Abstract

INTRODUCTION In response to mass casualty events, The Hartford Consensus brought together subject matter experts across multiple disciplines in health care and public safety to create guidelines and publications intended to improve survivability in active shooter events. Among the recommendations was the earlier recognition and treatment application of life-threatening hemorrhage control. These recommendations culminated in efforts to create the Stop the Bleed Campaign, which aims to empower the layperson to render aid in a life-threatening bleeding emergency. As of February 2020, the program has held over 86,000 courses, trained over 1.4 million attendees, and over 77,000 instructors since its inception. In addition to spreading within the United States, American College of Surgeons (ACS) Stop the Bleed (StB) classes have been held in 118 different countries. This systematic narrative review aims to answer the following research question: What does the ACS StB Initiative do well, and where can it improve? MATERIALS AND METHODS The following search terms were utilized: "Stop the Bleed," "American College of Surgeons," "bleeding control," "first-aid," tourniquet, "wound pack," "direct pressure" hemorrhage, and bystander. The inclusion criteria were that the article needed to speak to the program or some aspect of bystander first aid, the article needed to be in a civilian setting, the article needed to be more than a case study or overview, and the first aid tools needed to be in the StB curriculum. 4 databases were searched, which produced 138 articles for screening. One hundred four full-text articles were able to be retrieved, and 56 articles were determined to meet the inclusion criteria once the full text was reviewed. RESULTS Fifty-six articles were included in the final review and were placed into the following categories: Needs Within the Community, Confidence and Knowledge, Training Modalities, Barriers and Gaps in Training, Instructor Selection, Skill Retention, and Patient Outcomes. The articles were then organized into each outcome for synthesis and reporting of the results. The program overwhelmingly improves short-term confidence, but gaps in skill retention, data collection on patient outcomes, and settings that would benefit were identified. CONCLUSION StB is an effective tool in building confidence in laypersons, which is its biggest strength. A review of the literature shows several areas where the curriculum and materials could be better developed. Research can also be further refined to better quantify the program's impact.

Abstract

CONTEXT Some medical schools integrate STOP THE BLEED(®) training into their curricula to teach students how to identify and stop life threatening bleeds; these classes that are taught as single day didactic and hands-on training sessions without posttraining reviews. To improve retention and confidence in hemorrhage control, additional review opportunities are necessary. OBJECTIVES To investigate whether intermittent STOP THE BLEED(®) reviews were effective for long term retention of hemorrhage control skills and improving perceived confidence. METHODS First year osteopathic medical students were asked to complete an eight item survey (five Likert scale and three quiz format questions) before (pretraining) and after (posttraining) completing a STOP THE BLEED(®) training session. After the surveys were collected, students were randomly assigned to one of two study groups. Over a 12 week intervention period, each group watched a 4 min STOP THE BLEED(®) review video (intervention group) or a "distractor" video (control group) at 4 week intervals. After the 12 weeks, the students were asked to complete an 11 item survey. RESULTS Scores on the posttraining survey were higher than the pretraining survey. The median score on the five Likert scale items was 23 points for the posttraining survey and 14 points for the pretraining survey. Two of the three knowledge based quiz format questions significantly improved from pretraining to posttraining (both p<0.001). On the 11 item postintervention survey, both groups performed similarly on the three quiz questions (all p>0.18), but the intervention group had much higher scores on the Likert scale items than the control group regarding their confidence in their ability to identify and control bleeding (intervention group median = 21.4 points vs. control group median = 16.8 points). CONCLUSIONS Intermittent review videos for STOP THE BLEED(®) training improved medical students' confidence in their hemorrhage control skills, but the videos did not improve their ability to correctly answer quiz-format questions compared with the control group.

