A person can bleed out in under 5 minutes!

Research into active shooter and mass casualty events shows the majority of casualties do not die from their primary injuries but rather from bleeding out while waiting for help to arrive.

In 2013, just a few months after the active shooter disaster at Sandy Hook Elementary School in Newtown, CT, the American College of Surgeons (ACS) in collaboration with the medical community and representatives from the federal government, the National Security Council, the U.S. military, the Federal Bureau of Investigation, and governmental and nongovernmental emergency medical response organizations, among others, formed a committee. The goal was to create a protocol for national policy to enhance survivability from active shooter and intentional mass casualty events. The committee’s recommendations are called the Hartford Consensus.

The participants of the Hartford Consensus concluded that by providing first responders and civilian bystanders with the skills and basic tools to stop uncontrolled bleeding in an emergency situation, lives would be saved. The first responder program has received very good response and is widely being used across the country. The next step is to focus on needs of civilian bystanders. They have developed the Stop the Bleed course and kit. You may start seeing these kits in grocery stores, offices, and schools.

As medical providers you are perfectly primed to become certified instructors of this course. You simply need to attend a class where you will be given instructions on registering as an instructor. You can bring this excellent information to your neighbors, churches, schools, and agencies. There is no cost for the course. You can find courses online at bleedingcontrol.org or EMSC can bring a class to you. Gather 10 of your closest family members, friends, or colleagues and contact us at tdickson@utah.gov.

Hemorrhage Background

Hemorrhagic shock is second only to traumatic brain injury as the leading causes of death in trauma patients in a non-military setting. Hemorrhagic shock is the most common type of shock experienced by trauma victims and is due to loss of circulating blood volume. The potentially deadly flow of events that follow blunt, penetrating and/or amputation injuries starts with a decrease in venous return to the heart (less blood returns to the right side of the heart) due to the loss of blood. This reduction leads to a decrease in cardiac filling and, in turn, a decrease in stroke volume, or how much blood the heart can pump out. This causes a subsequent decline in blood pressure, which then activates baroreceptors, leading to an initial response of the body to increase heart rate (tachycardia). The reason for the increase in heart rate is because of the following equation: Cardiac Output (CO) is equal to Stroke Volume (SV) times Heart Rate (HR) or CO=SV x HR. Therefore, if the stroke volume decreases due to blood loss, the heart rate must increase to try to maintain cardiac output. Children’s hearts are particularly good at doing this.

Once the blood loss exceeds 20-30% of the total blood volume, the body cannot effectively maintain a high heart rate or cardiac output. Patients usually become hypotensive and then bradycardic. While this is getting into the details of pathophysiology, know that you can save a life by controlling a bleed!

What is a Life-Threatening Bleed?

This is probably something you have seen in patient transport, but STOP the BLEED has a great visual: see above insert

Trauma Care Response (STOP the BLEED)

1. Ensure your own safety
2. Alert others (for the bystander, call 911)
3. Bleeding - find it by exposing the area (this naturally happens for EMS providers as you march down the ABCDE of trauma)
4. Compress - apply pressure by:

• Covering the wound with clean cloth and applying pressure with BOTH hands
  
• Packing the wound with clean material and then applying pressure with BOTH hands
  
• OR using a tourniquet when the above options do not control the bleed
  
• The tourniquet should be placed 2-3 inches above the bleed, but do not place it directly over a joint; go above the joint
  
• Make the free end as tight as possible before winding/twisting until the bleeding stops
  
• Secure the tourniquet and note the time it was placed
  

Trauma Resuscitation

There is ongoing research and discussion regarding optimal fluid resuscitation, as it is felt that aggressive crystalloid resuscitation (normal saline or lactated ringers) may make bleeding worse through dilution of platelets and other products the body needs to clot or coagulate blood. It is believed large volumes of crystalloid can worsen hypothermia and acidosis as well, and higher pressures may disrupt any clots that have already formed. Therefore, especially in adults, some patients (those who don’t also have head injury) are allowed “permissive hypotension” where the body can tolerate lower blood pressures as long as the patient otherwise is stable. The practice of permissive hypotension is not as well studied in children. Consider consulting your medical control or a Pediatric Emergency Medicine physician for advice if you have a hypotensive pediatric trauma patient.

In conclusion, use stop the bleed techniques such as pressure, packing, and tourniquets as soon as possible to help prevent major hemorrhage. If we can stop the bleed before too much blood volume is lost, we can keep our patients from going into hemorrhagic shock, and from needing aggressive resuscitation and mass transfusions.

References:

Bulgar, EM et al. An Evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. April-Jun 2014. (2) 163-173.

Cantle PM and Cotton, BA. Balance Resuscitation in Trauma Management. Surg Clin North Am. Oct 2017. Vol 97 (5): 999-1014.

Colwell, Christopher. UpToDate: Initial management of moderate to severe hemorrhage in adult trauma patient. Nov 2018.

Kirkman, E and Watts, S. Heamodynamic changes in trauma. British Journal of Anesthesia. Aug 2014. Vol 113 (2):266-275

UpToDate.com

https://attheu.utah.edu/facultystaff/saves-lives-stop-the-bleed2/

https://www.bleedingcontrol.org/~/media/bleedingcontrol/files/stop%20the%20bleed%20booklet.ashx

Tranexamic Acid

One of the concerns in trauma is blood loss. This is true whether treating an adult or pediatric patient. A current study looks at the medication tranexamic acid (TXA) and its benefits for the pediatric trauma patient. The study is called - Traumatic Injury Clinical Trial Evaluating Tranexamic Acid in Children (TIC-TOC).1

TXA is a "cool" medication in this emergency department pharmacist’s opinion.

