Page 83 - Journal of Special Operations Medicine - Winter 2015

Remote Telementored Ultrasound-Directed Compression
to Potentially Accelerate Hemostasis in
Exsanguinating Junctional Vascular Injuries

Andrew W. Kirkpatrick, MD; Jessica Lynn McKee, MSc; Ian McKee;
Nova L. Panebianco, MD, MPH; Chad G. Ball, MD

ABSTRACT

Bleeding to death has been identified as the leading extremity) is the iTClamp. This device offers immediate
cause of potentially preventable injury-related death wound closure and mechanically assisted direct- pressure
worldwide. Temporary hemorrhage control could allow tamponade from the purposefully induced wound he-
the patient to be transported to a site capable of dam- matoma. While this device has been effective in case
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age-control surgery. A novel device that may offer a fast reports and cadaver studies, there remains concern that
5
and effective means of controlling nontruncal bleeding internal bleeding will continue despite the apparent ces-
(junctional and extremity) is the iTClamp (Innovative sation of external blood loss.
Trauma Care; http://innovativetraumacare.com). This
case study demonstrated that a motivated and intelli- Remote mentored tele-ultrasound (RMTUS) is a tech-
gent, but untrained, first responder could successfully nique in which a remote expert, using informatics tech-
localize the actual anatomic site of an exsanguinating nologies, is able to guide a novice clinical sonographer
bleed and then could relatively easily compress this site responding to an urgent medical situation. It has global
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to control the bleeding site by using ultrasound-guided application, essentially permitting remote guidance any-
manual-compression techniques. where on (or above) Earth that has Internet connectiv-
ity, 7–10 taking advantage of techniques first pioneered by
Keywords: hemorrhage; iTClamp; ultrasound; bleeding, the National Aeronautics and Space Administration. 11,12
control Using this philosophy, a wide range of ultrasound exam-
inations and ultrasound-guided therapeutic techniques
have been demonstrated using just-in-time training of
inexperienced responders. 13,14 Ultrasound-guided man-
Introduction
ual compression (UGMC) of pseudoaneurysms is a
Bleeding to death has been identified as the leading cause well-established technique to achieve pseudoaneurysm
of potentially preventable injury-related death world- closure, especially of the common femoral arteries. 16,17
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wide. Even more unfortunate is the fact that many of Our goal was thus twofold: we sought to (1) demon-
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these deaths arise from conditions that might be com- strate whether an ultrasound-naïve nonphysician re-
pletely preventable if temporary hemorrhage control sponder could be remotely guided to perform UGMC
could be obtained to allow the patient to be transported in the pseudoaneurysm created by the iTClamp from
to a site capable of even basic damage-control surgery. an exsanguinating junctional groin wound and (2) de-
This is true in both civilian and military experiences. Re- termine if and when bleeding cessation occurs with the
views of the combat experience prior to the Global War placement of the iTClamp 50 on such a wound.
on Terrorism suggest that traumatic hemorrhage resulted
in greater than 50% of all battlefield deaths. Another Case Report
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large, contemporary review of potentially survivable
deaths of US combat fatalities revealed that hemorrhage Ethical approval for this case study was obtained from
was related to 90% of cases (truncal, 67%; extremity, the University of Memphis, and all techniques were con-
14%; and junctional [axilla, groin, neck], 19%). At the ducted in accordance with the Animal Welfare Act and
3
Memorial Hermann Hospital in Houston, Texas, most implemented Animal Welfare Regulations. All care was
early inhospital deaths resulted from hemorrhage and in strict compliance with the “Guide for the Care and
occurred early, at a median of 2.6 hours after admission. 4 Use of Laboratory Animals.” 18

A novel device that may offer a fast and effective means A 30kg castrated pig was studied after the induction of
of controlling nontruncal bleeding (junctional and general anesthesia. An exsanguinating junctional groin

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