Management of non-compressible torso hemorrhage of the abdomen in civilian and military austere environments: a scoping review

Abstract

Background: Non-compressible abdominal hemorrhage (NCAH) is the leading cause of potentially preventable deaths in both civilian and military austere environments, and an improvement in mortality due to this problem has not been demonstrated during the past quarter century. Several innovations have been developed to control hemorrhage closer to the point of injury.

Objective: This review assessed NCAH interventions in civilian and military settings, focusing on austere environments. It identified innovations, effectiveness, and knowledge gaps for future research.

Methodology: The Joanna Briggs Institute for Evidence Synthesis methodology guided this scoping review to completion. Studies evaluating NCAH with human participants in civilian and military austere environments that were eligible for inclusion were limited to English language studies published between December 1990 and January 2023. The PCC (Participant, Concept, Context) framework was used for data synthesis. Deductive and inductive thematic analyses were used to assess the literature that met inclusion criteria, identify patterns/themes to address the research questions and identify common themes within the literature. A stakeholder consultation was conducted to review and provide expert perspectives and opinions on the results of the deductive and inductive thematic analyses.

Results: The literature search identified 868 articles; 26 articles met the inclusion criteria. Textual narrative analysis of the 26 articles resulted in the literature addressing four main categories: NCAH, penetrating abdominal trauma, resuscitative endovascular balloon occlusion of the aorta (REBOA), and ResQFoam. The deductive thematic analysis aimed to answer three research questions. Research question 1 addressed the effectiveness of REBOA, damage control resuscitation, and damage control surgery in managing NCAH in austere environments. No effectiveness studies were found on this topic. Research question 2 identified three knowledge gaps in NCAH management in austere environments. The analysis identified early hemorrhage control, prehospital provider decision-making ability, and REBOA implementation as knowledge gaps in NCAH. Research question 3 identified five innovations that may affect the management of NCAH in the future: transport of patients, advanced resuscitative care, expert consultation, REBOA implementation, and self-expanding foam implementation. The inductive thematic analysis resulted in four recurrent themes from the literature: prehospital care, decision-making, hemorrhage control, and mortality in NCAH. During the stakeholders' consultation, the results of the deductive and inductive thematic analyses were reviewed and agreed on by the stakeholders. Special emphasis and discussion were given to prehospital management, expert opinions in the prehospital environment, decision-making in the prehospital environment, transport and resuscitation in the prehospital setting, REBOA, alternative discussion for research, and research gaps.

Conclusion: NCAH is still a significant cause of preventable death in both military and civilian austere environments, even with ongoing research and interventions aimed at extending survival in such conditions. This scoping review has identified several potential concepts that could reduce the mortality associated with a preventable cause of death due to hemorrhage in austere environments.

Keywords: abdomen; hemorrhage; laparotomy.

Figure 1

Graphic presentation of scoping review methodology. AAST, American Association for the Surgery of Trauma; ACS, American College of Surgeons; ATS, American Trauma Society; CCMJ, Critical Care Medical Journal; EAST, Eastern Association for the Surgery of Trauma; EJTES, European Society of Trauma and Emergency Surgery; NCTH, Non-compressible torso hemorrhage; NTRI, National Trauma Research Institue; WTA, Western Trauma Association. Adams et al.

Figure 2

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram selection. *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. ATS, American Trauma Society; CCMJ, Critical Care Medicine Journal; EJTES, European Society of Trauma and Emergency Surgery; JACS, Journal of the American College of Surgeons; JTACS, Journal of Trauma and Acute Care Surgery; NTRI, National Trauma Research Institute; REBOA, resuscitative endovascular balloon occlusion of the aorta; WJS, World Journal of Surgery. From: Page et al.

Figure 3

Thematic Analysis Categories and Themes. NCAH, non-compressible abdominal hemorrhage; POI, point of injury.