Page 85 - Journal of Special Operations Medicine - Winter 2015

an attempt to appreciate bleeding cessation. At 20 min- This case study demonstrated that a motivated and in-
utes after the arteriotomy, active bleeding was difficult telligent, but untrained, first responder could successfully
to visualize on ultrasound, and at 27 minutes after the localize the actual anatomic site of an exsanguinating
arteriotomy, bleeding appeared to have stopped. While bleed and then could relatively easily compress this site to
bleeding was appreciated on ultrasound subjectively, the control the bleeding site using ultrasound-guided manual-
hematoma size did not change substantially over the compression techniques. This approach might comprise
course of the procedure, leading to the understanding a potential treatment algorithm for using UGMC tech-
that the bleeding decreased over time before stopping niques with novice users. In such an approach, a rapidly
and did not continue uncontrolled for 27 minutes. Fol- hemostatic device such as the iTClamp is used to quickly
lowing bleeding cessation, attempts were made to ap- control major vascular injury by creating an acute false
preciate proximal and distal flow in the injured limb. or pseudoaneurysm. This quickly contains blood loss but
While proximal arterial flow was captured, potentially retains mobility and independence of the casualty. De-
indicating lack of thrombosis in the artery itself, distal pending on the environment, such treatment might be de-
flow could not be appreciated. At 57 minutes after the finitive. However, if the environment and logistics permit,
arteriotomy, the iTClamp was removed from the wound with RMTUS, the actual anatomic site of extravasation
and we were able to visually observe that the bleeding could be definitively localized and compressed to acceler-
had stopped and a clot had formed exterior to the artery ate the natural processes of hemostasis.
itself.
With the greater availability of portable ultrasound, this
might constitute a mentored technique that could be used
Discussion
early after wounding/injury in an environment where
Efforts are under way in both civilian and military care there is a provider, an ultrasound device, and Internet
to improve hemorrhage control for all injuries, recog- connectivity. Traditional standard-of-care packing, how-
nizing that this offers the greatest chance of prevent- ever, would not permit such an approach, as gauze pack-
ing unnecessary postinjury death. Thus, improvements ing would introduce an air-containing impediment with
in techniques, systems applications, and even pharma- very high acoustic impedance to the wound, which would
cology have led to improved hemorrhage control and/ preclude meaningful ultrasound imaging.
or outcomes. 22–24 However, the inability to treat junc-
tional hemorrhage with standard tourniquets has been It should be emphasized that RMTUS guidance is not
identified as a capability gap by the US military. 25,26 In required for the iTClamp to be efficacious but is merely
response to this challenge, the Combat Ready Clamp a potential technical adjunct. First responders in emer-
(CRoC; Combat Medical; http://combatmedicalsystems. gent situations need to be able to deal with hemorrhage
com) was developed to exert mechanical pressure di- control without outside direction, particularly noting the
rectly over a wound or indirectly over the groin to arrest challenges of establishing wireless connections and tele-
hemorrhage. In vivo studies have demonstrated effec- mentorship in unstable environments. The iTClamp has
25
tiveness of this device, although the application required demonstrated the ability to not only stop the external
1 to 2 minutes in ideal conditions and the application egress of blood from a wound but also to stop the bleeding
of compression pressures of 800–900mmHg, which in- and ultimately form a clot, which may offer advantages
duced complete ischemia of the proximal external and over the CRoC and other hemorrhage-control devices
internal iliac arteries, effectively blocking all collateral in terms of quicker initial application, less pressure ap-
circulation in the swine leg. Thus, while effective in a plication required, possible preservation of collateral limb
25
laboratory setting, there remain uncertainties about its flow, and the ability to take the required skill out of the
practical application in fully operational settings. skill set of hemorrhage control. Further evaluations, espe-
cially including comparative studies, are thus warranted.
Portable, hand-carried ultrasound devices are another
technology that is ever improving and is increasingly be- Disclosures
ing used in operational settings, both civilian and mili-
tary. 27–29 While ultrasound is versatile, portable, easily This case study was supported by Innovative Trauma
repeatable, and without radiation, it is very user-depen- Care, of which J. L. McKee is an employee. A. W.
dent, which has, until recently, limited its use to highly Kirkpatrick received the donation of the NanoMaxx
trained specialists with the time to learn all the skills and portable ultrasound machine for unrestricted research
pitfalls required to use ultrasound accurately. However, purposes from the SonoSite Corporation.
with global Internet availability, having remote experts
who are able to guide on-scene novices through image References
acquisition, as well as to interpret the images in discus- 1. Champion HR. Epidemiological basis for future improvements
sion with the on-scene provider, is more practical. 7,30,31 in trauma care. Semin Hematol. 2004;41:173.

Telementored US-Directed Compression in Vascular Injury 73