SHOCK
“the rude unhinging of
the machinery of life”
1872 Gross
WHY?
• Uncontrolled bleeding is a leading cause of
trauma deaths
• Despite advances in trauma care, the
mortality rate of patients requiring large
volume blood transfusion remains in excess of
30%
Who?
• 27 year old male had industrial pipes fall on
him from a truck
• EMS and MD1 extricate, intubate, and bring
him to you
• 90/50, 125, GCS 3T
• Open book pelvis, bilateral femur and ankle
fractures, distended abdomen
Resuscitation 2014;
TIC, PCC, TXA
Joli Dace, PharmD, BCPS
Christopher Wistrom DO
Robb R Whinney DO FACOS
Mercy Health System
Janesville WI
December 2014
No disclosures
HISTORY OF FLUID RESUSCITATION IN TRAUMA
16251667-
Circulation described-Harvey
Animal to human transfusion-Denis, Lower
182818651888-
Human to human transfusions-Blundell
Civil War- First transfusion of trauma patient
Ringer’s solution
19091916-
Transfusion of trauma patient-Crile
WWI- citrated glucose blood, gum saline
1930-
Hemorrhagic Shock defined-Blalock
19441947-
WWII, Allied blood transfusions
Albumin
1960-
Crystalloid required 3:1-Shires
19801990s
1998-
Hypertonic saline in Trauma-DeFillipe
Factor VIIa in trauma
Hb-based blood substitute in Trauma-Gould
HISTORY OF FLUID RESUSCITATION IN TRAUMA
1990s
2001
2000s
2000s
2008
2010
2010
2012
2013
Europe starts expanding use of PCC
Rivers study on Goal Directed Therapy in Sepsis
TEG and ROTEM to define Trauma Induced Coagulopathy
PRBC: FFP 1:1
PRBC: FFP: Platlets 1:1:1
PRBC: FFP: Platlets: Fibrinogen 1:1:1:1
Whole Blood in Military study
CONTROL Factor VII trial (the END!!!!)
CRASH-2 tranexamic acid (TXA) and trauma patients
MATTERs tranexamic acid
CRASH-3 TXA in head injury patients (in process)
• ATLS gives the most sage commentary:
– Stop bleeding
– “the amount of fluid and blood required for
resuscitation is difficult to predict on initial
evaluation”
– Management guided by patient response
Prehospital Fluid
Delay of aggressive fluid resuscitation until
operative intervention for hypotensive
patients with penetrating torso injuries
improves outcomes
Bickell 1994
Prehospital Fluid
• Hemorrhage induced hypotension in
trauma is predictive of mortality and
morbidity
• Requirements for large volume of
crystalloid resuscitation is associated with
increased mortality
– Heckbert presented a retrospective review at
EAST (published in J Trauma):
Prehospital Fluid
• Prehospital fluid administration is associated with higher
mortality in trauma patients: a National Trauma Data
Bank analysis.
• Patients receiving IV fluids were significantly more likely
to die in nearly all subsets of trauma patients.
• Routine use of prehospital IV fluid for all trauma patients
should be discouraged.
– Ann Surg. 2011, Haut ER, et al. The Johns Hopkins Hospital
Colloid vs Crystalloid
• The debate will never end… over 50 studies
over 50+ years with no winner
2011 South Africa
• Colloid vs crystalloid in trauma patients
• Colloid:
– Superior initial resuscitation using colloid
– Decreased lactate levels
– Less renal injury after penetrating trauma
Hypertonic Saline
• Provides smaller volume resuscitation
• Rapid restoration of hemodynamics with
laboratory evidence of improved
microcirculatory hemodynamics
• The role of hypertonic saline in trauma
resuscitation is still being defined
Blood substitutes
Despite many years of
research, the ideal blood
substitute continues to elude
researchers….
Cryoprecipitate
• A cryoprecipitate:RBC ratio of 1:1 has been
shown to reduce 24-hour and 30-day
mortality in civilian trauma.
• Rx: One 10-unit bag of cryoprecipitate for
every 10 units of red cells transfused.
Goal Directed Therapy
• Early Goal-Directed Therapy in the
Treatment of Severe Sepsis and Septic
Shock. Emanuel Rivers, et al. Engl J Med
2001
• Prospective randomized trial
Massive transfusion
• Multicenter prospective cohort
• 415 blunt injured adults required >/=8 units PRBCs
within the first 12 hours
• FFP:PRBC transfusion ratio >/=1:1.5 is associated
with a lower risk of mortality after massive
transfusion.
Sperry JL, et al. J Trauma. 2008 University of Pittsburgh Medical Center
Massive transfusion
• A greater than 1:1 FFP:PRBC ratio has
– Decreases mortality
– Not associated with a higher organ failure
– Not associated nosocomial infection
– Twofold higher risk of ARDS
Blood as a Therapy/Drug
GOAL
To increase Oxygen delivery to
hypoxic tissues while minimizing
side effects
PRBC Ingredients
•
•
•
•
Red blood cells
White blood cells
Proteins
Ions
Blood Complications
• May transmit diseases
• Transfusion reactions
• Spoils: stored blood is not “Normal Blood”
Old Blood is bad blood!!!
• Fitzgerald et al
– Sepsis model showed 28 day old RBC
transfusion decreased systemic O2 uptake
• Marik et al
– Transfusion of 3u of PRBC to a Hg of 9-11
G/dl in septic mechanically ventilated
patients had no improvement in O2 uptake
– in fact patients receiving blood >15 days old
had splanchnic ischemia
Fitzgerald RD, et al. Crit Care Med 1997;25:726-732
Marik PE, et al. JAMA 1993;269:3024-3029
Old Blood is bad blood!!!
