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Stop haemorrhage at conflicts by the most advance Tourniquets, Haemostatic Agents and blood transfusion. • Introduction: Haemorrhage is considered as the leading cause of death and the most dangerous threat on soldiers’ lives in conflict zones which is accounted for 91% of mortality causes (Bennett, 2017). However, while the majority of death actually happen before arriving to a proper medical facility, 90% of survivable death could be prevented by control bleeding (Vitalis et al., 2017). Moreover, the austere environment of conflict should be taken in consider while care is provided (Antebi et al., 2016). In details, the North Atlantic Treaty Organization (NATO) standard of war injuries emphasize that at least before the second hour from injury, patient should be treated at a proper medical facility including surgical team (Vitalis et al., 2017). Moreover, Tourniquet, Haemostatic agents and blood transfusion are the most advance methods that could use in conflict areas. However, this essay will review these advances methods at the earlier two roles of care which could reduce the mortality rate which occurred because of haemorrhage. • Roles of care In the battlefield, a system of care is needed to optimize and improve the services in term of improve survival rate. In addition, UK, US, France and Israel defence forces generally follow NATO roles of medical care which has four level are listed as: Role 1 where the medical team accompanied with the military unit which is called also point of injury (POI) , Role 2 represent the first surgical team where they are locating behind the line of engagement and it is a mobile unit according to tactical situations, Role 3 is the first hospital that patients can be transported to which located behind the war zone and content the majority of the services that may be needed, Role 4 symbolize the hospital at home country (Vitalis et al., 2017). However, because of the fact that the large number of death happened at the point of injury (POI), the Israel Defence Forces (IDF) increased their medical capacity at the point of injury with physicians which may enhance outcome of patients without solid evidence. However, this presence of ALS (physicians or paramedics) at POI decrease the effort on the further roles by the early diagnosis of death signs which help to avoid unnecessary evacuation in addition to the early treatment of high severely injured patients whom may die without immediate care (Antebi et al., 2016). In the role 1, Combat medics in the US army have a range of skills that they capable to provide in austere environments such as application of tourniquets, giving fluids and pain medications while MEDEVAC staff which is a team that responsible of providing care onroute are qualified to provide packed red blood cells or thawed plasma. In this role, it is rare to have a physician even as a part of evacuation team until role 3, instead nurse practitioner or physician’s assistant can manage the role 1 with the same capabilities of physicians. In contract, life savers in the Israel Defence Forces (IDF) which include physician and paramedics are capable to provide freeze-dried plasma and tranexamic acid in addition to all treatment that are given by US army medics. (Antebi et al., 2016). • Tourniquet Because the high incidence of the preventable death that mostly caused by haemorrhage at point of injury, the necessity of stop bleeding by applying a tourniquet has been spotlighted. However, the most injuries that cause bleeding were from pelvic and lower extremities injuries which the improvement of Personal Body Armor (PBA) does not protect (Radowsky et al., 2016). Furthermore, injuries of extremities were more significant in the US army which 76.8% of them resulted from fragmentation of explosive and 18.5% accounted for gunshot (Antebi et al., 2016). Moreover, the distribution of the application of tourniquet was mentioned by (Shlaifer et al., 2017) as 66% on lower limbs while nearly the same percentage on the sides of application. However, Shlaifer et al. (2017) stress that the immediate application of tourniquet is more effective by preventing blood loss and in case of need more than one tourniquet on the same limp, Combat Application Tourniquet was applied. In contrast, (Beaven et al., 2017) examine two new tourniquets which could apply once instead of applying two tourniquets on the same limp especially the Combat Application Tourniquet. Furthermore, this study concludes that both new tourniquets which they are: Tactical Mechanical Tourniquet and Tactical Pneumatic Tourniquet, came with fully efficient on stop bleeding except they examine them on non-medical cases. Nevertheless, Shlaifer et al. (2017) found that the successful rate of applying the first tourniquet at the point of injury reaches to 70% despite the level of caregiver or type of tourniquet. Furthermore, the trained paramedics, physicians and medics from ALS course have the capability to remove the tourniquet and start direct pressure dressing which is considered as a second treatment if the tourniquet insufficient which nearly quarter of the application of tourniquet was converted to direct pressure with 7% rate of failed. However, some cases of haemorrhage control need to be perdurable such as controlling the bleeding that result from open pelvic fracture. In these cases, (Radowsky et al., 2016) emphasised that clips are a stable way and can save time for ligation. However, this idea need more investigation about generalize it on other kinds of haemorrhage, capability of soldiers to apply it under austere environment and its result on survival rate. Otherwise, Bennett (Bennett, 2017) mentioned that from the previous wars in Iraq and Afghanistan, the most injured regions of the body as a result of conflict are truncal, junctional, and extremities. (67%, 19%, and 