Introduction
Hemorrhage from junctional areas is a leading cause of potentially preventable death in combat and civilian trauma casualties. Reference Eastridge, Mabry and Seguin1–Reference Smith, Shapiro and Sarani3 Many strategies for hemorrhage control exist, including direct pressure, hemostatic dressing application, injectable sponges, and junctional tourniquets. Reference van Oostendorp, Tan and Geeraedts4 However, most of them require a significant time to apply, require specialized equipment, and may not effectively control bleeding from a major artery, such as the femoral or axillary artery. Reference Kragh, Kotwal and Cap5,Reference Chen, Benov and Nadler6
The manual pressure points (MPP) technique utilizes specific anatomical points where arteries can be manually pressed against bony structures to stop blood flow distal to these points, thus controlling distal hemorrhage. Reference Slevin, Harrison, da Silva and White7 It is an old technique that has fallen out of favor and became unrecommended by leading prehospital care guidelines 8–Reference Singletary, Charlton and Epstein10 following a volunteer study showing low success rates and early restoration of flow in ten healthy volunteers. Reference Swan, Wright, Barbagiovanni, Swan and Swan11 A recent study shows significantly higher success rates, but with the pressure time limited to three minutes. Reference Pikman Gavriely, Lior and Gelikas12
This report presents a case where this technique was employed as a last resort, for a long time, with remarkable success. It is written in compliance with the Case Report Guidelines (CARE) Reference Gagnier, Kienle and Altman13 with necessary adaptations for describing the prehospital phase of care. Informed consent for publication was obtained from the casualty.
Patient Information
The patient has consented to the writing and publication of this report. A 21-year-old, healthy cadet in a special forces unit’s training sequence was accidentally shot from behind with a high-velocity, 5.56mm caliber rifle during a live-fire drill performed in a remote location with limited access. Within seconds, he was attended by the commander on-site and the unit’s paramedic, who identified massive bleeding from the left infraclavicular region.
Point-of-Injury to Trauma Bay Care
A general timeline of the injury and prehospital care is described in Figure 1. Upon initial examination, massive, pulsatile hemorrhage was identified from what appeared to be a two-centimeter diameter exit wound immediately inferior to the lateral border of the left clavicle. Initial care included the application of a hemostatic bandage (QuikClot Combat Gauze; Teleflex Inc.; Wayne, Pennsylvania USA) with direct digital pressure inside the wound. The casualty was alert, arterial oxygen saturation (SpO2) was 95% in room air (RA), respiratory rate (RR) was 20 breaths/minute, and heart rate (HR) was 112 beats/minute. Pain level was 8/10 using a Verbal Numerical Rating Score (VNRS). Aeromedical evacuation (MEDEVAC) was requested. Casualty was exposed and covered with a blanket.
General Timeline of the Injury and Prehospital Care.
Abbreviations: ToI, Time of Injury; SpO2, arterial oxygen saturation; RA, room air; HR, heart rate; RR, respiratory rate; VNRS, verbal numerical rating score; MEDEVAC, medical evacuation.
The casualty was loaded onto an ambulance with a paramedic-led team and evacuation started seven minutes post-injury, with direct pressure maintained on the wound. Eleven minutes post-injury, the ambulance team was joined by the unit’s surgeon. Casualty remained alert, SpO2 decreased to 92% in RA, RR = 20 breaths/minute, and HR = 120 beats/minute. Automatic blood pressure (BP) measurement using a Wireless Vital Signs Monitor (WVSM; Athena GTX; Johnston, Iowa USA) was unsuccessful, likely due to vibrations exerted on the ambulance by the rugged terrain. The VNRS = 8/10. The blood-soaked hemostatic bandage was expelled from the wound. The commander maintained direct pressure. Oxygen supplementation was given at 10L/minute through a non-rebreathing mask with a reservoir. Vascular access was obtained through the left median cubital vein, and 1g Tranexamic acid was administered. Twenty-eight minutes post-injury, the ambulance arrived at the landing zone and waited for MEDEVAC’s arrival. A BP of 88/60mmHg was measured. One unit of freeze-dried plasma was initiated. Thirty-two minutes post-injury, visible massive hemorrhage resumed. Packing with hemostatic bandage was performed, followed by direct pressure. Casualty was alert, but SpO2 measurement failed in both hands. The HR =140 beats/minute, BP = 90/60mmHg, and VNRS = 8/10. Total 50mg of ketamine was given intravenously for analgesia (in two consecutive 25mg doses, nine minutes apart), and second venous access was obtained through the right median cubital vein. Warming was initiated using an active heating blanket (ReadyHeat; Techtrade LLC; Orlando, Florida USA).
