Saving Lives with Tourniquets: A Review of Penetrating Injury Medical Examiner Cases

The impacts of governing agency: A comparison of resources in the patchwork of medicolegal death investigation systems

In the United States, medical examiners and coroners (MECs) fill critical roles within our public health and public safety systems. These professionals are primarily charged with determining the cause and manner of death as they investigate deaths and respond to associated scenes and mass fatalities and can also help identify trends in public health crises through medicolegal death investigations. Despite their instrumental role, they are organized in disparate systems with varying governing structures, functions, staffing, caseload, budget, and access to resources. This paper examines data from the 2018 Census of Medical Examiner and Coroners to evaluate MEC operations in the United States. The findings show that MEC offices' organizational and operational governance structures greatly influence resources, workloads, and access to information and services. Standalone MEC offices were generally better resourced than those affiliated with law enforcement, public health, forensic science, district attorneys, or other agencies.1.

Tourniquet Use in the Prehospital Setting

PURPOSE

Tourniquets are a mainstay of life-saving hemorrhage control. The US military has documented the safety and effectiveness of tourniquet use in combat settings. In civilian settings, events such as the Boston Marathon bombing and mass shootings show that tourniquets are necessary and life-saving entities that must be used correctly and whenever indicated. Much less research has been done on tourniquet use in civilian settings compared to military settings. The purpose of this study is to describe the prehospital use of tourniquets in a regional EMS system served by a single trauma center.

METHODS

All documented cases of prehospital tourniquet use from 2015 to 2020 were identified via a search of EMS, emergency department, and inpatient records, and reviewed by the lead investigator. The primary outcomes were duration of tourniquet placement, success of hemorrhage control, and complications; secondary outcomes included time of day (by EMS arrival time), transport interval, extremity involved, who placed/removed the tourniquet, and mechanism of injury.

RESULTS

Of 182 patients with 185 tourniquets applied, duration of application was available for 52, with a median (IQR) of 43 (56) minutes. Hemorrhage control was achieved in all but two cases (96%). Three cases (5.8%) required more than one tourniquet. Complications included five cases of temporary paresthesia, one case of ecchymosis, two cases of fasciotomy, and two cases of compression nerve injury. The serious complication rate was 7.7% (4/52). Time of day was daytime (08:01-16:00) = 15 (31.9%), evening (16:01-00:00) = 27 (57.4%), and night (00:01- 08:00) = 5 (10.6%). The median transport interval was 22 (IQR 5] minutes. The limbs most often injured were the left and right upper extremities (15 each). EMS clinicians and police officers were most often the tourniquet placers. Common mechanisms of injury included gunshot wounds, motorcycle accidents, and glass injuries.

CONCLUSION

Tourniquets used in the prehospital setting have a high rate of hemorrhage control and a low rate of complications.

Tourniquets, types and techniques in emergency prehospital care: A narrative review

Massive uncontrolled hemorrhage is an important cause of preventable death in trauma. Therefore, applying an arterial tourniquet (TQ) is recommended as a pre-hospital measure to control bleeding after severe traumatic bleeding. Limb TQ applies circumferential compression proximally to the injury site to compress the arteries, resulting in blood flow and consequently hemorrhage interruption. The use of commercial tourniquets (C-TQ), which are designed, tested, and registered to control hemorrhages in pre-hospital care, is a consensus. However, they are still uncommon in many prehospital emergency services and the overall level of evidence in most studies is low. This narrative review aimed to characterize the importance of tourniquets use in prehospital emergency care and its application techniques. Furthermore, it proposes to stimulate the development of new devices, more accessible and easier to use, to suggest new directions of studies and medical education demands, with manikin and simulation development.

A framework for the design and implementation of Stop the Bleed and public access trauma equipment programs

Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.

