Page 35 - JSOM Fall 2019

Background FIGURE 4 Image provided by Innovative Trauma Care. Available at
https://www.innovativetraumacare.com/. Used with permission.
Uncontrolled hemorrhage remains the number one cause of
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mortality from potentially survivable combat trauma. Along
with tension pneumothorax and compromised airway, uncon-
trolled hemorrhage has been the primary focus of TCCC since
its inception. The reintroduction and use of limb tourniquets
in the modern US military for the prehospital treatment of
life-threatening extremity hemorrhage was first controversially
recommended in the original 1996 report describing TCCC in
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Special Operations Forces. The hemostatic dressings Com-
bat Gauze (2008), Celox Gauze (2014), and ChitoGauze
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(2014) were subsequently recommended by the Committee
on Tactical Combat Casualty Care (CoTCCC) to help address
external hemorrhage at locations not anatomically amenable
to tourniquet use or as an adjunct to tourniquet conversion.
XStat (hemostatic compressed foam sponges) was the most re-
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cent hemostatic adjunct recommended in 2016. Junctional
tourniquets (the Combat Ready Clamp, the Junctional Emer-
gency Treatment Tool, and the SAM Junctional Tourniquet)
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were added to the TCCC Guidelines in 2013 as another op- reducing potentially survivable injuries from this cause. Fre-
tion for use when the bleeding occurs at those locations. quent emergency tourniquet application has reduced death
rates by 85%, from 23.3 deaths per year to 3.5 deaths per
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With the near-ubiquitous use of body armor among US forces year. 1,29,30 Tourniquets, however, cannot be applied in the head
and the increased use of TCCC, particularly the first-line use and neck region.
of tourniquets at the point of injury, the overall rates of com-
bat-related death have decreased remarkably over the past 18 Eastridge et al. provide a detailed analysis of all battlefield
years of combat. 16–19 Coincidentally, the use of body armor deaths from 2001 to 2011. 1,29,30 This study found that 87.3%
along with changes in wounding patterns from improvised ex- of battlefield death occurs prehospital, with 35.2% occurring
plosive devices (IEDs) has shifted the anatomical distribution instantaneously and 52.1% occurring acutely, meaning death
of injuries. 15,20 Since the Vietnam Conflict, there has been a occurs from minutes to hours post injury and prior to reach-
significant reduction in the percentage of chest injuries, from ing an MTF. The analysis also described 24.3% of these as
13.4% to 5.9%, along with a near doubling in the relative potentially survivable injuries. Of the potentially survivable
incidence of CMFI and PNI from 16% to 30.0% in the first 4 injuries, 90.9% were related to hemorrhage (Figure 5), of
years of conflict in Afghanistan and Iraq. 20,21 which 19.2% were junctional injuries. Junctional injuries were
further classified as 60.8% located in the axilla or groin and
Combat trauma patients often sustain wounds to more than 39.2% located in the cervical region. This means that 7.5% of
one zone of the neck, and wounds are no longer well defined the total potentially survivable injuries were noted to be in the
as previously seen with gunshot wounds (Figure 4). The neck (Figure 6).
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emerging wounding pattern is scattered with multiple small
fragments penetrating to various depths and from varying The current recommendation in TCCC for the treatment of
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angles. Injuries to the major vascular structures of the head CMFI and PNI is hemostatic dressings applied with at least 3
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and neck region can lead to uncontrolled bleeding, hypoten- minutes of sustained direct pressure. Hemorrhage in the head
sion, shock, and death. 22–26 Even seemingly innocuous injuries
can lead to higher than anticipated blood loss 24,25 and can be FIGURE 5 Adapted from Eastridge BJ, Mabry RL, Seguin P, et al.
lethal. 23,27,28 Death on the battlefield (2001–2011): implications for the future
of combat casualty care. J Trauma Acute Care Surg. 2012;73
(6 suppl 5):S431–S437.
As previously noted, anatomic and physiological complexities
of the head and neck make wounds in this region a challenge
to treat, especially for the Role 1 provider. These regions are
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not amenable to tourniquet use or circumferential pressure
dressings. The anatomy of the scalp makes compression chal-
lenging, and packing with hemostatic dressing is not possible.
Compression of the neck can lead to airway compromise and
harmful disruption in cerebral perfusion. Finally, the large
blood vessels found in the head and neck can produce rapid
exsanguination when they are injured. Currently, the TCCC
guidelines recommend Combat Gauze or XStat as options for
hemorrhage control in these areas.
It is important to note the many lessons in hemorrhage control
that have been learned in the last decade and a half of conflict.
The US military’s focused efforts to prevent exsanguination
from extremity wounds have been remarkably effective in

iTClamp Mechanical Wound Closure Device | 33