Forty-four minutes post-injury, MEDEVAC arrived, spending four minutes on the ground. Vital signs were SpO2 = 88% on 10L/minute of oxygen, HR = 140 beats/minute, and BP =88/60mmHg. Due to repeating failure of hemorrhage control with a hemostatic bandage and direct pressure, the medical leader on the helicopter instructed a MEDEVAC medic to perform an MPP on the subclavian artery in the supraclavicular area, pressing it with the fingers against the first rib (caudally), proximal to the bleeding wound, with apparent immediate cessation of the bleeding. The pressure was maintained throughout the 21 minutes of flight and an additional seven minutes until arrival at the trauma bay of a Level 1 trauma center. Due to growing fatigue, the medic used the unoccupied hand to support the pressing hand. Two minutes into the flight, SpO2 = 95% on 10L/minute oxygen, and HR = 150 beats/minute. The BP was not measured as two low-titer O-type whole blood units were simultaneously transfused to both arms. Eleven minutes into the flight, HR decreased to 125 beats/minute. Upon landing, SpO2 was 100% on 10L/minute oxygen, and HR = 115 beats/minute.
Upon arrival at the trauma bay, 76 minutes post-injury, the casualty was alert, SpO2 = 100% on 10L/minute oxygen, HR = 125 beats/minute, and BP = 121/87mmHg. Two units of non-crossmatched packed red blood cells (PRBC) were transfused, and the casualty was taken for exploration in the operating room, revealing a complete transection of the left axillary artery at the transition point from the left subclavian artery and a brachial plexus injury. Intraoperative angiography image is displayed in Figure 2. Entry wound was not identified upon initial exploration and exposure. The artery was repaired using a saphenous vein interposition graft. Two additional units of PRBC, five units of fresh-frozen plasma, and five units of platelets were transfused during surgery, and the casualty was admitted to the intensive care unit (ICU).
Intraoperative Angiography of the Casualty’s Left Subclavian Artery Demonstrating Complete Transection between the Subclavian Artery and the Axillary Artery.
A computerized tomography angiography scan performed post-op revealed a good filling pattern of contrast medium within the graft and a significant pulmonary contusion in the left lung. An entry wound five millimeters below the left scapula was later identified by physical examination. The casualty was discharged from the ICU three days post-op and was transferred to a rehabilitation center.
Follow Up
Upon writing this report, the casualty was medically discharged from service and resumed multidisciplinary rehabilitation for the brachial plexus injury. Two months post-injury, the casualty underwent a brachial plexus repair with a vascularized ulnar nerve graft.
Discussion
This case report’s primary interest is what appears as an effective and prolonged use of the pressure points technique. Evidence supporting this conclusion includes the cessation of apparent bleeding upon application, the continuous deterioration preceding it during the hemostatic bandage and direct pressure, and the significant and sustained improvement following the pressure application and blood transfusion. While blood transfusion indeed had a beneficial effect, it is unlikely that this effect would have been sustained should significant hemorrhage from a torn axillary artery was to continue for over 20 minutes. Additionally, the success in controlling the bleed is unlikely to be attributed to the effect of Tranexamic acid or to the hemostatic dressing, considering the bleeding source was a transected major artery. Reference Kheirabadi, Scherer, Estep, Dubick and Holcomb14 The decrease in BP does not explain the cessation of the bleeding, especially considering it did not resume even when BP returned to normal levels while the artery remained transected.