Older blood = less O2 delivery
Older blood = More cytokines
More cytokines = More reactions
Old Blood is bad blood!!!
•
•
•
•
Macrophage function altered
Decreased Lymphocyte antigen response
Decreased Helper cell activity
Increased Suppressor cell activity
There is a dose response relationship!!
Recommendations
•
•
•
•
•
Stop Bleeding
Acute hypovolemic anemia needs blood
Maintain euvolemia with crystalloids
Use leukocyte deplete blood
Newer blood is more effective
Recommendations
• Hgb 6 - Healthy pt without heart disease
• Hgb 10- patients with symptomatic CAD
• Transfusions should be based on
symptoms, not on absolute numbers
Trauma Induced Coagulopathy
20 years ago…
• Traumatic coagulopathy from major
hemorrhage was believed to be a late
consequence of
– hemodilution
– acidosis
– Hypothermia
– loss of coagulation proteins through bleeding and
consumption
Old Standard
•
•
•
•
Prothrombin time (PT)
Activated partial thromboplastin time (aPTT)
Plasma fibrinogen concentration
PT and aPTT– very initiation of clot formation
– only 5% of the entire thrombin is generated
– unhelpful for distinguishing between lack of coagulation factors
and substrate.
• Tests were not developed to assess coagulopathy in acute
bleeding situations such as trauma
• They don’t assess clot quality and stability, which are
important determinants of TIC
20 years ago…
Trauma
Hemorrhage
Coagulopathy
THE END OF VIIa
•
J Trauma. 2010 Sep;69(3):489-500. doi: 10.1097/TA.0b013e3181edf36e.Results of the CONTROL trial: efficacy and
safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage.Hauser CJ1,
Boffard K, Dutton R, Bernard GR, Croce MA, Holcomb JB, Leppaniemi A, Parr M, Vincent JL, Tortella BJ, Dimsits J,
Bouillon B; CONTROL Study Group.Author informationAbstractBACKGROUND:Traumatic coagulopathy
contributes to early death by exsanguination and late death in multiple organ failure. Recombinant Factor VIIa
(rFVIIa, NovoSeven) is a procoagulant that might limit bleeding and improve trauma outcomes.METHODS:We
performed a phase 3 randomized clinical trial evaluating efficacy and safety of rFVIIa as an adjunct to direct
hemostasis in major trauma. We studied 573 patients (481 blunt and 92 penetrating) who bled 4 to 8 red blood
cell (RBC) units within 12 hours of injury and were still bleeding despite strict damage control resuscitation and
operative management. Patients were assigned to rFVIIa (200 μg/kg initially; 100 μg/kg at 1 hour and 3 hours)
or placebo. Intensive care unit management was standardized using evidence-based trauma "bundles" with
formal oversight of compliance. Primary outcome was 30-day mortality. Predefined secondary outcomes
included blood products used. Safety was assessed through 90 days. Study powering was based on prior
randomized controlled trials and large trauma center databases.RESULTS:Enrollment was terminated at 573 of
1502 planned patients because of unexpected low mortality prompted by futility analysis (10.8% vs. 27.5%
planned/predicted) and difficulties consenting and enrolling sicker patients. Mortality was 11.0% (rFVIIa) versus
10.7% (placebo) (p = 0.93, blunt) and 18.2% (rFVIIa) versus 13.2% (placebo) (p = 0.40, penetrating). Blunt trauma
rFVIIa patients received (mean ± SD) 7.8 ± 10.6 RBC units and 19.0 ± 27.1 total allogeneic units through 48
hours, and placebo patients received 9.1 ± 11.3 RBC units (p = 0.04) and 23.5 ± 28.0 total allogeneic units (p =
0.04). Thrombotic adverse events were similar across study cohorts.CONCLUSIONS:rFVIIa reduced blood product
use but did not affect mortality compared with placebo. Modern evidence-based trauma lowers mortality,
paradoxically making outcomes studies increasingly difficult.
Now…
Evolving plan…
Viscoelastic testing
• TEG or ROTEM provide a real-time graphic
representation of clot formation enabling
clinicians to individualize correction of
coagulopathy more accurately and
substantially faster than standard coagulation
tests
Viscoelastic Testing
• Excellent to assess coagulopathy in trauma.
• Performed at the bedside using whole blood (not
plasma) samples so the contribution of platelets and
fibrinogen to the clot kinetics can be assessed.
• Provide a timely assessment of the initiation of
coagulation AND of the clot formation process and the
maximal clot strength
• Considered the gold standard for diagnosing premature
dissolution of the clot, which has been identified as an
important contributor to mortality
Trauma-induced coagulopathy (TIC)
Multifactorial etiology:
–
–
–
–
–
–
–
–
Blood loss
Hypothermia
Acidosis
Loss coagulopathy
Dilutional coagulopathy
Consumption coagulopathy
Hyperfibrinolysis
Metabolic changes
Recommendations
• Stop surgical bleeding
• Warm fresh whole blood or best practice
component therapy in a ratio of 1:1:1:1
(plasma:platelets:cryoprecipitate:RBCs)
• TXA
• PCC
• Fibrinogen concentrate
• Point of care TEG directed care
Management of Trauma
Hemorrhage: Possible Role of
Kcentra, a 4-factor Prothrombin
Complex Concentrate
Joli Dace, PharmD, BCPS
Mercy Hospital and Trauma Center
Objectives




