Aorta Compression and Interposed Abdominal Compressions

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Aorta Compression and Interposed Abdominal Compressions

Post by Ryan » Thu Nov 15, 2012 3:33 am

Aorta Compression

So I was talking to an Emergency Medical Doctor from Sweden whom has surgical and ATLS training. I was specifically talking to him about Black Hawk Down (BHD) and the scene where SPC James E. Smith suffers a gunshot wound to the thigh to which Delta medic Kurt Schmid attends. No exit wound noted, retracted artery, extreme blood-loss. So here was the conversation...

I referenced some quotes from BHD and he replied:

"So bleeding in the pelvis is not new to me. However I deal with it in an antiseptic, structured hospital environment, not in a megaseptic, dangerous, chaotic and hostile hell. In awe, as I said.

However my original assumption proves correct when I read the text. The medic was desperately trying to STOP arterial blood-flow to the legs, not promote it. This is the general tactic in all major bleeds in the lower part of the body: shut it down and keep the blood pressure up in the vital upper parts. The lower pressure to the abdomen is a technique called aortic compression, widely used on the field but actually also in the operating theatre. Difficult, straining, very limited in it's effectiveness and highly depending on the patients physique: on obese or muscular patients you basically have to put your entire body-weight directly on your fingertips, pinpointing the aorta to get any effect. Thin old ladies are easy.

The situation described is horrific. The split second decisions, and always having to factor in the possibility of an early rescue. If no rescue is in sight, it becomes both easier and harder, cause then it's up to you to do whatever you can (and even the things you can't, which is the hard part). Then I would probably have made an abdominal incision, Cesarian style, to find and clamp the aorta. Once six liters of saline has gone in there's basically no chance of saving him otherwise. Also, with this kind of wound there's a high risk of damages to the rectum or colon with subsequent leakage of content to the abdomen and bloodstream. If the blood loss doesn't finish him, the septic chock might. The really tangy question in that situation is addressed in the text: morphine or not? Morphine can make the blood pressure drop. Not giving morphine means two things:

1. I would have to cut through the abdomen of a living, conscious patient. I don't even want to imagine that.
2. The heart rate of that patient will rise through the roof- in a heart that's already under a lot of strain. I may very well have a cardiac arrest on my hands."

Some references in BHD lead me to believe, after exhausting many, many medical possibilities that Delta medic Schmid attempted such a compression on the abdominal aorta, to prevent the vast majority of blood-flow from that main vessel exiting his body through his gaping entry wound. Direct pressure was applied to the wound and he usually tried to work with two-three man teams in such techniques. Though I cannot confirm it, I suspect it to be the case.

Image

I'm not going to ask "Do you think he did the right thing?" Because I'm sorry, but I know he did, if so he used such a technique. He really did all he could, what an incredible man...

What I am going to ask is, do you think this applicable in the TCCC setting? I mean even CPR is said to be a no-go in the TCCC setting until you are at the CCP or in an ambulance/out of the danger zone for some teams.

And... now some people have stated:
- He should of used a tourniquet.
- If is was modern day, you should use quick-clot - especially before going in to "pinch" or 'clamp' an artery.

What are your thoughts on these solutions? Kragh, the Delta surgeon at the time has been going over it since and came up with a possible solution - the CRoC, an abdominal or "truncal" tourniquet (http://www.mysanantonio.com/news/milita ... 343318.php and http://news.georgiahealth.edu/archives/5001 and http://www.smartplanet.com/blog/rethink ... conds/9125).

For more of a read: http://www.ncbi.nlm.nih.gov/pubmed/7818062 ...

Interposed Abdominal Compressions (IAC)

"IAC stands for interposed abdominal compression. IAC-CPR includes all the steps of conventional external cardiopulmonary resuscitation (CPR) with the addition of interposed abdominal compressions by a second or third rescuer, applied in counterpoint to the rhythm of chest compression. Pulses of central abdominal pressure are applied with overlapping hands just headward of the umbilicus alternating with chest compressions. Scattered early reports published between 1957 and 1980 hinted at the virtue of abdominal binding and abdominal compression in the resuscitation of children and animals from cardiac arrest. In the decade of the 1980s extensive studies in animals and in electronic models suggested a rough doubling of systemic blood flow when interposed abdominal compressions were added to otherwise standard CPR. In the 1990s randomized clinical trials involving several hundred patients showed a doubling of immediate resuscitation success and longer-term survival with IAC-CPR, compared to standard CPR. American Heart Association committees on emergency cardiovascular care are currently evaluating, IAC-CPR in evidence-based reviews of national Guidelines for both basic and advanced life support."

Image

This technique has just come into our protocols. The QAS (Queensland Ambulance Service) are trialling it. What are your thoughts on IAC and combined IAC-CPR?
As it is a pump, it is opposite to the compression of preventing blood-flow, but more maximizing blood flow.

For more of a read: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678249/ and http://circ.ahajournals.org/content/86/6/1692.abstract ...