Abstract

BACKGROUND A reliable scoring tool to detect the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis for ischemic stroke is warranted. The present study was designed to develop and validate a new nomogram for individualized prediction of the probability of hemorrhagic transformation (HT) in patients treated with intravenous (IV) recombinant tissue plasminogen activator (rt-PA). METHODS We enrolled patients who suffered from acute ischemic stroke (AIS) with IV rt-PA treatment in our emergency green channel between August 2016 and July 2018. The main outcome was defined as any type of intracerebral hemorrhage according to the European Cooperative Acute Stroke Study II (ECASS II). All patients were randomly divided into two cohorts: the primary cohort and the validation cohort. On the basis of multivariate logistic model, the predictive nomogram was generated. The performance of the nomogram was evaluated by Harrell's concordance index (C-index) and calibration plot. RESULTS A total of 194 patients with complete data were enrolled, of whom 131 comprised the primary cohort and 63 comprised the validation cohort, with HT rate 12.2, 9.5% respectively. The score of chronic disease scale (CDS), the global burden of cerebral small vascular disease (CSVD), National Institutes of Health Stroke Scale (NIHSS) score ≥ 13, and onset-to-treatment time (OTT) ≥ 180 were detected important determinants of ICH and included to construct the nomogram. The nomogram derived from the primary cohort for HT had C- Statistics of 0.9562 and the calibration plot revealed generally fit in predicting the risk of HT. Furthermore, we made a comparison between our new nomogram and several other risk-assessed scales for HT with receiver operating characteristic (ROC) curve analysis, and the results showed the nomogram model gave an area under curve of 0.9562 (95%CI, 0.9221-0.9904, P < 0.01) greater than HAT (Hemorrhage After Thrombolysis), SEDAN (blood Sugar, Early infarct and hyper Dense cerebral artery sign on non-contrast computed tomography, Age, and NIHSS) and SPAN-100 (Stroke Prognostication using Age and NIHSS) scores. CONCLUSIONS This proposed nomogram based on the score of CDS, the global burden of CSVD, NIHSS score ≥ 13, and OTT ≥ 180 gives rise to a more accurate and more comprehensive prediction for HT in patients with ischemic stroke receiving IV rt-PA treatment.

Abstract

BACKGROUND Pediatric patients require massive transfusion (MT) in a variety of settings. Multiple studies of adult MT support balanced ratio transfusion to improve outcomes, however it is unclear if these findings can be extrapolated to pediatric populations. The use of balanced transfusion ratios, MT protocols, hemostatic adjuncts, and even the definition of a MT in children are all open questions. This review presents details of care from current practices in pediatric MT and summarizes practice strategies while providing insight from our single center experience. METHODS PubMed, EMBASE, and Web of Science were searched using MeSH index and free text terms for articles from 1946 to 2017. Articles were independently reviewed by two reviewers. Studies were assessed for definition of MT, factors predicting MT, MT complications, blood product ratios, hemostatic adjuncts, protocol logistics, and clinical outcomes. RESULTS A heterogeneous composite of 29 articles was included in the analysis. Of these, 45% reported a formal transfusion protocol or adopted one during the study. Seven unique definitions of pediatric MT were reported; the most common was >1 total blood volume within 24 hours. A total of 18,369 patients were assessed, and 1,163 received MT (6.3%). Overall mortality for patients requiring MT in studies reporting mortality was high (range 14.7% to 51.2%). We identified 14 patients receiving MT at our center with an age range of 8 months to 18 years and average transfusion of 38.1 ml/kg RBC (range: 22.1 ml/kg to 156.7 ml/kg). CONCLUSIONS Current practices of pediatric MT demonstrate a variety of site-specific interventions with a persistently high mortality rate. A national focus on improving techniques of massive transfusion in children has the potential to save the lives of these children. LEVEL OF EVIDENCE Level IV and V, Systematic Review.

