Page 130 - JSOM Winter 2018

Data evaluating the effectiveness of human JTQs in canines 2. Secure the primary layer in place with a secondary layer of
are lacking; however, the Combat Ready Clamp and AAJT roll gauze and elastic adhesive bandage material such as
demonstrated effective hemorrhage control for groin hem- Coban; duct tape is alternate option.
orrhage in swine >50 kg. 43,44 As such, the JTQs designed for a. Overlay the wrap by approximately 50% on each turn,
humans may serve as an adjunctive method for controlling in barber pole fashion.
life-threatening junctional hemorrhage in medium- to large- b. Wrap the bandage such that one finger fits between the
breed dogs. Additional evaluation of the effectiveness and field bandage and skin. The intent is to wrap with enough
applicability of JTQs in a canine model is warranted before tension to cause a tamponade effect in the abdomen
making an absolute recommendation for their use. Of note, without causing too much constriction.
in a swine model, removal of the AAJT after only 2 hours re- c. Ensure the wrap does not interfere with the canine’s
sulted in potential life-threatening ischemic-reperfusion injury ability to urinate or defecate, or consider placing a uri-
and hyperkalemia, whereas another swine model revealed nary catheter (preferred) with a closed collection set to
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that application for 240 minutes resulted in small-intestine maintain hygiene and monitor urinary output.
and liver ischemia, persisting hyperkalemia, metabolic acido- 3. Continually monitor perfusion indices (i.e., heart rate,
sis, and myoglobinemia. 45 blood pressure, respiratory rate and effort, mucous mem-
brane color, and pulse oximetry [if available]) while plac-
External Abdominal Counterpressure ing the wrap. Note: Some canines may require a degree of
(a.k.a., Antishock Trousers) chemical restraint (i.e., sedation and analgesia) to facilitate
External abdominal counterpressure (EAC) may be a viable application of the counterpressure wrap, particularly, in the
tool for treating canines experiencing uncontrollable intraab- presence of pelvic fractures.
dominal hemorrhage subsequent to the blunt trauma. 46–48 By
increasing intraabdominal pressures, EAC creates a tampon- EAC may stay in place for up to 12 hours. Removal occurs
ade effect on bleeding intraabdominal organs and vasculature, once hemodynamics or perfusion indices stabilize, more defin-
thereby stopping or significantly slowing intraabdominal hem- itive veterinary care is available, or the wrap compromises the
orrhage. Unless pelvic limb fractures are present, the counter- canine’s condition. To remove the EAC:
pressure wrap should incorporate the pelvic limbs to prevent
compartmentalizing blood into the limbs. When the pelvic 1. Start from the most cranial aspect and release pressure
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limbs are incorporated, the circumferential counterpressure caudally.
wrap also facilitates venous return to the heart, similar to the a. Gradually release the pressure applied by loosening
concept of antishock trousers (ASTs) used in people. Despite only a few centimeters of the wrap at 10- to 15-minute
ASTs having a questionable survival benefit in people, exper- intervals. Note: Abrupt removal may cause a hypoten-
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imentally, EAC has been shown to provide a greater increase sive crisis due to redistribution of blood or rebleeding
in cardiac index, a slower rate of decline in mean arterial from a previously tamponaded vessel.
pressure, attenuation of hemorrhage, and a greater survival b. Continuously monitor perfusion indices after each re-
advantage in canines. Evidence from humans supports apply- lease to identify the potential onset of hemodynamic
48
ing a pressure between 20mmHg and 25mmHg for up to 48 collapse. Signs of hemodynamic collapse warrant reap-
hours is considered safe and effective. Clinical trials evaluat- plication of the EAC.
50
ing the effectiveness of EAC in canines are lacking; however,
anecdotal experience supports EAC as a therapeutic benefit Limitations to EAC use include the following: (1) although the
in managing canine traumatic hemoperitoneum. Contrain- goal of applying EAC is to staunch bleeding, the potential in-
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dications for EAC include diaphragmatic rupture, penetrating crease in arterial blood pressure induced by EAC may initially
thoracic injury, abdominal evisceration, cardiogenic shock, exacerbate hemorrhage; and (2) EAC is resource and labor
cardiac tamponade, and pulmonary edema. intensive, and, if performed correctly, application significantly
prolongs on-scene time—a factor that is not ideal when oper-
The following describes the EAC technique : ating in a tactical, high-threat environment. 47,49
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Materials required:
• Primary contact layer (at least one): rolled cotton, cast Despite its limitations, considering the lack of available pre-
padding, towels, clothing or similar material hospital interventions for abating intraabdominal hemorrhage,
• Secondary securing layer: elastic bandage material (Co- EAC may be a viable tool for managing traumatic hemoperito-
ban ) or duct tape. neum in canines until reaching definitive veterinary care.
™
Application: Conclusion
1. Wrap the hind limbs and abdomen circumferentially with
a primary layer of rolled cotton, cast padding, towels, or Massive hemorrhage remains one of the leading causes of
other suitable clothing material, ensuring all hair and ex- immediate and early post-traumatic deaths. To increase the
posed skin are covered: canine’s chance of survival, it remains imperative to iden-
a. Start distally at the toes of each hind limb and wrap prox- tify and control hemorrhage immediately. Identifying major
imal just caudal to the 13th rib. Inclusion of the 13th rib sources of external and internal hemorrhage involves a com-
incurs a greater risk for compromising ventilation. bination of knowing the mechanism of injury, anatomic injury
b. Wrap each limb separately and/or place a rolled towel patterns, visual and hands-on head-to-tail physical assessment,
between the limbs and then wrap the limbs together and, when available, point-of-care ultrasound for identifying
as one unit. If using cast padding, overlay the wrap by intracavitary hemorrhage. Once the source of bleeding is iden-
approximately 50% on each turn in a “barber pole” tified, immediate and appropriate hemostatic interventions
fashion. are warranted to prevent exsanguination. Effective first-line

128 | JSOM Volume 18, Edition 4 / Winter 2018