Define PCC and availability in US
Compare Kcentra with plasma
Brief overview of coagulation cascade
Review possible Kcentra use in trauma:



Emergent reversal of oral anticoagulants
Management of trauma hemorrhage
Discuss Kcentra nursing considerations



What
are
PCCs?
“Prothrombin complex concentrates”
Concentrated clotting factors
Derived from pooled human plasma
PCC Products
Available in US
Therapeutic
Clotting Factors
Profilnine SD®
II, IX, X
Kcentra®
II, IX, X, VII
Feiba® NF
II, IX, X, aVII
Alternative Names





3f-PCC
4f-PCC
BeriPlex® P/N (outside US)
Activated 4f-PCC
Factor VIII Inhibitor
Bypassing Activity
3-6,18
Comparison: Kcentra and FFP
Kcentra®
FFP
Clotting Factors
II, VII, IX, X
II, V, VII – XIII; fibrinogen
Anticoagulants
AT, heparin, protein C &
S
protein C & S
Preparation
Dilute each 500mg vial
with 20mL
Thaw; ABO match
Volume
Average 40 -100
mL/dose
Average 30 mL/kg
Each unit over 30-60 min
Administration Rate
•Weight-based (~820min)
•7x faster than FFP3
Less volume and faster
administration = faster


Dilutional coagulopathy
Risk of transfusion-
Coagulation Cascade
Image borrowed from AnaesthesiaUK at http://www.frca.co.uk/images/clotting_cascade.gif
Action of oral anticoagulants:
Warfarin inhibits factors II, VII, IX,
and X (vitamin K dependent
clotting factors).
Novel oral anticoagulants (NOACs)
inhibit either factor Xa or IIa.
Emergent Warfarin Reversal1-4,7
Warfarin prevalent; worse trauma outcomes1
Kcentra approved for warfarin reversal in either:



