ARES Medical group,
INC.
Uncontrolled hemorrhage remains the most common cause of preventable death after injury (1-3). Rapid control of hemorrhage and replacement of lost blood reduces this mortality (4). Standard trauma care in most areas of the United States is predicated on an initial limited assessment and intervention by emergency medical services (EMS) at the scene (when it is safe for them to come on scene) with subsequent transport of the patient to a trauma center, where they are assessed and resuscitated by the trauma team in the emergency department (ED), and if the patient survives they are then taken to the operating room for definitive hemorrhage control (5,6) The results of this strategy for a patient with severe life-threatening hemorrhage is sub-optimal. Most of these patients will die within 30 minutes of their injury (7,8) The median duration for time of injury to arrival in the trauma bay is more than 45 minutes, and the average time to obtain surgical hemostasis is 2.1 hours from the time of injury (3).
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In 1996 the US Special Operations Command and the Uniformed Services University created a set of best-practice evidence-based point of injury (POI) trauma care guidelines specifically designed to address the most common immediate life-threatening processes seen on the battlefield. These guidelines were called Tactical Combat Casualty Care (TCCC) and focused on early placement of tourniquets for acute hemorrhage from extremity wounds; compression devices for otherwise uncontrolled junctional hemorrhage and needle decompression for presumed tension pneumothorax. Early application of these interventions in the field reduced potentially preventable mortality in combat casualties by 67% in the War on Terror (9).
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The Committee on TCCC subsequently performed a 20-year retrospective review of all combat deaths. The results of this assessment resulted in the recommendation to initiate resuscitation and obtain hemorrhage control as close as possible to point of injury (POI) rather than in the trauma bay (10). Reviews of military autopsy and trauma registry data demonstrate the majority of preventable mortality occurs prior to arrival at a medical treatment facility (MTF); nearly half of these deaths were deemed potentially survivable if the appropriate resuscitation and hemorrhage control had been initiated at the POI and during transport (11, 12). Multiple studies in the last 10 years have demonstrated reduced mortality with the early resuscitation with whole blood as compared to component therapy during prehospital transport (13-15).
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Coupling early whole blood resuscitation with zone 1 resuscitative endovascular balloon occlusion for non-responders in the military has been termed advanced resuscitative care. The most recent TCCC guideline advocates far-forward initiation of whole blood resuscitation and the placement of zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) for non-responders (16).
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US Air Force Special Operations Surgical Team validated these therapies at a far-forward MTF and were able to stabilize 19 of 20 critically injured casualties during an 18-month period using REBOA prior to transfer to a facility that could perform operative stabilization
(17). The Joint Medical Augmentation Unit (SOCOM asset) also used advanced resuscitative care to successfully stabilize a severely injured soldier whose initial injury severity score (ISS) was 66 (18 [ISS > 25 is associated with more than 50% mortality]).
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A forward medical team capable of providing en-route advanced resuscitation and hemorrhage control including but not limited to advanced airway management, chest decompression, tourniquet application, intravenous and intraosseous access, and blood product transfusion as close to the POI is now the standard of care for all US and NATO special operations teams (19- 21). In the civilian setting European countries, as well as a select few areas in the United States, have successfully implemented prehospital care teams comprised of physicians, advanced paramedics, certified registered nurse anesthetists, and/or nurses, capable of performing these time-critical advanced resuscitative interventions (22–25).
The ARES (Acute Resuscitation and Emergency Stabilization) Team is a elite tactical medical squad within the Spartanburg County Sheriff's SWAT Team that provides life-saving intervention during high-risk operations where traditional EMS providers are not permitted to go until the scene is declared safe for civilians. A trauma surgeon and the SWAT Medic currently comprise the team. The goal is to be able to provide hemorrhage control, advanced airway management, perform resuscitation using whole blood and administer appropriate sedation, analgesia and medications as close to the POI as possible and continue care through the subsequent transport to Spartanburg Medical Center.
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REFERENCES:
1. Drake SA, Holcomb JB, Yang Y, et al. Establishing a regional trauma preventable/potentially preventable death rate. Ann Surg. 2020;271(2):375–382.
2. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–S437.
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3. Holcomb JB. Transport time and pre- operating room hemostatic interventions are important: improving outcomes after severe truncal injury. Crit Care Med. 2018;46(3):447–453.
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4. Kalkwarf KJ, Drake SA, Yang Y, Thetford C, Myers L, Brock M, Wolf DA, Persse D, Wade CE, Holcomb JB. Bleeding to death in a big city: an analysis of all trauma deaths from hemorrhage in a metropolitan area during 1 year. J Trauma Acute Care Surg. 2020;89(4):716–722.
