Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield

Correspondence to Dr C Wright, ; [email protected]

Key Messages

• Haemorrhage is one of the leading causes of morbidity and mortality in trauma patients.

• Studies have tested haemostatic agents in the laboratory environment but there are very few looking at its use in the clinical setting.

• We reviewed the use of haemostatic agents in injured patients during the conflicts in Iraq and Afghanistan who presented to deployed UK medical treatment facilities.

• We showed an association between the use of haemostatic agents and improved survival, mostly in those with more severe injuries, which is particularly evident in those administered Celox.

Haemorrhage is a leading cause of mortality in major trauma patients on the battlefield, second only to traumatic brain injury (TBI).¹ Several studies have found it to be the most common cause of potentially preventable death.^2–4 In one analysis of US military casualties, over 90% of the potentially survivable injuries were associated with haemorrhage,² and of these patients the most common regions affected were truncal (67.3%), junctional (19.2%) and extremity (13.5%).²

Recent terrorist attacks have highlighted that the battlefield is no longer confined to traditional boundaries of conflict zones, and the injury patterns they produce are similar to military patients injured in war. During the recent terrorist attacks in London and Manchester, large numbers of casualties sustained injuries where haemorrhage was a major component, highlighting the need for methods of haemorrhage control to be made available to civilian pre-hospital clinicians.^{5 6}

The introduction of combat tourniquets has improved survival from extremity haemorrhage.⁷ The first step in the treatment of external haemorrhage is to apply direct pressure to the wound, followed by the application of a tourniquet if the anatomical site of the injury allows it.⁸ Junctional haemorrhage affects areas where the trunk of the body meets the limbs. It is difficult to control haemorrhage at these points as, by definition, tourniquets cannot be used to provide circumferential pressure above the wound, and so we rely solely on directly applied pressure. Another study from the United States of America analysing patients injured in Iraq and Afghanistan between 2001 and 2010 identified haemorrhage control of this type as the most frequent intervention.⁹

Haemostatic agents can be used as an adjunct to...