TXA works by inhibiting plasminogen activation. Plasminogen activates into plasmin, which in turn, breaks down fibrin. This is the scaffolding of the blood clot.2 In layman’s terms, it inhibits the breakdown of blood clots. The cool part is that TXA does not promote clotting. It only inhibits the breakdown of existing blood clots. The best way to think of it is as a ‘blood bank sparing’ medication. TXA is commonly used to reduce morbidity and mortality in adult trauma patients and in 2011 the Israeli National EMS started using it in prehospital adult patients.3 In pediatric patients, it is currently used in open heart surgery and with mass transfusion protocols.

The TIC-TOC study examines the use of TXA in children with torso or head injuries.1 The results could be very interesting and may lead to the use of TXA in pediatric trauma patients.

Positive results could mean improvement in morbidly and mortality for the pediatric patient. Hopefully, this will lead to prehospital TXA protocols for pediatric patients as well. We will eagerly watch for the results of the TIC-TOC study.

1. https://clinicaltrials.gov/ct2/show/NCT02840097

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838717

3. https://tsaco.bmj.com/content/2/1/e000056

4. https://www.uptodate.com/contents/tranexamic-acid-pediatric-drug-information?sectionName=Pediatric&topicId=12854&search=txa&usage_type=panel&anchor=F1062673&source=panel_search_result&selectedTitle=2~116&kp_tab=drug_pediatric&display_rank=1#F1062673

In hospitals, in 2010, the Joint Commission made a “standardized approach to hand-off communications” a National Patient Safety Goal. There is a movement to standardize EMS hand-off as well starting with Utah's Central Trauma Region. When you deliver a patient to the trauma bay at Primary Children's Hospital you will be handed a pocket card like the one below. It can guide your 30 second report.

Cold weather easily brings to mind hot chocolate, roaring fires, and snowmen, but the winter months also bring an increase in carbon monoxide poisonings.

Carbon monoxide is a deadly, odorless, tasteless, and colorless gas often referred to as the “invisible killer.” It is released whenever we burn fuels such as gasoline, wood, natural gas, and oil. This gas can build up when heating systems, gas appliances and vehicles, and generators are used or ventilated improperly. Every year in the United States, carbon monoxide poisoning is responsible for more than 430 deaths and approximately 50,000 emergency department (ED) visits.

Season’s Greetings! As we settle in for the winter months and reflect on the past year goals and accomplishments, may your reflections include a job well done. You helped save the lives of children through the work that you do. We hope this newsletter brings valuable information that helps increase your knowledge regarding pediatric emergency care. If you are in need of a speaker, educational material, or a PEPP course, please feel free to contact any member of the EMSC program staff. We are here to help you and provide you with the resources needed to reduce death and disability from injury and illness for our pediatric population.

I want to take this opportunity to share a study recently released in the Prehospital Emergency Care Journal, Ready for Children: Assessing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting. Dr. Hilary Hewes, Utah EMSC Medical Director, was one of the primary authors of this study. A link to the article can be found here:

https://www.tandfonline.com/doi/full/10.1080/10903127.2018.1542472

A web-based assessment was conducted of EMS agencies across the country to determine whether a Pediatric Emergency Care Coordinator or Champion (PECC), was present to oversee pediatric training and issues and if a process was in place to assess psychomotor skills for EMS personnel in using pediatric equipment. With 8,166 EMS agencies responding nationally, 23 percent of the agencies reported having a PECC and 47 percent of the agencies evaluated pediatric skills twice a year.

Utah’s response to the survey indicated that 38.5 percent of our agencies had a PECC and 36.6 percent of the agencies had a skills assessment process in place. The goals of the National EMSC program is to reach 30% for having a PECC and annual skills assessment.

According to the study results, “the presence of a PECC can potentially increase provider confidence and safety for all pediatric prehospital patients regardless of volume or location.” Though agencies in urban settings with higher pediatric call volumes were likely to have a PECC and conducted pediatric skills assessments, PECCs may enhance the frequency of skills assessments for EMS agencies that infrequently treat children.

Whether you reside in an urban or rural setting, our EMSC County coordinators may be able to provide pediatric skills assessment and training in your area. The PEPP courses provide hand-on skills assessment. Erik Andersen, Paramedic, Lead EMSC PEPP Coordinator, can assist with these courses. Tia Dickson, RN, Pediatric Clinical Consultant, can provide additional educational materials and speakers for conferences and in-services.

Allan Liu, EMSC Coordinator, can be contacted for agencies interested in creating a pediatric emergency care champion. In the future, we hope to develop a Pediatric Readiness recognition program for both hospitals and EMS agencies with specialized staff, training, equipment, and guidelines to stand ready to treat pediatric emergencies.

We look forward to rolling out these resources to you and doing all we can to improve pediatric care in Utah. Thank you for your continued support. May 2019 bring blessings of good health and happiness to you and your families.

EMSC Pediatric Education for Prehospital Providers

Register online at peppsite.org. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth