Noncompressible Torso Hemorrhage: A Review with Contemporary Definitions and Management Strategies
Introduction
Vascular disruption with hemorrhage remains a leading cause of death in both civilian1, 2 and wartime trauma.3, 4 Broadly classified, hemorrhage occurs from either compressible sites, meaning those locations amenable to immediate control with manual pressure or tourniquet application, or from noncompressible sites, meaning locations not amenable to control with direct pressure or tourniquet application (Fig. 1).5 In the civilian setting, hemorrhage is present in 15% to 25% of admissions, and studies from the wars in Afghanistan and Iraq show that the rate of vascular injury in combat is approximately 10%.4, 5, 6 Although extremity injury is overall most common, the focus of this review is on the management of vascular disruption and hemorrhage from sources within the torso, including the thorax, abdomen and pelvis, once these patients reach definitive care. An excellent review of the prehospital management strategies for these injuries is provided by Kerby and Cusick elsewhere in this issue.7
Section snippets
Hemorrhage as a problem in trauma
Control of bleeding from vascular disruption within the torso is not readily amenable to control with direct pressure and is therefore referred to as noncompressible torso hemorrhage (NCTH). Civilian studies demonstrating that NCTH accounts for 60% to 70% of mortality following otherwise survivable injuries (ie, no lethal head or cardiac wounds) clearly emphasizes the lethality of this injury pattern.1, 2 Hemorrhage is also a significant problem in the wartime setting, accounting for up to 60%
Definition
These observations have resulted in a thrust within the combat casualty care research community to better define and classify locations and patterns of NCTH. Despite its obvious significance, until the wars in Afghanistan and Iraq a consensus definition of NCTH was lacking. Recently reports have emerged from the military’s Joint Trauma System and select civilian institutions proposing a unifying classification of this injury pattern. It has been the aim of these studies to establish a cohesive
Military and civilian perspectives
One of the first studies to recognize the importance of uncontrolled truncal was by Holcomb and colleagues,5 who reviewed autopsy findings of special operations forces personnel killed early in the wars in Afghanistan and Iraq, between 2001 and 2004. A panel of experts reviewed the records of 82 fatalities and judged them as nonsurvivable (eg, lethal head or cardiac wounds) or potentially salvageable. This study was one of the first to specifically use the term “noncompressible truncal
Epidemiology of noncompressible torso hemorrhage
A recent study of the US JTTR presented at the American Association for the Surgery of Trauma in 2011 used the definition presented in Table 1 to characterize the epidemiology of NCTH in patients injured in Iraq and Afghanistan between 2002 and 2010. Using the injury pattern criteria alone, 1936 patients were identified as having an injury putting them at risk for NCTH, which was nearly 13% of battle-related casualties. When the physiologic and procedural inclusion criteria were applied to this
Clinical management strategies in torso hemorrhage control
The aim of this section is to provide a summary of tools and adjuncts available for the control of torso hemorrhage within the context of current literature. Despite advances in surgical understanding, technique, and technology, one fundamental tenet remains: proximal and distal control are essential when managing suspected vascular injury.
Putting it all together: current applications and future directions
NCTH will continue to challenge clinicians, and future research strategies require a novel approach to reduce the mortality of this injury complex. The first step requires recognition and characterization of the problem, best served by a unifying definition enabling investigators to compare true like with like. Efforts to develop such a definition are under way in both military and civilian settings. In addition, it is important to characterize not only mortal injury patterns in relation to
Summary
Vascular disruption with concomitant hemorrhage is the leading cause of potentially preventable death in both civilian and military trauma. NCTH is a particularly challenging entity which, despite being an intuitive concept, lacks a formal definition. Management requires rapid decision making, aggressive resuscitation, and surgery with an emphasis on early hemostasis. Despite the emergence of DCR and adjuncts such as endovascular surgery, the principles of proximal and distal control remain.
The
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The authors have nothing to disclose. The views and opinions expressed in this article are those of the authors and do not reflect the official policy or position of the US Air Force, US Department of Defense, or the US Government.