Why are pressure dressings (pressers) not used in trauma?

From the Guidelines

The use of pressers in trauma is not recommended as a first-line treatment because there is inadequate evidence to support their effectiveness in controlling bleeding, and they may worsen outcomes by masking ongoing bleeding and causing tissue ischemia. According to the 2015 international consensus on first aid science with treatment recommendations 1, the correct management of hemorrhage and the enhancement of hemostasis in the first aid setting are essential to maintaining the circulating blood volume in acute trauma. The study found that there was inadequate evidence to support the use of proximal pressure points or limb elevation to control bleeding, which suggests that pressers may not be effective in this context.

Instead, the preferred approach for managing hemorrhage in trauma includes the use of localized cold therapy for closed bleeding in extremities, hemostatic dressings when standard first aid hemorrhage control fails, and tourniquets in the civilian setting when standard first aid hemorrhage control fails to control severe external limb bleeding 1. The task force recognized that the use of these methods will have cost and training implications, but they believed that these costs would be moderate and justified considering the benefit of maintaining circulating blood volume in the management of trauma.

Key points to consider in the management of trauma include:

• The use of hemostatic dressings and tourniquets as adjuncts to standard first aid hemorrhage control
• The importance of maintaining circulating blood volume through the use of blood products and volume resuscitation
• The need to protect the victim from further injury by splinting fractures in position and avoiding the use of cervical collars unless absolutely necessary
• The recognition of concussion after head trauma and the importance of proper burn management, including cooling and wound care.

Overall, the management of trauma requires a multifaceted approach that prioritizes the control of hemorrhage, maintenance of circulating blood volume, and protection of the victim from further injury, rather than relying on pressers as a first-line treatment.

From the Research

Reasons for Limited Use of Pressors in Trauma

• The use of pressors in trauma patients is limited due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure in hypotensive trauma patients 2.
• Hypotensive resuscitation is advocated based on limited data that lower systolic blood pressure and mean arterial pressure will result in improved mortality 2.
• Large-volume fluid replacement may promote coagulopathy by diluting coagulation factors, and an excessive level of mean arterial pressure may induce bleeding by preventing clot formation 3.

Alternative Approaches to Pressors in Trauma

• Fluid resuscitation is the first-line therapy to restore intravascular volume and to prevent cardiac arrest, but it must be limited to the bare minimum to maintain arterial pressure and minimize dilution of coagulation factors 3.
• Early vasopressor support may be required to restore arterial pressure and prevent excessive fluid resuscitation, but the use of vasopressors in trauma patients is still a topic of debate 3, 2.
• The objectives of hemodynamic resuscitation in hypotensive trauma patients are restoring adequate intravascular volume with a balanced ratio of blood products, correcting pathologic coagulopathy, and maintaining organ perfusion 2.

Evidence on the Use of Pressors in Trauma

• Some studies suggest that vasopressors may be useful in traumatic shock resuscitation to counteract vasodilation in hemorrhage as well as other clinical conditions such as traumatic brain injury, spinal cord injury, multiple organ dysfunction syndrome, and vasodilation of general anesthetics 2, 4.
• A retrospective cohort study found that first-line vasopressin exhibited faster time to distributive shock reversal in the unadjusted analysis, but failed to maintain this difference in the multivariable analysis 4.
• The National Association of Emergency Medical Services Physicians (NAEMSP) has developed recommendations on the prehospital use of vasopressors in shock related to trauma, based on a review of the available evidence 5.