Acute major bleed

Urgent surgery or invasive procedure within 6h2
(head, spine, uncontrolled GI, extremity/compartment syndrome)
INR
Reversal
≤ 1.5
vitamin K 5 - 10 mg IV STAT
1.6 – 1.9
vitamin K + FFP
2.0 – 3.9
Kcentra 25 un/kg (max 2500 un) ± vitamin K IV
4.0 – 6.0
Kcentra 35 un/kg (max 3500 un) ± vitamin K IV
> 6.0
Kcentra 50 un/kg (max 5000 un) ± vitamin K IV
For vitamin K administration in non-emergent
warfarin reversal, see 2012 Chest Guideline7.
68
Emergent NOAC (Novel Oral
Anticoagulant) Reversal Strategies8-12
NOAC Drug Class
NOAC Agents
Factor Xa Inhibitors


apixaban (Eliquis)
rivaroxaban (Xarelto)
Direct Thrombin (IIa)
Inhibitor

dabigatran (Pradaxa)
Coagulation Tests
anti-Xa, PT, aPTT
ECT, dilute TT, aPTT
Activated Charcoal?
Yes, if last dose < 2h ago.
Yes, if last dose < 2h ago.
Hemodialysis?
Not useful.
Yes – prolonged (2h+)
PCC to reverse?
Kcentra 25 – 50 un/kg
Kcentra 25 – 50 un/kg
Alternative
Reversals?

69

? FEIBA 25 un/kg10
aDabi-Fab (future)11
Management of Trauma
Hemorrhage – Standards of Care16




Consider TXA early (bleeding or at risk)
Correct hypothermia, acidosis, hypotension
Maintain Hgb (7-9 g/dL), platelets (50-100k)
Fibrinogen – maintain > 1.5 – 2 mg/dL19

Depleted earlier than blood factors


Risk factors for low fibrinogen level on
admission14:


at 142% blood loss vs. 200-240% before fII, fVII
critically low13
injury severity score, shock, SBP<90, prehospital
fluid needs
Calcium – maintain iCa > 0.920
70
PCC in Trauma Hemorrhage

Evidence of benefit – evolving.
Lack of prospective trials demonstrating mortality
benefit

Retrospective reports demonstrate decreased INR,
bleeding, need for PRBCs, stabilized blood pressure22-25

Guidelines differ16,17; local use positive
Thrombosis risk: low (0-1.4% for current 4fPCCs)

Exclusion criteria: DIC, HIT

optimal Kcentra dose: uncertain. (?25-50 un/kg; max 100kg)



Possible role of PCC in:



Massive hemorrhage unresponsive to conventional tx
TEG-guided: ongoing bleed with CT > 90s15
Hgb-driven “Coagulation Box” model: Hgb < 5.526
71
Kcentra – Nursing Considerations