Abstract

BACKGROUND Despite significant attempts to educate civilians in hemorrhage control, the majority remain untrained. We sought to determine if laypersons can successfully apply one of three commercially available tourniquets; including those endorsed by the United States Military and the American College of Surgeons. METHODS Pre-clinical graduate health science students were randomly assigned a commercially-available windless tourniquet: SAM(R) XT, Combat Application Tourniquet(R) (CAT), or Special Operation Forces(R) Tactical Tourniquet (SOFT-T). Each was given up to one minute to read package instructions and asked to apply it to the HapMed(R) Leg Tourniquet Trainer. Estimated blood loss was measured until successful hemostatic pressure was achieved or simulated death occurred from exsanguination. Simulation survival, time to read instructions and stop bleeding, tourniquet pressure, and blood loss were analyzed. RESULTS Of the 150 students recruited, 55, 46, and 49 were randomized to the SAM XT, CAT, SOFT-T, respectively. Mean overall simulation survival was less than 66% (61%, 72%, 65%; p=0.55). Of survivors, all three tourniquets performed similarly in median pressure applied (319 mmHg, 315 mmHg, and 329 mmHg; p=0.54) and median time to stop bleeding (91 sec, 70 sec, 77 sec; p=0.28). There was a statistical difference in median blood loss volume favoring SOFT-T (SAM XT 686 ml, CAT 624 ml, SOFT-T 433 ml; p=0.03). All 16 participants with previous experience were able to successfully place the tourniquet compared to 81 of 131 (62%) first-time users (p=0.008). CONCLUSION No one should die of extremity hemorrhage, and civilians are our first line of defense. We demonstrate that when an untrained layperson is handed a commonly accepted tourniquet, failure is unacceptably high. Current devices are not intuitive and require training beyond the enclosed instructions. Plans to further evaluate this cohort after formal "Stop the Bleed" training are underway. LEVEL OF EVIDENCE Level II; Therapeutic study type.

Abstract

Importance: More than 500000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively. Objective: To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised). Design, Setting, and Participants: This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks. Interventions: Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application. Main Outcomes and Measures: Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test. Results: A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P < .001 for each pairwise comparison). When comparing tourniquets applied correctly, all tourniquet types had higher estimated blood loss, had longer application time, and applied less pressure than the CAT. Conclusions and Relevance: The B-Con principles for correct CAT application are not fully translatable to other commercial or improvised tourniquet types. This study demonstrates a disconnect between the B-Con course and tourniquet designs available for bystander first aid, potentially stemming from the lack of consensus guidelines. These results suggest that current B-Con trainees may not be prepared to care for bleeding patients as tourniquet design evolves. Trial Registration: ClinicalTrials.gov identifier:NCT03538379.

Abstract

BACKGROUND The mortality of trauma patients requiring massive transfusion to treat hemorrhagic shock approaches 17% at 24 hours and 26% at 30 days. The use of stored RBCs is limited to less than 42 days, so older RBCs are delivered first to rapidly bleeding trauma patients. Patients who receive a greater quantity of older RBCs may have a higher risk for mortality. METHODS AND MATERIALS Characterizing blood age exposure requires accounting for the age of each RBC unit and the quantity of transfused units. To address this challenge, a novel Scalar Age of Blood Index (SBI) that represents the relative distribution of RBCs received is introduced and applied to a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized controlled trial (NCT01545232, https://clinicaltrials.gov/ct2/show/NCT01545232). The effect of the SBI is assessed on the primary PROPPR outcome, 24-hour and 30-day mortality. RESULTS The distributions of blood storage ages successfully maps to a parameter (SBI) that fully defines the blood age curve for each patient. SBI was a significant predictor of 24-hour and 30-day mortality in an adjusted model that had strong predictive ability (odds ratio, 1.15 [1.01-1.29], p = 0.029, C-statistic, 0.81; odds ratio, 1.14 [1.02-1.28], p = 0.019, C-statistic, 0.88, respectively). CONCLUSION SBI is a simple scalar metric of blood age that accounts for the relative distribution of RBCs among age categories. Transfusion of older RBCs is associated with 24-hour and 30-day mortality, after adjustment for total units and clinical covariates.

