the hands of the ones who apply the first dressing. That is so simple, profound, true, and we have finally now developed a way to get that message across to the population, and that's the BCON course that I'll talk about for a couple of slides. They say that time changes things, but you actually have to change them yourself, and I have this quote from Andy Warhol, because Lynn Jacobs in Hartford, Connecticut, when they had the Newtown shooting, they said, we need a trauma surgeon to be involved in this process to see if the surgical community has something to offer to prevent these types of tragedies. And he realized that these children injured with a high-velocity weapon like Dr. Christmas just talked about, there was really no potential life-saving management that could have been afforded these children, even if it was in the first five minutes. It just was beyond our capabilities today. However, he said, you know, there's a lot of patients who bleed to death, and maybe we could use this type of impetus and a stimulus to do better in terms of educating our population as regards stopping the bleeding. So that's why we have the Bleeding Control Basic Course, Stop the Bleed. You can see the sponsoring organizations down below. This is really critical. It's like teaching our folks in our country CPR. It's like learning how to use an AED. So stopping the bleeding is simple for us, because we do this professionally. Those of us in the room understand the concepts. But it would be great, wouldn't it, if everybody at every school, every teacher was able to do this out in the playground when somebody trips and has an injury with substantial bleeding. So just a couple of slides. The BCON course has about 50 slides. How many of y'all are teaching it or plan to teach BCON? Yeah, see, that's 90% of the folks in the room, if not 100%. So this is a great opportunity for us. I'm really happy. We did it in Pittsburgh for a school district, and we were doing it school district by school district when they have 500 teachers that you can talk to at once, but then you need about 30 different folks to do the hands-on part of it. You can do that, and it works very well, and I'm glad we're doing it, and I hope it becomes part of education, elementary education, if you will, that we teach kids. It's like this is part of the ABCs for your education. Pressure points. We learned about these in doctor school and nursing school, and they still hold true, and they're still helpful. If there's a pressure point proximal to where there is some bleeding, this is one method to stop bleeding that does work. It hasn't gone away, but fortunately now, we believe that tourniquets are effective, and when I was a medical student, tourniquets were great, and then for the next 25 years, tourniquets were a tool of the devil, and you weren't allowed to use them, and now all of a sudden, for the last five-ish years, maybe 10, tourniquets are okay again. I think they were always okay. I think those of us who were in a circumstance to need to apply a tourniquet wouldn't hesitate to do so in the hospital, in the pre-hospital setting. We know that tourniquets save lives and have been doing so since probably before 17, 18. Since I put this talk together, there has been a publication of a study from a Texas consortium, a Texas tourniquet work group, and they looked at about a five-year population of folks with extremity injuries, so 1,000 patients with arm or leg penetrating vascular injuries, and they looked at the effect of tourniquet. The patients of that 1,000 that got a tourniquet were five times more likely to survive than the ones who didn't have a tourniquet applied. That's a big group of patients. That's substantial data, and should anybody doubt that tourniquets are effective or a tool that we need to be familiar with, that pretty much puts it to rest. They are important. The combat application tourniquet or the CAT tourniquet is the military's preferred tourniquet, easy to use, and can be rapidly applied. I see Dr. Vail, who always has a tourniquet or two or three or four, four he has on him right now, so he's the role model for have a tourniquet because you might need one. I usually have a belt on. I think maybe that's cheating, but anyway. Okay. He said 20% effective. So tourniquet application. Apply immediately, especially if blood is spurting out of the wound. You don't need to remove the clothing. Put it above the bleeding site, not distal to it. Tighten it until it stops, and if the bleeding is not controlled by the initial tourniquet, put on a second one. Don't apply it over the knee or elbow, and don't apply it over bulky items in a pocket, which in Myrtle Beach seems to be guns. So if you don't put it over, you have to take the gun out of the pocket first, I think. I didn't see it written anywhere, but some things just make sense in medicine. Tourniquet pain. Tourniquets hurt, and you should tell the patient it's going to hurt. Doesn't mean you did it wrong. Doesn't mean you should take it off, and once the medics show up, they have some morphine or fentanyl, and they can probably make the patient feel a little bit better. No amputations have been recorded or caused by tourniquets when they're left in place for less than two hours, and indeed, the warm ischemia time for muscles, extremities, is about six hours. So you wouldn't want to leave a tourniquet on for six hours, but you should never fear an hour or two, because again, you're saving somebody's life. It's better to risk damage to the arm or leg than to have the victim bleed to death. Tourniquet mistakes, and just remember these are