Verbal orders



Administration





Clarify which “PCC”, what un (fIX)/kg dose,
indication
Contact blood bank or pharmacy to alert of STAT
order
Weight-based dose; rate variable (~10-20 min)
Emergent reversal. Give ASAP (expires 4hrs after
mixed)
Document lot numbers (blood product)
Monitor for allergic reactions and thrombosis (0.91.4%)
Cost
72
References
1.Dossett LA, Riesel JN, Griffin MR, Cotton BA. Prevalence and implications of preinjury warfarin use: an analysis of the National
Trauma Database. Archives of Surgery. 2011.
2.National Advisory Committee on Blood and Blood Products. Recommendations for use of prothrombin complex concentrates in
Canada. Accessed on 11/7/2014. http://www.nacblood.ca/guidelines/PCC-Recommendations-Final-2014-05-16.pdf.
3.Kcentra website: www.Kcentra.com. Maintained by CSL Behring. Accessed on 11/7/14.
4.Lexi-Comp, Inc. (Lexi-Drugs). Lexi-Comp, Inc.;January 29, 2015.
5.Tanaka KA, Szlam F. Treatment of massive bleeding with prothrombin complex concentrate: argument for. J Thromb Haemost.
2010;8:2589-91.
6.Godier A, Susen S, Samama C-M. Tanaka KA, Szlam F. Treatment of massive bleeding with prothrombin complex concentrate:
argument against. J Thromb Haemost. 2010;8:2592-95
7.Holbrook A, Schulman S, Witt DM, et al. Evidence-Based Management of Anticoagulant Therapy. Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest.
2012;141(2)(Suppl):e152S-e184S.
8.Nutescu EA, Dager WE, Kalus JS, Lewin JJ, Cipolle MD. Management of bleeding and reversal strategies for oral anticoagulants:
Clinical Practice Considerations. Am J Health-Syst Pharm. 2013;70:1914-1929.
9.Tran H, et al. New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/ bleeding
management. Int Med J. 2014;44:525-536.
10.Dager WE, Gosselin RC, Roberts AJ. Reversing dabigatran in life-threatening bleeding occurring during cardiac ablation with factor
eight bypassing activity. Crit Care Med. 2013; 41(1):e42-46.
11.Grottke O, van Ryn J, Sprink HMH, Rossaint R. Prothrombin complex concentrates and a specific antidose to dabigatran are
effective ex-vivo in reversing the effects of dabigatran in an anticoagulation/liver trauma experimental model. Crit Care. 2014;18:R27.
12.Dickneite G. Prothrombin Complex Concentrates as Reversal Agents for New Oral Anticoagulants: lessons from preclinical studies
with Beriplex. Clin Lab Med. 2014;34:623-635.
73
References, cont.
13. Hiippala ST, Mllyla GJ, Vahtera EM. Hemostatic Factors and Replacement of Major Blood Loss with Plasma-Poor Red Cell
Concentrates. Anesth Analg. 1995;81:360-5.
14. Rourke C, et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient
outcomes. J Thromb Haemost. 2012;10:1342-51.
15. Sorensen B, Fries D. Emerging treatment strategies for trauma-induced coagulopathy. Brit J Surg. 2012;99(Suppl1): 40-50.
16. Spahn DR, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care.
2013;17:R76.
17. Kozek-Langenecker SA, et al. Management of severe perioperative bleeding. Guidelines from the European Society of
Anaesthesiology. Eur J Anaesthesiol. 2013;30:270-382.
18. Fries D. The early use of fibrinogen, prothrombin complex concentrate, and recombinant-activated factor VIIa in massive bleeding.
Transfusion. 2013;53(s):91s-95s.
19. Tanaka KA, Esper S, Bolliger D. Perioperative factor concentrate therapy. Brit J Anaesth. 2013;111(S1): i35-i49.
20. Schochl H, Grassetto A, Schlimp CJ. Management of Hemorrhage in Trauma. J Cardiothor Vasc Anesth. 2013;27(4): S35-S43.
21. Franchini M, Lippi G. Prothrombin complex concentrates: an update. Blood Transfus. 2010;8:149-54.
22. Joseph B, et al. Factor IX complex for the correction of traumatic coagulopathy. J Trauma. 2010;72(4):828-834.
23. Schick KS, Fertmann JM, Jauch KW, Hoffmann JN. Prothrombin complex concentrates in surgical patients: retrospective evaluation
of vitamin K antagonist reversal and treatment of severe bleeding. Crit Care. 2009;13:R191.
24. Carvalho MC, Rodrigues AG, Conceicao LM, Galvao ML, Ribeiro LC. Prothrombin complex concentrate (Octaplex): a Portuguese
experience in 1152 patients. Blood Coag Fibrin. 2012;23:222-228.
25. Lorenz R, et al. Efficacy and safety of a prothrombin complex concentrate [Beriplex] with two virus-inactivation steps in patients
with severe liver damage. Eur J Gastroenterol Hepatol. 2003;15:15-20.
26. Hilbert P, et al. The “Coagulation Box” and a New Hemoglobin-Driven Algorithm for Bleeding Control in Patients with Severe
Multiple Traumas. Arch Trauma Res. 2013;2(1):1-10.
27. Majeed A, Eelde A, Agren A, et al. Thromboembolic safety and efficacy of prothrombin complex concentrates in the emergent