Oxidized dextran crosslinked polysaccharide/protein/polydopamine composite cryogels with multiple hemostatic efficacies for noncompressible hemorrhage and wound healing

Noncompressible hemorrhage caused by gunshots and sharp objects leads to higher trauma mortality, and cryogels have great potential in controlling noncompressible hemorrhage applications owing to their shape-memory properties. However, the use of non-toxic crosslinkers to prepare cryogels for noncompressible hemorrhage remains a challenge. In this study, a series of cryogels were prepared using oxidized dextran (ODex) as a biocompatible crosslinker, combined with the good hemostatic properties of chitosan (CS) and human-like collagen (HLC), and polydopamine nanoparticles (PDA-NPs) were also introduced to strengthen the shape recovery speed of the cryogels and further enhance their hemostatic performance. The CS/HLC/ODex/PDA-NPs (CHOP) cryogels presented a highly interconnected macroporous structure, powerful water/blood absorption capacity, robust mechanical performance, and rapid water/blood-triggered shape recovery. In vitro coagulation and coagulation mechanism tests showed that CHOP exhibited strong procoagulant ability, high adhesion to blood cells and fibrinogen, and the capacity to activate platelets and intrinsic pathways. In vivo hemostatic tests indicated that CHOP could effectively shorten the bleeding time and reduce the bleeding volume of liver incision bleeding and liver noncompressible hemorrhage. Meanwhile, CHOP exhibited good biocompatibility and biodegradability, and could promote wound healing. These results suggest that CHOP cryogels will be a promising hemostatic dressing.

Pain management for casualties receiving lifesaving interventions in the prehospital scenario: Raising awareness of our human nature

BACKGROUND

Lifesaving interventions (LSIs) are the hallmark of medical care in trauma casualties, reducing mortality and morbidity. Analgesia is another essential treatment, which has been shown to improve outcomes and decrease long-term complications. However, oligoanalgesia is common, and information regarding its relation to the performance of LSIs is scarce. The purpose of this study was to assess the relation between the performance of LSIs and analgesia administration in the prehospital environment.

METHODS

A retrospective database-based study was performed, including all trauma casualties treated by Israeli Defense Forces physicians and paramedics during 2006 to 2017 and admitted to hospitals participating in the Israeli National Trauma Registry. Included LSIs were tourniquet application, administration of tranexamic acid and freeze-dried plasma, and administration of chest decompression. Casualties treated with endotracheal intubation or cricothyroidotomy were excluded.

RESULTS

In the multivariable logistic regression analysis, LSIs were associated with prehospital analgesia administration (odds ratio [OR], 3.59; confidence interval [CI], 2.56-5.08; p < 0.001). When assessing for the different LSIs, tourniquet application (OR, 2.83; CI, 1.89-4.27; p < 0.001) and tranexamic acid administration (OR, 4.307; CI, 2.42-8.04; p < 0.001) were associated with prehospital analgesia administration.

CONCLUSION

A positive association exists between performance of LSIs and administration of analgesia in the prehospital environment. Possible explanations may include cognitive and emotional biases affecting casualty care providers.

LEVEL OF EVIDENCE

Retrospective study, level IV.

Penetrating injuries in Germany - epidemiology, management and outcome an analysis based on the TraumaRegister DGU®

Background

The management of penetrating wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. In Germany, penetrating injuries are reported to occur in 4–5 % of the severely injured patients who are enrolled in the TraumaRegister DGU® (trauma registry of the German Trauma Society). They include gunshot injuries, knife stab injuries, which are far more common, and penetrating injuries of other origin, for example trauma caused by accidents. The objective of this study was to assess the epidemiology and outcome of penetrating injuries in Germany, with a particular focus on the level of care provided by the treating trauma centre to gain more understanding of this trauma mechanism and to anticipate the necessary steps in the initial treatment.

Materials and methods

Since 2009, the TraumaRegister DGU® has been used to assess not only whether a trauma was penetrating but also whether it was caused by gunshot or stabbing. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2018. Excluded were patients with a maximum abbreviated injury scale (MAIS) score of 1 with a view to obtaining a realistic idea of this injury entity, which is rare in Germany.