While the concept of controlling a massive arterial hemorrhage by applying occlusive pressure proximally is intuitive, the effectiveness of this technique is very much controversial. As the performance of a real-life clinical effectiveness study borders on impossible, available data come from healthy volunteer studies or manikin-based experiments. A study performed in 2009 Reference Swan, Wright, Barbagiovanni, Swan and Swan11 on ten volunteers has shown early (20-60 seconds) flow restoration flow after successful occlusion, concluding pressure points to be “an optimistic euphemism.” This study has prompted a change in leading prehospital care guidelines, 8–Reference Singletary, Charlton and Epstein10 which currently recommend against the use of pressure points. Following studies have shown better success rates when performed on manikins Reference Kragh, Mann-Salinas and Kotwal15 or when using martial arts techniques, Reference Slevin, Harrison, da Silva and White7 and recently in a larger number of healthy volunteers, Reference Pikman Gavriely, Lior and Gelikas12 but all of these experiments were conducted for a limited time interval, mainly in order to limit healthy participants’ discomfort. This case report supports the possibility that providers are more likely to overcome the physical difficulty of applying this technique for a prolonged time in real-life scenarios since they are literally “holding the casualty’s life in their hands.” This state-of-mind is evident in the testimony made by the medic who performed the technique in this case, who reported feeling complete numbness in his fingers, which he overcame by adding pressure with his other hand.
There are additional interesting aspects to this case. The failure of hemostatic bandages and direct pressure is hardly surprising in a significant arterial tear Reference Kheirabadi, Scherer, Estep, Dubick and Holcomb14 such as the axillary artery. The casualty’s survival may be attributed to the partial limitation of the bleeding by these attempts, adequate blood-products resuscitation, and eventually, the successful application of the pressure point. The arterial hypoxia, which responded to oxygen supplementation, may have resulted from the profound shock or from the pulmonary contusion caused by the cavitation effect created by the high-velocity bullet, as the bullet itself did not enter the rib cage. The residual damage resulting from the brachial plexus injury underlines the importance of novel treatments for peripheral neural trauma.
Limitations
This case report is based mainly on prehospital data obtained from the providers involved in the care of the casualty in all tiers and obtained early after the incidence. Therefore, it is based on their perception, which may be subject to bias knowing the results. However, it is backed by objective measurements, and all of the reports, including the casualty’s, support each other.
Conclusion
This case report, together with the results of recent studies, support the re-consideration of the pressure points technique, especially for immediate response by a near layperson or combatant, and as a last resort measure in junctional hemorrhage.
Conflicts of interest/funding/disclaimer
Authors declare no conflict of interests. The views expressed in the article are the authors’ and not an official position of any institution. The work was conducted as part of the IDF Medical Corps Trauma and Combat Medicine Branch’s mission of quality control and improvement in trauma care, and did not receive any designated funding.
Casualty’s Perspective
“I felt a massive impact and immediately got on my knees to understand what happened. The bullet hit my back and came out of my chest/shoulder. It hit a main artery, so blood was spraying everywhere. I shouted and the medic and paramedic came immediately. They tried using Combat Gauze, but blood just kept coming. After I got on the helicopter, they pressed against the back of my neck, which was painful, and kept asking me how I feel. Thanks to everyone’s quick response and professionalism, I am still here today.
Author Contributions
GA has drafted the manuscript and lead the data collection. CG, AK, RPG, and MB contributed to data collection and manuscript writing. RPG and GA have conducted the literature review. AB supervised the data collection process. OA and AB provided critical revision and expert guidance.
Acknowledgements
The authors would like to thank the casualty and the providers for their cooperation, and the members of the Israel Defense Forces Trauma and Combat Medicine Branch for their invaluable contribution to data collection for the improvement of care.