13% respectively). Additionally, the junctional haemorrhage is responsible for 17.5% of the preventable deaths in war of Afghanistan and Iraq (Kotwal and Butler, 2017). For this kind of haemorrhage, the Food and Drug Administration (FDA) reviewed and authorized 4 type of junctional haemorrhage control to be used in casualties’ care which are: the abdomen Aortic and Junctional tourniquet (AAJT), the Combat ready Clamp (CRoC), the junctional Emergency Treatment Tool (JETT), and the SAM Junctional Tourniquet (SJT). In addition, if there are not junctional tourniquet available, a Combat Gauze could be placed with direct pressure. Moreover, (Kotwal and Butler, 2017) mentioned studies that examine all the four junctional tourniquets in term of many aspects such as: efficacy, time of efficacy and time to apply. In general, these studies vary in their result but agreed that all types of junctional tourniquet were safe to apply. Nevertheless, truncal haemorrhage does not fit with any tourniquet so far which need other solution such as Haemostatic agents. • Haemostatic: Despite the efficiency of the tourniquet on stop bleeding, haemostatic dressing is one of the new methods that has been examined recently on haemorrhage at battlefield. There is a lot of supported evidence that promote topical haemostatic agents could contribute to control severe bleeding especially when the source of bleeding does not fit with the existed types of tourniquets (Bennett, 2017). Additionally, there are types of haemostatic agents and there is a huge debate about the best. In details, deciding the initial haemostatic agent between QuikClot granules and HemCon was going through a long argument until committee on Tactical Combat Casualty Care (CoTCCC) decided that HemCon is the initial haemostatic agent because of the side effect of QuikClot which produce burn when blood contact with it. However, both agents are carried by medic soldiers and both can be use. Subsequently, since 2008, the QuikClot become the initial haemostatic because of its benefit and convenience based on recent studies until 2015 when the FDA add to the CoTCCC guidelines a new haemostatic agent called Xstat which is basically a syringe device that effectively used on gunshot wounds. In addition, Xstat was invented to treat deep-tract or narrow-entrance wounds based on tests on animal wound model trial. Recently, a new study compares the QuikClot with Xstate and they found that Xstate consume less time to apply it and prevent loss more blood during the application especially in case of subclavian bleeding with 100% survival rate (Bennett, 2017). However, stop bleeding by tourniquets or haemostatic agents does not enough to replace the amount of loss blood where the body need days to compensate to restore the whole functional activities of the body including healing process. In addition, the body need to occupy blood vessels with fluid to avoid hypotension and shock whether that fluid is blood products or crystalloid fluid which underwent a long process of examines that will be shown in the next part. • Transfusion During the First World War, Haemorrhage was not considered as the initial cause of shock instead it was considered just a factor of shock. In that period, surgeons also noticed that shock was provoked when the circulation returned which they thought it happened because of a toxic factor. Moreover, this idea led surgeons in 1917 to amputate the injured limp to prevent toxic material from leaking to the body. Furthermore, these believes stayed until the Second World War where a study examines the blood toxicity of injured patient and it found that the primary cause of shock is haemorrhage and person could loss 75% of their blood and survive (Hawk, 2018). In addition to the previous solution to treat haemorrhagic patients under austere environment at battlefield that mentioned earlier (tourniquet and haemostatic dressing), there is a transfusion of blood products which include plasma, red blood cells, and platelets to replace the loss blood which associated with 50% improved outcomes. Moreover, (Vitalis et al., 2017) found that deliver blood products early especially red blood cells, plasma, and platelets has shown a proved improvement on the military injured soldiers survival rate. In addition, the most used of blood products at the battlefield is plasma as a result of ease to use and usually available with every medical units. Furthermore, since 2016, an institutional statement has stressed to start red blood cells and plasma before patients arrive to Role 2. Additionally, (Vitalis et al., 2017) showed that the most place that patients could receive transfusion is en-route between Role 1 and Role 2. Moreover, on the civilian level, early transfusion showed a significant reduction of the probability of shock at time of admission (Brown et al., 2015). However, the challenges that restrict transfusion at Role 1 is the importance of stabilize their condition with elimination of life threats as much as the team can do and also to clear beds for the flow of patients (Vitalis et al., 2017) However, providing a crystalloid fluid which was the first replacement of blood in haemorrhage has been associated with many undesirable reactions such as: inflammatory reaction, hypothermia and acidosis (Brown et al., 2015). Furthermore, (Hess and Holcomb, 2008) state that initiate resuscitation of shock with crystalloid fluid combine with insufficient coagulopathy and massive loss of platelets and coagulation factors. However, (Brown et al., 2015) believed that transfusion of RBC for patients with signs of shock is better in term of outcome than treat with crystalloid fluid. In addition, (Hess and Holcomb, 2008) mentioned a retrospective study that strongly suggest use the ratio 1:1 of red blood cells to plasma with trauma patients which produce improved outcomes and increased survival rate as same as fresh whole blood does. Moreover, Hess and Holcomb (Hess and Holcomb, 2008) also mentioned the Borgman study which propose the early deliver of plasma at least 1 unit to every 2 unit of red blood cells combine with improved control of the bleeding. Furthermore, administration of one component of the optimal 1:1:1 ratio of red blood cells to plasma to platelets over the other will lead to dilution of the others. However, Carrying the whole blood units is better than many blood components (Vitalis et al., 2017). Moreover, mismatch the same blood type is one of the big issues that restrain the early transfusion at battlefield which can be avoided with many solutions like use hand tags or necklaces illustrate soldiers’ blood type (Vitalis et al., 2017). However, the protocols of transfusion have been established depend on the experiences of practitioners and managers of blood banks (Hess and Holcomb, 2008). In addition, (Vitalis et al., 2017) said that the physician did not depend on the vital signs of patients when they decide to transfuse blood products to them. However, Until today. It is not clear which patients should receive blood transfusion and when (Brown et al., 2015). This protocol need to be reviewed again based on the new studies at battlefield and it should evaluate all the risk that could associated with giving or not giving blood. In addition, the protocol should consider the conflicts atmosphere and the best time and place to transfuse patients in regard to patients’ outcomes and tactical situation. • Limitation: One of the limitation that restrict improving the survival rate on conflicts is documentation at Role 1 and Role 2 which decrease the knowledge and improvement that could be applied in these areas (Antebi et al., 2016). In details, Vitalis et al. (Vitalis et al., 2017) state that it is really difficult to collect data from Role 1 and Role 2 because of the austere situation and limited time which better to spend on save lives than documentation. In addition, the flow of causalities to these roles as a result of closeness to hot zones complicate the documentation unless the armies assign personnel solider or medics to just document data of patients or could use technology to do that. However, this data must focus on the patients, treatment, providers and changes on their states then analysed to be use as an improvement tool of survival rate and life quality of soldiers. • The conclusion: To conclude, it is difficult to prefer some of the new tourniquets and haemostatic agents to treat haemorrhagic patients on the others. for example, each kind of tourniquet has its advantages and disadvantages similar to the haemostatic agents. In contrast, there is such agreement on replacement of loss blood by the whole blood or blood products instead of crystalloid fluid in the time of absence a reliable protocol which organise which patient or where should be transfused. However, In the future, fighter will apply more tourniquet than military medical services as a result of that they are the nearest person to the bleeding patient usually is a military unit member which draw attention to the level of medical training they have been received to protect each other by activate First aid process which include stop haemorrhage and illuminate lives threats (Shlaifer et al., 2017). In general, the future war will have different strategies which could limit the delivery of care at the right time. These changes in war style should encourage military medical services to invest much effort to invent and examine new care devices, methods and strategies (Hulsebos and Bernard, 2016). • References: - Antebi, B., Benov, A., Mann-Salinas, E.A., Le, T.D., Cancio, L.C., Wenke, J.C., Paran, H., Yitzhak, A., Tarif, B. and Gross, K.R. (2016) 'Analysis of injury patterns and roles of care in US and Israel militaries during recent conflicts: Two are better than one', Journal of trauma and acute care surgery, 81(5), pp. S94. - Beaven, A., Briard, R., Ballard, M. and Parker, P. (2017) 'Two New Effective Tourniquets for Potential Use in the Military Environment: A Serving Soldier Study', Military medicine, 182(7), pp. e1932. - Bennett, B.L. (2017) 'Bleeding Control Using Hemostatic Dressings: Lessons Learned', Wilderness & environmental medicine, 28(2), pp. S49. - Brown, J.B., Sperry, J.L., Fombona, A., Billiar, T.R., Peitzman, A.B. and Guyette, F.X. (2015) 'Pre-trauma center red blood cell transfusion is associated with improved early outcomes in air medical trauma patients', Journal of the American College of Surgeons, 220(5), pp. 797-808. - Hawk, A.J. (2018) 'How Hemorrhage Control Became Common Sense.', The journal of trauma and acute care surgery, . - Hess, J.R. and Holcomb, J.B. (2008) 'Transfusion practice in military trauma', Transfusion Medicine, 18(3), pp. 143-150. - Hulsebos, H. and Bernard, J. (2016) 'Consider autotransfusion in the field', Military medicine, 181(8), pp. e947. - Kotwal, R.S. and Butler, F.K. (2017) 'Junctional Hemorrhage Control for Tactical Combat Casualty Care', Wilderness & environmental medicine, 28(2), pp. S38. - Radowsky, J.S., Rodriguez, C.J., Wind, G.G. and Elster, E.A. (2016) 'A Surgeon's Guide to Obtaining Hemorrhage Control in Combat-Related Dismounted Lower Extremity Blast Injuries', Military medicine, 181(10), pp. 1300-1304. - Shlaifer, A., Yitzhak, A., Baruch, E.N., Shina, A., Satanovsky, A., Shovali, A., Almog, O. and Glassberg, E. (2017) 'Point of injury tourniquet application during Operation Protective Edge—What do we learn?', Journal of Trauma and Acute Care Surgery, 83(2), pp. 278-283. - Vitalis, V., Carfantan, C., Montcriol, A., Peyrefitte, S., Luft, A., Pouget, T., Sailliol, A., Ausset, S., Meaudre, E. and Bordes, J. (2017) 'Early transfusion on battlefield before admission to role 2: A preliminary observational study during “Barkhane” operation in Sahel', Injury, .
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