Page 114 - JSOM Summer 2020

collapse.” Van Roekens et al. also described external aor- victim, and by lowering the patient from waist height to floor
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tic compression in a case of tetralogy of Fallot cyanotic crisis. height so rescuers are atop victims and can lock their arms.
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This involved clinicians applying digital PEAC along with an With these strategies, and with maximal effort, participants
improvised abdominal tourniquet (i.e., a circumferentially ap- could manually compress almost 70% of their body weight
plied blood pressure cuff). The treatment was associated with for approximately 2 minutes. Using a single knee, participants
an increase in arterial oxygen saturation from 19% to 35%. compressed approximately 80% of their body weight and
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Used as a temporizing measure, Van Roekens suggest “external could maintain the maximal effort for as long as 20 minutes.
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manual compression of the abdominal aorta can be as effective In short, we have demonstrated that using two hands or a knee
as surgical clamping or vasopressors” and can garner valuable is worthwhile when there is no alternative. However, our am-
time to bridge patients to definitive surgical repair. 36 balance studies have demonstrated why a device or invasive
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intervention should decrease the likelihood of exsanguination
Trauma during transfer. In other words, it is not a case of PEAC or a
PEAC after trauma was reportedly taught to tactical provid- device, but rather PEAC until a device can be reliably applied,
ers in the 1990s to temporize inguinal hemorrhage. However, especially if providers are to remain with their seat belt on
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the first written description may be a 1983 article in Polish during ambulance or helicopter transfer. 33
on first aid hemorrhage control (Figure 2). The first, written,
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English-language recommendation for trauma appears to be Recently, we confirmed using ultrasound that rescuers with
from retired consultant general surgeon Harry Espiner, in The minimal training could rapidly arrest femoral artery blood
Guardian newspaper. He suggested two fists, one placed above flow using bimanual PEAC. Moreover, we showed that
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and one below penetrating abdominal wounds to control hem- PEAC could stop femoral blood flow within 20 seconds, albeit
orrhage. Our team (Douma et al.) described a peer-reviewed in healthy volunteers. Although our participants tolerated
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case report of PEAC application for a trauma patient in 2013. the compression (median pain score on a 0–10 scale: 5; range,
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In that case, PEAC resulted in returned consciousness of a 4–7), Soltan et al. have reported greater pain in obese women
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moribund victim of multiple GSWs to the abdomen pelvic and and a increased pain and compression failure were reported
lower limb. Notably, a heavier rescuer (>90kg) arrested bleed- in a junctional tourniquet trial in a participant with above-
ing, resulting in the patient regaining consciousness. Transfer of average body mass. 36
care to a lighter rescuer, as well as ambulance transfer, resulted
in ineffective PEAC, clinical deterioration, and, ultimately, From a practicality standpoint, we are pleased to report we
death. An additional series of four illustrative cases have been have taught PEAC to more than 200 clinicians and 80 other
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recently published by Dr Bruce Paix et al. from Australia. course participants. Training is free, reliable (using instructor
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Furthermore, a clinical team from Montreal has demonstrated demonstration and student return demonstration), requires
the use of an ultrasound probe to identify the aorta, compress no equipment and takes less than 5 minutes. Moreover, reme-
it, and confirm that compression was effective. 32 dial instruction is infrequently required because the bimanual
technique approximates that used for cardiac chest compres-
FIGURE 2 External aortic compression. sions. Figure 3 outlines how PEAC could be integrated into
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Early description of bimanual external compression of the
“abdominal artery.” Adapted from Badowski and Zaras. 29 a chain of survival for life-threatening abdominal-pelvic and
junctional hemorrhage (Figure 3). 34
FIGURE 3 Life-threatening abdominal-pelvic and junctional
hemorrhage chain-of-survival.
Proposed “chain of survival” for life-threatening abdominal-pelvic
and junctional hemorrhage. Adapted from Douma et al. 34

Proposed Role and Rationale for PEAC in Trauma
Tactical Combat Casualty Care proposes a “platinum ten min-
utes” to highlight the importance of early temporizing con-
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Feasibility Studies trol of massive hemorrhage. Recent work argues for a shorter
Our 2013 case led to a comprehensive research program, 3-minute window. After all, blood flow from a single femoral
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including feasibility, technique optimization, application artery approximates 3L/min during stress. Like us, Tjardes
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during transfer, and ultrasound assessment in healthy vol- and Luecking challenge whether a device can be reliably re-
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unteers. We found that (perhaps intuitively) heavier rescuers trieved and applied in that brief time. In contrast, manual or
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compress more weight and that compression efficiency is in- genicular PEAC can be applied immediately. Junctional tour-
creased by optimizing technique. Specifically, we found that niquet application conservatively takes longer than a minute.
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one-handed compression resulted in the transmission of less Use of REBOA in Zone 3 trauma (i.e., the area extending dis-
than 30% of the rescuer’s body weight. Compression efficiency tally from the lowest renal artery to the aortic bifurcation) is
is increased with a second hand, a hard surface beneath the promising, especially because it occludes femoral vessels via an
112 | JSOM Volume 20, Edition 2 / Summer 2020