Quality Corner: A Glimpse Into the Future of Trauma Care

Many advances in trauma care have come from the battlefields of previous wars, but at no time in history have there been so many promising new treatments as now during the Global War on Terrorism (GWOT).

Army Col. John Holcomb, MD, and Navy Capt. Frank Butler, MD, were advocates of training Army Rangers and Navy SEALs in the concepts of Tactical Combat Casualty Care (TCCC) in the early days of the GWOT. TCCC teaches the skills of tourniquet and hemostatic agent application for hemorrhage control. But most important, it teaches a simple but dramatic change in mentality for the injured: from being helpless victims waiting for a medic to come save them to taking control of their own destiny by quickly and aggressively treating themselves through self-aid and buddy care. As a result, Ranger and SEAL survival rates were so superior to the rest of the military’s that TCCC has now been adopted as standard predeployment training for all military combatants. Close to 15% of wounds that were fatal in previous wars are survived today.

Improved tourniquets, hemostatic agents such as QuikClot Combat Gauze and TCCC training courses may be the most valuable military medical innovations ever to benefit civilian EMS. These treatments and trainings have already been embraced by many EMS agencies, police departments and other first responders throughout the United States. As a result many victims of mass shootings and explosive incidents have been saved who otherwise would have died.

Looking at what else military medics in Iraq and Afghanistan have been doing over the past few years gives us a glimpse into the future of prehospital trauma care. It is nothing short of incredible.

TXA

Tranexamic acid is a synthetic antifibrinolytic that inhibits the body’s natural occurring cycle of breaking down clots that have formed at wound sites. Combat medics have been administering TXA to patients with penetrating torso injuries, major amputations, shock and other evidence of severe bleeding. TXA has been used to prevent excessive blood loss in surgery for many years, but to be effective in trauma it must be administered within 3 hours of injury. One gram of TXA is administered IV and may be repeated once in severe cases after volume resuscitation has been begun.

Hextend

Hextend is synthetic compound of 6% hetastarch, which has proven to be an effective volume expander. Once administered Hextend increases osmotic pressure intravascularly, drawing fluid in from the interstitial spaces. Five hundred ccs of Hextend will increase vascular volume by 800 ccs within an hour. This gives Hextend a volume-expanding capacity six times the equivalent of crystalloid solutions presently used by civilian EMS, such as normal saline or lactated Ringer’s. Hextend has the additional benefit of remaining in the vasculature for up to eight hours. In comparison 75%–80% of crystalloid solutions will be lost from the vascular compartment into the interstitial space within just half an hour.

Stasis or Arsenal Foam

One of the most deadly and frustrating of all traumatic injuries for prehospital providers is a noncompressible intra-abdominal bleed. The only option that has ever been available in combat or civilian EMS is rapid transport to a medical facility where the patent can be opened up and, if timely enough, the wound surgically repaired. The Defense Advanced Research Projects Agency (DARPA) has developed a solution currently being trialed by combat medics. Stasis foam is a polymer that’s injected into the abdomen as two liquid bases in a fashion similar to the double-barreled syringe used for epoxy. When the liquids combine they expand to 30 times their original volume, quickly filling the abdominal cavity and tamponading any sites of bleeding. Stasis foam creates a plastic-like cast of the internal anatomy, which can be removed in surgery, allowing definitive repairs to be made.

XStat

XStat is a large syringe filled with 93 1-mm tablet-size sponges coated with a hemostatic agent. Once the sponges come into contact with blood, they rapidly expand. The combination of the tamponading effect caused by these rapidly expanding sponges and the hemostatic agent impregnated within them has proven effective in controlling hemorrhage within 15 seconds. XStat is designed for control of major hemorrhage of junctional wounds of the neck, axilla and groin—areas not amenable to tourniquet application.

Given all the above innovative treatments, the future of prehospital trauma care has never looked brighter than it does today. These battlefield innovations seem likely to soon make it possible for EMS to save the lives of severely traumatically injured patients that were never savable before.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies. He has 30 years’ experience in EMS. Contact Joe at jhayes763@yahoo.com.