What are you thoughts on both techniques? Especially when it comes to combat, a firefight - for LE and Military medics.
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Re: Aorta Compression and Interposed Abdominal Compressions

Post by tacticalguy » Fri Nov 16, 2012 5:37 am

I already gave my thoughts on the IAC. I'm gonna wait for you guys to trial it out and the follow-on study before I get excited.
As far as the AC goes, I've put an arterial clamp on in the field. I've also seen a medic do it under fire, before. It all depends on three factors; the severity of injury, the medic's focus and the environment. I've also used MAST and a BP cuff as a hemorrhage control device.
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Re: Aorta Compression and Interposed Abdominal Compressions

Post by AGR416 » Fri Nov 16, 2012 10:36 am

At a medical conference for the norwegian mil a couple of years ago, one of the speakers was Dr. John Hagmann of Deployment Medicine International:

http://www.deploymentmedicine.com/home.html

He is one of the main driving forces behind many of today's combat medical procedures, to include TCCC, TQ use, haemostatic agents etc.

He spoke about that incident, and why the treatment was done the way it was done. Schmidt, the medic, was an 18D before going over to Delta Force. The procedure they were taught at that time for stopping femoral bleeds was to use a clamp. They were also taught to perform incisions to get to the artery if indicated. The issue however, according to Dr Hagmann, was that the live tissue training they were doing at the time was not relevant at all. They were performing the procedure on goats, and the goat anatomy was too different from human anatomy for the procedure to effective in real life. I am no expert on goat anatomy, so I have to trust Dr Hagmann's explanation. According to him, on goats the arteries and veins run on the surface of the muscle tissue, as opposed to humans where they are located deeper. So, even if the artery retracted on a goat, it was still just a matter of cutting through the skin to get to the artery.

According to Dr Hagmann, Schmidt did everything he could, in accordance with how he was trained and equipped. But, because of the faulty live tissue training, he could not have saved him. Abdominal aorta compression was not mentioned.

Proximal femoral bleeds or arterial bleeds in the inguinal region are a medics nightmare. TQ's can be difficult to apply successfully, or ineffective or viable at all. The Combat Ready Clamp seems to be a very good alternative for controlling junctional bleeding, though I have not seen it or tried it. It is non-invasive, a very positive aspect as most people probably wouldn't want to perform a laparotomy in the field, or start cutting in the inguinal region/pelvic region to try to find the torn artery and clamp it.

According to TCCC guidelines, abdominal aorta compression is not an approved area of use for the CRoC:

http://www.health.mil/dhb/meetings/2011 ... 0FINAL.pdf

As for the manual technique, it would definately be applicable in the field care phase of TCCC, when there are more people available to assist. As part of CUF, I don't know, it will depend on the situation. If the medic can get the pt and himself behind proper cover, and he is not needed for the fighting, he could do it, but it would make examining and applying other treatments a lot more difficult. I do see issues maintaing enough pressure during the casualty evac phase, if he is evaced by foot on a litter.

I do not think that QuickClot or any other haemostatic agent would have worked in that situation, based on how far up the artery had retracted away from the cavity. Could have bought him some more time, maybe. TQ? Maybe, difficult to say as it depends on how far up the artery was and if the TQ could be placed successfully and be effective.

Don't really know enough to talk about IAC, but if it is found to be more effective in a pt needing CPR, then it is probably a viable technique.

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Re: Aorta Compression and Interposed Abdominal Compressions

Post by Ryan » Fri Nov 16, 2012 11:36 am

AGR416 wrote: According to TCCC guidelines, abdominal aorta compression is not an approved area of use for the CRoC:

http://www.health.mil/dhb/meetings/2011 ... 0FINAL.pdf
It's not working for me but you can upload attachments at the bottom here - unfortunately not pdf. Got another format? [EDIT: Received via email, thanks mate, will upload as attachment]

They look like they do some really good courses. Thanks for the links.

I'd like to know the reasoning behind where it works and why; original concepts unfortunately do not always turn to reality and medical testing - real-life can change the course of such technologies and inventions. Made for one use, turns out to be better for another or just another alternative. It's easy to extrapolate from incomplete data.

Nice information by the way - I too heard they did some training on pigs, even dogs.

A quote from doc86military from youtube:
"If you cant evac soon then they're as good as dead... As far as in field goes, unless you can get someone to a hospital of any kind soon then you're just wasting time. As callous as that sounds compression of any kind has not been proven successful in a tactical environment." And hence why TCCC has strict CPR guidelines which normally focus away from any combat situation.
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Re: Aorta Compression and Interposed Abdominal Compressions

Post by Ryan » Fri Jun 28, 2013 2:01 am

CQB-TEAM Education and Motivation.

"Pragmatism over theory."
"Anyone with a weapon is just as deadly as the next person."
"Unopposed CQB is always a success, if you wanted you could moonwalk into the room holding a Pepsi."

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Re: Aorta Compression and Interposed Abdominal Compressions

Post by Ryan » Sun Jul 20, 2014 1:07 pm

CQB-TEAM Education and Motivation.

"Pragmatism over theory."
"Anyone with a weapon is just as deadly as the next person."
"Unopposed CQB is always a success, if you wanted you could moonwalk into the room holding a Pepsi."

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