Abstract

BACKGROUND This project involved the development and evaluation of a new visual bleeding feedback (VBF) system for tourniquet training. We hypothesized that dynamic VBF during junctional tourniquet training would be helpful and well received by trainees. MATERIALS AND METHODS We designed the VBF to simulate femoral bleeding. Medical students (n = 15) and emergency medical service (EMS) members (n = 4) were randomized in a single-blind, crossover study to the VBF or without feedback groups. Poststudy surveys assessing VBF usefulness and recommendations were conducted along with participants' reported confidence using a 7-point Likert scale. Data from the different groups were compared using Wilcoxon signed-rank and rank-sum tests. RESULTS Participants rated the helpfulness of the VBF highly (6.53/7.00) and indicated they were very likely to recommend the VBF simulator to others (6.80/7.00). Pre- and post-VBF confidence were not statistically different (P = 0.59). Likewise, tourniquet application times for VBF and without feedback before crossover were not statistically different (P = 0.63). Although participant confidence did not change significantly from beginning to end of the study (P = 0.46), application time was significantly reduced (P = 0.001). CONCLUSIONS New tourniquet learners liked our VBF prototype and found it useful. Although confidence did not change over the course of the study for any group, application times improved. Future studies using outcomes of this study will allow us to continue VBF development as well as incorporate other quantitative measures of task performance to elucidate VBF's true benefit and help trainees achieve mastery in junctional tourniquet skills.

Abstract

BACKGROUND The rate of failing to apply a tourniquet remains high. HYPOTHESIS The study objective was to examine whether early advanced training under conditions that approximate combat conditions and provide stress inoculation improve competency, compared to the current educational program of non-medical personnel. METHODS This was a randomized controlled trial. Male recruits of the armored corps were included in the study. During Combat Lifesaver training, recruits apply The Tourniquet 12 times. This educational program was used as the control group. The combat stress inoculation (CSI) group also included 12 tourniquet applications, albeit some of them in combat conditions such as low light and physical exertion. Three parameters defined success, and these parameters were measured by The Simulator: (1) applied pressure ≥ 200mmHg; (2) time to stop bleeding ≤ 60 seconds; and (3) placement up to 7.5cm above the amputation. RESULTS Out of the participants, 138 were assigned to the control group and 167 were assigned to the CSI group. The overall failure rate was 80.33% (81.90% in the control group versus 79.00% in the CSI group; P value = .565; 95% confidence interval, 0.677 to 2.122). Differences in pressure, time to stop bleeding, or placement were not significant (95% confidence intervals, -17.283 to 23.404, -1.792 to 6.105, and 0.932 to 2.387, respectively). Tourniquet placement was incorrect in most of the applications (62.30%). CONCLUSIONS This study found high rates of failure in tourniquet application immediately after successful completion of tourniquet training. These rates did not improve with tourniquet training, including CSI. The results may indicate that better tourniquet training methods should be pursued.

Abstract

BACKGROUND Hemorrhage coupled with coagulopathy remains the leading cause of preventable in-hospital deaths among trauma patients. Use of a transfusion protocol with a predefined ratio of 1:1:1 (1 each of red blood cells [RBC], frozen plasma [FP] and platelets) has been associated with improved survival in retrospective studies in military and civilian settings, but such a protocol has its challenges and may increase the risk of respiratory complications. We conducted a randomized controlled trial to assess the feasibility of a 1:1:1 transfusion protocol and its effect on mortality and complications among patients with severe trauma. METHODS We included 78 patients seen in a tertiary trauma centre between July 2009 and October 2011 who had hypotension and bleeding and were expected to need massive transfusion (>= 10 RBC units in 24 h). We randomly assigned them to either the fixed-ratio (1:1:1) transfusion protocol (n = 40) or to a laboratory-results-guided transfusion protocol (control; n = 38). The primary outcome, feasibility, was assessed in terms of blood product ratios and plasma wastage. Safety was measured based on 28-day mortality and survival free of acute respiratory distress syndrome. RESULTS Overall, a transfusion ratio of 1:1:1 was achieved in 57% (21/37) of patients in the fixed-ratio group, as compared with 6% (2/32) in the control group. A ratio of 1:1 (RBC:FP) was achieved in 73% (27/37) in the fixed-ratio group and 22% (7/32) in the control group. Plasma wastage was higher with the intervention protocol (22% [86/390] of FP units v. 10% [30/289] in the control group). The 28-day mortality and number of days free of acute respiratory distress syndrome were statistically similar between the groups. INTERPRETATION The fixed-ratio transfusion protocol was feasible in our study, but it was associated with increased plasma wastage. Larger randomized trials are needed to evaluate the efficacy of such a protocol in trauma care. Trial registration: ClinicalTrials.gov, no. NCT00945542.