Page 113 - JSOM Summer 2020

vessels are more superficial and run adjacent to long bones. In “multipurpose”; 3,362 for (compression and (aorta or vena
contrast, our discussion focuses on bleeding that is less amena- cava)).mp”; and 14 for a combination of “exp Hemorrhage,”
ble to direct pressure, such as abdominopelvic and junctional “(abdominal hemorrhage or abdomen or pelvis),” (external
hemorrhage. In these latter cases, indirect pressure, or pres- aortic compression or proximal external aortic compression
sure that is applied over the aorta proximal to the hemorrhage or aortic compression or external manual compression or
can be similarly expedited. We propose that this be done with manual external aortic compression or indirect pressure).mp,”
hands or a knee, and preceding more definitive temporizing and (compression and (aorta or vena cava)).mp.” A search of
measures, which can, in turn, be divided into noninvasive Google Scholar returned 132 results. An additional six grey-
(e.g., tourniquet) devices or invasive (i.e., REBOA). literature articles (e.g., conference presentations, newspaper
articles, textbooks, course documents, practice guidelines)
PEAC, whether via a device, the rescuer’s hands, or the res- were obtained via the Google search engine and two addi-
cuer’s knee, reduces or occludes distal blood flow in noncom- tional articles were identified through consultation with ex-
pressible regions. 14–16 The common goal is to compress the perts. Sixteen articles were included in this review. Results are
central vessels against the spinal cord and a hard surface, such described in narrative form in the specific sections that follow.
as a concrete roadside or extrication board. In this article,
we review the published data, with a focus on manual and Postpartum Hemorrhage
genicular compression after postpartum hemorrhage (PPH), After life-threatening peripartum hemorrhage and PPH, ex-
aortic rupture, and penetrating trauma. We wish to encourage ternal aortic compression is endorsed by the World Health
PEAC as a temporizing measure in the chain of survival and to Organization, the Advanced in Labour and Risk Manage-
18
achieve the Hartford Consensus mandate: that no one should ment International program for emergency obstetrical care,
19
die from uncontrolled bleeding. 17 and the Queensland Ambulance Service. In a 1996 study
20
that investigated healthy postpartum volunteers, Riley and
Burgess reported that manual PEAC successfully arrested
14
Methods
femoral artery pulses in 11 of 20 healthy postpartum moth-
A medical librarian conducted a search of the Ovid MED- ers. Soltan et al. performed a two-stage quasi-experimental
21
LINE, In-Process & Other Non-Indexed Citations, and trial of external aortic compression after PPH and compared a
Google Scholar databases for literature dating from 1946 to device (the El-Minia aortic compression device) versus aortic
3 May 2019, using the following search terms: (external aor- manual pressure. During the first period, PPH annually caused
tic compression OR proximal external aortic compression OR six deaths and 22–31 complications. The PPH incidence de-
vena cava compression) AND (abdomen or pelvis) OR (hem- clined from 4.6% in 1999 to 0.9% at the end of the study. In
orrhage) OR (emergency or trauma). A flow diagram of the 2008 and 2009, there were no deaths due to PPH and only
search process is provided in Figure 1. In addition, references four complications were recorded in each of these 2 years.
from included studies were assessed. Similar results were found with manual pressure and device
aortic compression. Moreover, Soltan et al. established ex-
21
21
FIGURE 1 Search flow diagram. ternal aortic compression as an effective measure to prevent
severe shock and death, second only to blood transfusions in
treatment effect (20 units of blood required in 2008 using the
device versus 72 units needed in 2009 using manual compres-
sion, which the authors attributed to bleeding while switching
compressors; p <.001). Balanced against these positive data is
a retrospective assessment of PPH treatment with and without
aortic compression in which no difference was found in blood
loss or time to hemorrhage control. 22

Soltan et al. also looked at Doppler velocimetry and demon-
23
strated that femoral blood flow could be substantially reduced
for longer than 2.5 hours without creating abdominal com-
partment syndrome or lasting lower-extremity neurovascular
injury. External aortic compression devices have also been fa-
vorably reviewed by van Oostendorp et al. and Smith et al.
1
2
At least one transport program, CareFlight Australia, uses the
Abdominal Aortic and Junctional Tourniquet (Compression
Works; http://compressionworks.com) for PPH (in addition
to using it for trauma). 24,25 However, an extensive review of
devices is outside the scope of this review.
A search of Medline returned 315,167 results for “exp Hem- Cardiovascular System
orrhage”; 81,233 for “(abdominal hemorrhage or abdomen Manual PEAC was used as a temporizing measure after aor-
or pelvis)”; 3,017 for a combination of “exp Hemorrhage” tic aneurysmal rupture. Kin et al. published a case report of
26
and “(abdominal hemorrhage or abdomen or pelvis)”; 139 epigastrial PEAC performed on an 83-year-old woman with
for “(external aortic compression or proximal external aortic a ruptured infrarenal aortic aneurysm. In their words, “with
compression or aortic compression or external manual com- continuous external manual compression, the femoral pulse
pression or manual external aortic compression or indirect was not palpable on either side, while the radial systolic blood
pressure).mp,” where “.mp” in the search term stands for pressure exceeded 100mmHg within 5min of circulatory

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