reversal of warfarin coagulopathy. Thromb Res. 2012;129:146-51.
28. Innerhofer P, et al. The exclusive use of coagulation factor concentrates enables reversal of coagulopathy and decreases
transfusion rates in patients with major blunt trauma. Injury, Int J Care Injured. 2013;44:209-216.
74
Thank you
Questions?
jdace@mhsjvl.org
TXA (tranexamic acid)
Christopher Wistrom DO
Associate EMS Medical Director
Mercy Health Systems
12/4/2014
What Is It?
• TXA is a lysine derivative compound. That
blocks fibrin receptor site on plasminogen
therefore doesn’t allow fibrin to bind and
secures the integrity of the already existing
clot
In the Literature
•
•
•
•
CRASH-2
MATTERS
MATTERS 2
CRASH-3
CRASH-2
•
•
•
•
•
20,211 patients
274 hospitals
40 countries
10,096 with TXA 10,115 placebo
Results
– Treatment within 1 hour of injury
• Mortality TXA group 5.3% v. Placebo 7.7%
– Treatment within 3 hours of injury
• Mortality TXA group 4.8% v. Placebo 6.1%
– No effect on Vascular occlusive events
MATTERs
•
•
•
•
Retrospective study with 900 NATO casualties
TXA reserved for more severely injured
Results No difference in mortality at 24 hours
28 days TXA group with half the mortality of
non TXA group
MATTERs-2
• Retrospective observational study
• 1332 patients from Trauma Registry
• 4 groups with endpoint of mortality at
discharge
– TXA 18.2%
– Cryoprecipitates 21.4%
– TXA and Cryo 11.6%
– Neither 23.6%
CRASH3
• Currently underway
• Seeing to answer question of TXAs utility in
isolated head trauma
• Goal to enroll 10,000 patients
• No answers on this yet
• At this time NO indication for TXA in isolated
head trauma
Dosing
• 10mg/kg bolus given over 10 min
– Standard adult dose is 1 G
• 10mg/kg infusion over 8 hours
In the hospital
• Has a history of use in orthopedic surgery
• Also has been used by some OB-GYNs
• Dentists and oral surgeons have used the
product for decades
In the streets
• Is being used by progressive EMS systems
throughout the country
• Several Helicopter services
• Ground based crews
• Using standard CRASH-2 Criteria for patient
selection (hx of trauma and either tachycardia
or hypotension)-contraindicated for isolated
head trauma at this time
On the battlefield
• Standard of care
• In conjunction with tourniquet use has saved
countless lives and dramatically decreased all
cause mortality
• Since CRASH-2 the WHO has added TXA to list
of essential drugs
Over the counter
• Japan and UK sold OTC for Menorrhagia
Why is this important?
• All indicators at this time point to TXA being a
highly useful therapy for those with trauma
associated life threatening bleeding
• Best results are if given within the first hour
• No signs at this time of any increase in DVT/PE
• Cheap. Easy. Safe
TAKE HOME POINTS
• TXA decreases mortality if given early (earlier
the better)
• TXA does not increase risk for DVT/PE
• TXA not currently indicated for isolated head
trauma
• It will be showing up in an ED near you, and
needs to be followed up with infusion in
ICU/OR
Works cited TXA
• http://www.nytimes.com/2012/03/21/health/tranexamicacid-cheap-drug-is-found-to-staunch-bleeding.html?_r=0
• The CRASH-2 Collaborators. Effects of tranexamic acid on
death, vascular occlusive events, and blood transfusion in
trauma patients with significant hemorrhage(CRASH-2): a
randomised, placebo-controlled trial. Lancet 2010; 376:2332..
• Morrison JJ, Dubose JJ,Rasmussen TE,Midwinter, MJ.
Military Application of Tranexamic Acid in Trauma
Emergency Resuscitation(MATTERs) Study. Arch Surg 2012;
147:113-9.
• JAMA Surg. 2013 Mar;148(3):218-25. doi:
10.1001/jamasurg.2013.764.
Source: CDC.gov and bls.gov
The Casualty Care in the Classroom
task force was formed in January
in response to an active shooter
tabletop drill mediated by the FBI last
winter with participants from all city
services and other local agencies.
Why
• Leading cause of preventable death in
trauma?
• How has the military approached this?
• Global war on terror medical studies.
• Application to civilian setting
Others Attempts
• Not a truly novel idea-it has been tried
• Others have tried expensive, invasive kits with
a large training burden
• Also have tried simple kits with poor
education and implementation plans
Development
Multidisciplinary team effort
Law Enforcement
EMS/FD
Medical Professionals
Educators
Our Program
•
•
•
•
•
•
Cost effective
Local approach
Local teachers
School specific implementation
Plan for sustainability
Blanket type distribution and training
For More Information
• E-mail- mhsCCC@mhsjvl.org
• Or visit our website at
– http://onlinemercy.com/casualtycarekits/