​
5. Carroll SL, Dye DW, Smedley WA, Stephens SW, Reiff DA, Kerby JD, Holcomb JB, Jansen JO. Early and prehospital trauma deaths: who might benefit from advanced resuscitative care?J Trauma Acute Care Surg. 2020;88(6):776–782.
6. Alarhayem AQ, Myers JG, Dent D, et al. Time is the enemy: mortality in trauma patients with
hemorrhage from torso injury occurs long before the “golden hour”. Am J Surg. 2016;212(6):1101–1105.
​
7. Oyeniyi BT, Fox EE, Scerbo M, Tomasek JS, Wade CE, Holcomb JB. Trends in 1029 trauma deaths at a level 1 trauma center: impact of a bleeding control bundle of care. Injury. 2017;48(1):5–12.
8. Beck B, Smith K, Mercier E, et al. Potentially preventable trauma deaths: a retrospective review.
Injury. 2019;50(5):1009–1016.
9. Butler FK. Two decades of saving lives on the battlefield: tactical combat casualty care turns 20. Mil Med 182 (3):e1563–e1568, 2017.
​
10. Morrison JJ, Oh J, DuBose JJ, O’Reilly DJ, Russell RJ, Blackbourne LH, Midwinter MJ, Rasmussen TE. En-route care capability from point of injury impacts mortality after severe wartime injury. Ann Surg. 2013;257(2):330–334.
11. Eastridge BJ, Hardin M, Cantrell J, Oetjen-Gerdes L, Zubko T, Mallak C, Wade CE, Simmons J, Mace J, Mabry R, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma 71: (1 Suppl): S4–S8, 2011.
12. Morrison JJ, Ross JD, Rasmussen TE, Midwinter MJ, Jansen JO. Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Shock 41 (5):388–393, 2014.
13. Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with survival for patients with combat-related traumatic injuries. J Trauma 66: (4 Suppl): S69–S76, 2009
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14. Gurney J, Staudt A, Cap A, Shackelford S, Mann-Salina E, Le T, Nessen S, Spinella P. Improved survival in critically injured combat casualties treated with fresh whole blood by forward surgical teams in Afghanistan. Transfusion 60: (Suppl 3): S180–S188, 2020.
15. Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK Jr, Gross K, Stockinger ZT. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA 318 (16):1581–1591, 2017.
16. Butler FK Jr, Holcomb JB, Shackelford S, Barbabella S, Bailey JA, Baker JB, Cap AP, Conklin CC, Cunningham CW, Davis M, et al. Advanced resuscitative care in tactical combat casualty care: TCCC guidelines change 18-01: 14 October 2018. J Spec Oper Med 18 (4):37–55, 2018.
17. Northern DM, Manley JD, Lyon R, Farber D, Mitchell BJ, Filak KJ, Lundy J, DuBose J, Rasmussen TE, Holcomb JB. Recent advances in austere combat surgery: use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations. J Trauma Acute Care Surg 85: (1S Suppl 2): S98–S103, 2018.
18. Lewis C, Nilan M, Srivilasa C, Knight RM, Shevchik J, Bowen B, Able T, Kreishman P. Fresh whole blood collection and transfusion at point of injury, prolonged permissive hypotension, and intermittent REBOA: extreme measures led to survival in a severely injured soldier – a case report. J Spec Oper Med 20 (2):123–126, 2020.
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19. Clarke JE, Davis PR. Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010–April 2011. Mil Med 177 (11):1261–1266, 2012.
20. Morrison JJ, Oh J, DuBose JJ, O’Reilly DJ, Russell RJ, Blackbourne LH, Midwinter M, Rasmussen TE. En-route care capability from point of injury impacts mortality after severe wartime injury. Ann Surg 257 (2):330–334, 2013.
21. Naumann DN, Beaven A, Naumann LK, Taylor B, Barker T, Seery J, Bowley DM. Where do surgeons belong on the modern battlefield. Mil Med 186 (5–6):136–140, 2020.
22. Lamhaut L, Qasim Z, Hutin A, Dagron C, Orsini J-P, Haegel A, Perkins Z, Pirracchio R, Carli P. First description of successful use of zone 1 resuscitative endovascular balloon occlusion of the aorta in the prehospital setting. Resuscitation. 2018;133:e1–e2.
23. Lendrum R, Perkins Z, Chana M, Marsden M, Davenport R, Grier G, Sadek S, Davies G. Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation. 2019;135:6–13.
24. Van Vledder MG, Van Waes OJF, Kooij FO, Peters JH, Van Lieshout EMM, Verhofstad MHJ. Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma. Injury. 2017;48(9):1865– 1869.
25. Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J Trauma. 2011;70(5):E75–E78.