mistakes, because some of them look like maybe they're okay. Not using a tourniquet when you need to. Waiting too long. Using it for minor bleeding. Putting the tourniquet too high up on the extremity. It should be pretty close to the wound if you're able to do so. Taking the tourniquet off when the victim is in shock. Not using a second tourniquet if you need it, and then the one that seems that people think is great is periodically loosening the tourniquet to allow blood flow to the injured extremity. The top of the slide said that's a mistake. Don't take it off. We'll just get a little oxygen down there. Whatever hemostasis you've achieved, you may lose and not regain, and you're going to be wasting some of their blood, because it's going to come squirting out the hole, and you don't know exactly which million red blood cells are the ones that they need to survive this injury. You have to give us a little bit of extra time at the hospital, so don't take the tourniquets off. This is a young woman who was going to run off with her boyfriend, and her mother said, no, I brought you into this world, and I can take you out. You're not going with him. This is one of the slash wounds that Dr. Christmas was talking about. She did have an internal jugular vein injury, but with just a little hemostatic agent, you have your leisure to get her fixed up in the operating room, and her mother ended up scarring her daughter, and I don't know if she did run away with her boyfriend. Junctional hemorrhage. Groin, buttocks, perineum, axilla, like this young woman, places where tourniquets don't work, and groin hemorrhage is the most common of those. Junctional wounds, quick clot, combat gauze, C-LOX, chitosan, topical hemostatics are functional. The most typical one that we have today that we see in most places is combat gauze. It works fine. We would open clothing around the wound, try to get rid of the excess blood, locate the source of most active bleeding, and then pack the wound. So this is from the B-Con course. Stick it in the hole, put pressure, but don't cover the hole, because it's just going to bleed underneath. Hold pressure for three minutes and ten minutes if using plain gauze. You know what? If I'm not in the hospital, I'm just going to hold pressure until we get to the hospital if I'm with a patient. There's no reason really to release pressure in this circumstance. If the initial packing fails to stop the bleeding, pack a second gauze on top and reapply pressure. I do have a bias against that statement, and I'll demonstrate it here in a couple of slides. You can leave the packing in place and then secure it and take off, get to the hospital. This is a commercial device, Croc. I don't own any stock in any of these companies. I just like the name of it. It sounds good. I don't know that folks would want to carry that around. Even though it's a lightweight metal, it still has some weight to it for the military. But you have to have something to stop junctional bleeding, and this is one of the proposed devices, and there are several on the market. So direct pressure, finger, hemostatic dressing, commercial device, sticking a Foley in the wound, don't really think that that's very often effective. People have talked about subclavian vessels and sticking it in the chest and pulling up on the Foley to try to tamponade. The number of times that's probably worked aren't as frequent as the number of times people have talked about it. It is a perfect indication for low blood pressure, again, as Dr. Christmas alluded to. All bleeding stops eventually. We know that. We say it to each other, and sometimes if you say it and a patient hears it, they're a little distressed by that because they're not as dumb, mostly, as we think. Hemorrhage control. So this is not a finger pointing at the title of this slide. This is an advanced hemorrhage control device, and I trust that everyone in the room has several advanced hemorrhage control devices available to them at this instant. If you're right-handed, it may be this one. If you're left-handed, I don't know. But you have some of these, and this is probably the first tool that I would use in the circumstance of being in the field, not in the hospital, to try to stop somebody's bleeding. And sometimes even in the emergency department, this is my go-to device for stopping bleeding. And I have some biases, like I said, about putting more and more gauze on stuff that's bleeding. What you're doing is you're diluting out the force on this. You're making it bigger and bigger, and so you're reducing the pressure from wherever the bleeding's coming from. So if you can find where the bleeding's coming from and put pressure there, all of this is just like putting a bunch of paper towels or toilet paper on top of the wound. Those aren't really designed for hemorrhage control, and neither is plain gauze. And so a stack of gauze is okay under some circumstances, but if you can find where the bleeding's coming from, just try to put discrete pressure where that is. I will say for this that if someone has what we see sometimes are patients coming into the emergency department with a tourniquet on their arm, and it's a dialysis patient with a bleed from their AV fistula, that is the quintessential case where if you touch where the bleeding's coming from, the bleeding stops. And these patients come in screaming because they have a tourniquet on, and then you have the opportunity to teach your medics. It's like, can you take the tourniquet off and you touch it? You don't put pressure, because the blood actually wants to go where it usually does, down