Results

From 2009 to 2018, there were 1123 patients with gunshot wounds, corresponding to a prevalence rate of 0.5 %, and 4333 patients with stab wounds (1.8 %), which were frequently caused by violent crime. The high proportion of intentionally self-inflicted gunshot wounds to the head resulted in a cumulative mortality rate of 41 % for gunshot injuries. Stab wounds were associated with a lower mortality rate (6.8 %). Every fourth to fifth patient with a gunshot or stab wound presented with haemorrhagic shock, which is a problem that is seen during both the prehospital and the inhospital phase of patient management. Of the patients with penetrating injuries, 18.3 % required transfusions. This percentage was more than two times higher than that of the basic group of patients of the TraumaRegister DGU®, which consists of patients with a MAIS ≥ 3 and patients with a MAIS of 2 who died or were treated on the intensive care unit.

Conclusions

In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicides. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required in order to provide the basis for evaluating the long-term quality of the management of patients with stab or gunshot wounds.

Tourniquet application by schoolchildren-a randomized crossover study of three commercially available models

BACKGROUND

Life-threatening hemorrhage is a major cause of preventable mortality in trauma. Studies have demonstrated the effectiveness and safety of commercial tourniquets when used by adult civilians. However, there are no data about tourniquet application by children.This study's goal is to determine which of three commercially available tourniquets is most effective when used by children.

METHODS

A randomized crossover study was conducted in four elementary schools in Montreal to compare three commercially available tourniquets. The study population is primary school children aged 10 to 12 years (5th-6th grade). A total of 181 students were invited to participate; 96 obtained parental approval and were recruited. Participants underwent a short 7-minute video training on the use of three commercial tourniquets and were subsequently given a 2-minute practice period. Students were evaluated on their ability to successfully apply the tourniquet and the time to complete application. After applying all three tourniquets, the students selected their favorite model. The primary outcome is the proportion of successful applications per tourniquet model. Secondary outcomes include time to successful application for each tourniquet model and tourniquet model preference.

RESULTS

The mechanical advantage tourniquet (MAT) outperformed the combat application tourniquet (CAT) and the stretch wrap and tuck tourniquet (SWATT) in terms of success rate (MAT, 67%; CAT, 44%; SWATT, 24%; p < 0.0001), time to application (MAT, 57 seconds; CAT, 80 seconds; SWATT, 90 seconds; p < 0.0001), and preference (MAT, 64%; CAT, 30%; SWATT, 6%; p < 0.0001).

CONCLUSION

In this study, the MAT performs better in terms of success rate, time to application, and preference when used by school-aged children. This study can be helpful when facilities are purchasing tourniquets for use by students.

Lessons Learned From the Battlefield and Applicability to Veterinary Medicine-Part 1: Hemorrhage Control

In humans, the leading cause of potentially preventable death on the modern battlefield is undoubtedly exsanguination from massive hemorrhage. The US military and allied nations have devoted enormous effort to combat hemorrhagic shock and massive hemorrhage. This has yielded numerous advances designed to stop bleeding and save lives. The development of extremity, junctional and truncal tourniquets applied by first responders have saved countless lives both on the battlefield and in civilian settings. Additional devices such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and intraperitoneal hemostatic foams show great promise to address control the most difficult forms (non-compressible) of hemorrhage. The development of next generation hemostatic dressings has reduced bleeding both in the prehospital setting as well as in the operating room. Furthermore, the research and fielding of antifibrinolytics such as tranexamic acid have shown incredible promise to ameliorate the effects of acute traumatic coagulopathy which has led to significant morbidity and mortality in service members. Advances from lessons learned on the battlefield have numerous potential parallels in veterinary medicine and these lessons are ripe for translation to veterinary medicine.