the patient's arm and go through and come back out like it normally does. It doesn't want to squirt out of the hole, so you just have to remind it, go down there, and the blood will go where it's supposed to go. It doesn't want to squirt out of the hole. So if people put a tourniquet above that, that's great, it'll work, but a stack of gauze won't work, and just try to remember that there are some times where your finger will be best. This was the one time that I specifically wanted to mention Pittsburgh. We give all these blood products, and we're trying to put blood back together. Dr. Schreiber is one of the national and international experts on blood products, so I won't say that I have half as much knowledge as Marty does about some of this. The great thing that they're doing in Pittsburgh now is that every level one, level two pediatric trauma center, they all have fresh whole blood available, and that's because the blood bankers covered 23 hospitals in southwest Pennsylvania and part of West Virginia. So this one great big blood bank has made available to all the trauma centers fresh whole blood, and just like you've heard about, under some circumstances, it's a miracle drug to stop bleeding. I've seen it work that way, that the bleeding just stopped. It's like, wow. And usually, once upon a time, we would give lots and lots of crystalloid, followed by lots of blood and blood products, and if you just start off with blood, like we're doing more and more now, that helps, and if you can have fresh whole blood, which seems to be coming back now, after being not available to us for the last 30 years in the civilian community, it makes a huge difference. So once we get to the hospital, we have the emergency department, we have the operating room, we have lots of tricks and devices to try to get somebody to stop bleeding. And what we really want to do is get to see quickly with ABCs, massive transfusion protocol, we would activate that early, start blood early, and control hemorrhage. Just a couple of slides about Reboa, because I think most of y'all, many of y'all have already started to use Reboa, and that's retrograde endovascular balloon occlusion of the aorta. I think everyone in this room knows about Reboa and what it's about, but this is an alternative to resuscitative thoracotomy with aortic compression. So instead of opening up the chest and putting a clamp on the aorta, why don't you just put a balloon? And Carl Hughes in 1954 started this, and it fell off the radar for the last 60 years. And so now, again, we have the opportunity to put a balloon into aorta, inflate it to minimize the amount of bleeding that a patient may be suffering, particularly from severe pelvic fractures and also from some instances of abdominal bleeding. So the skills are available. It's basically starting an arterial line in the groin, which most of our team members can do or participate in, and then measure how far you're going to put up the balloon and use that to control life-threatening hemorrhage. In concept, it's very simple. In application, it takes longer in most hands than most of us as trauma surgeons could take somebody to the operating room and open their belly. Especially if we do resuscitations in the operating room, you can open an abdomen and clamp the aorta at the diaphragm quicker than you can do a Reboa. Most of us don't have the luxury of taking patients straight to the operating room from the ambulance, and so Reboa is kind of an in-between way to stop bleeding short of doing an ED thoracotomy when one of those might be indicated. There are clearly complications also of Reboa that are warranted to mention. It's not for free that you do a Reboa. Things can happen to people. So to conclude my talk, this is where we want to be when we're trauma surgeons. We want to be rolling down the hallway. We want to get to the OR. We want to stop the bleeding. We want to get there where we can take the tourniquet off, we can access the wound, put our finger on the hole, and fix the patient. In the pre-hospital setting, I mentioned you could put your fingertip on the hole, local pressure. On scalp lacs, patients can bleed to death from scalp lacerations. They're not trivial, but usually there's one place that's bleeding or two sides of a vessel bleeding and you can stop the bleeding from a scalp lac just by using your finger and pushing in the right place. Putting a bunch of gauze just ends up with a red dressing by the time the patient gets to the hospital. Tourniquet, you can use. Proximal arterial pressure points, you can use. And the whole point of trauma system care and organization and what we're all about is getting the patient to the trauma center in a big hurry. In the hospital center setting, it's the same, putting your finger, applying local pressure, consider proximal arterial pressure, and rainy clips that the neurosurgeons use in the operating room for their scalp incisions are great. It's like a staple gun except they're plastic clips and you can run it right along a great big scalp lac. If it's really big and it's bleeding from multiple sites, that might be helpful instead of trying to put your finger in multiple places from somebody's bleeding scalp. Clamping or suturing visible vessels is still okay, particularly for surgeons. Applying tourniquets, yes. And then ED thoracotomy or Reboa do have a place and there are survivors of both of these procedures. And so, in all cases, get to the, these days, ideally hybrid operating room fast. Thank you.

tourniquets

hemorrhage control

trauma care

bleeding prevention

education on hemorrhage control

REBOA