The current state of the problem of temporary bleeding arrest in tactical conditions (literature review)

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Introduction.
The interest in the organization of pre-hospital care in the combat zone is due to the changing nature of modern military conflicts, the emergence of new means of first aid to the seriously wounded on the battlefield. In addition, new forms of warfare have led to the emergence of a new conceptual apparatus, without which the interpretation of the essence of modern conflicts is significantly difficult. The most common and widely used terms are "hybrid warfare", "irregular warfare", and "network-centric warfare".
The desire to improve the organization of medical care for the wounded on the battlefield has led to the widespread use of the term "tactical medicine" (TM) in Russian literature. In the Russian literature, the term "TM" became widespread after the publication of the Protocol on Providing tactical assistance to the Wounded on the Battlefield (TSSC —Tactical Combat Casualty Care), developed by the US Armed Forces in 1996 (after unsuccessful cases of providing assistance to the wounded in the military conflict in Somalia) [1]. A number of researchers believe that the key word in the term "TM" is tactics, in this case, a set of techniques and ways to achieve the goals of the tasks assigned to the unit. In the Armed Forces of the Russian Federation (Armed Forces of the Russian Federation), TM is considered as an element of the subject of training "Military medical training", which aims to train military personnel to provide PP to the wounded on the battlefield, taking into account the tactical situation [2].
The essence of TM is to choose a priority between the performance of a combat mission by a unit and the elimination of life-threatening consequences of injury. According to numerous studies, in the entire history of armed conflicts, the leading life-threatening complication is ongoing bleeding, which in 70% of cases occurs due to shrapnel wounds [1]. The generalization of the experience of local armed conflicts convincingly indicates that in the 21st century combined and multiple wounds, characterized by a special severity of damage to various organs and structures, prevail over isolated ones and account for over 65% of the structure of combat defeats [3]. At the same time, the proportion of combined wounds is 41.0 – 54.3% [1]. Among the wounds, a significant part of them are severe and extremely severe injuries 38.9 – 63.4%, manifested by bleeding [1]. Consequently, the structure of combat pathology characteristic of modern conflicts can lead to the formation of sources of bleeding from several anatomical areas.
The leading anatomical area that is being injured is the limbs, due to the lack of personal protective equipment. A number of authors who analyzed the epidemiology of combat injuries in modern military conflicts [4] indicate the predominance of limb injuries in the structure of combat trauma - from 46 to 74% [1], while the corresponding mortality rate reached 10% [5].
Recently collected data on Operations Iraqi Freedom and Enduring Freedom (in Afghanistan) show that 90% of military losses are the result of bleeding [6]. In 92% of cases, continued bleeding is the cause of death of military personnel due to unproven PP in time [7]. During the US war in Iraq and Afghanistan, 24.3% of the wounded died on the battlefield from "potentially preventable" wounds. Similar figures were obtained from the experience of providing assistance to the wounded in armed conflicts in the North Caucasus [8].
Thus, stopping the ongoing bleeding at the stage of providing PP significantly reduces mortality and is the most important element requiring immediate action. However, one should not forget that the organization of the provision of PP to the wounded on the battlefield is a complex task, the solution of which is achieved not only by performing medical measures, but also organizational and technical [2]. The content of PP measures for the wounded during the performance of tasks in the field of defense is determined by the specific conditions of the prevailing situation, primarily by factors complicating it, the main of which are: enemy fire, insufficient visibility and limited space, adverse weather conditions, delayed evacuation, limited time, information and resources, stressful situation, physical and geographical terrain conditions [1].
In order to reduce the risk of additional losses, the failure of personnel and to prevent the failure of the combat mission in TM, it is customary to provide PP to the wounded, based on the degree of danger of the situation on the line of combat, allocating three tactical zones [9]. The provision of PP on the battlefield should begin with ensuring one's personal safety, then ensuring the safety of others and the wounded. It is obvious that these rules run counter to the generally recognized principles of the "golden hour" and "platinum minutes". The priority in providing assistance is to eliminate threats to the life of the wounded as quickly as possible at the first opportunity.
Conditions critically dangerous to the life of a wounded person are conditions in which the death of a wounded person without assistance will occur within a few minutes:
• severe external bleeding;
• lack of consciousness;
• lack of breathing.
Thus, stopping the ongoing external bleeding, taking into account the principle of platinum minutes, should be immediate and should not interfere with the performance of combat missions. Therefore, the main place for stopping bleeding should be given in the "red" zone in the order of self-help in parallel with the implementation of the universal algorithm of actions described above [9].
According to the Order of the Minister of Defense of the Russian Federation dated 12/9/2022 No. 760, regulating the list of conditions in which PP is rendered by military personnel of the Armed Forces of the Russian Federation in combat conditions, the following methods of stopping bleeding are distinguished:
• finger compression of the artery;
• application of a hemostatic tourniquet;
• maximum flexion of the limb in the joint;
• direct pressure on the wound;
• applying a pressure bandage to the wound;
• the use of a local hemostatic agent (MGS).
The main preference in stopping bleeding in the red zone is given to using a tourniquet / turnstile according to the high and tight rule. At the same time, the question remains open about the problems that arise when using a tourniquet in the "red" zone. Israeli doctors providing pre-medical care adhere to a very liberal approach to the use of tourniquets, both in military and civilian settings. On the other hand, there are initial fears of further tissue damage (i.e. ischemic, neurological and subsequent to removal – reperfusion injury), which may eventually lead to amputation [10].
At TCCC, the use of tourniquets is considered a first-line remedy to stop ongoing bleeding. Although direct pressure on the wound is the preferred method of stopping blood flow, it is not always possible to use it due to the tactical situation. The advantages of using a tourniquet are: the permissibility of use under enemy fire and in dark conditions, the separation of a limb, multiple bleeding areas along one limb and a foreign body penetrating into the limb, which makes it impossible to apply direct pressure on the wound in this place [10].
Other methods of stopping bleeding are considered alternative. The main requirement for alternative methods is the ability to effectively stop bleeding, comparable to applying a tourniquet, as well as the possibility of immediate applicability. Therefore, the use of MGS, the imposition of a pressure bandage in the red zone do not meet these requirements and cannot be used.
The question of using the maximum flexion of the limb in the joint is also questioned, since the method is applicable only to victims who do not have fractures of the tubular bones of the limbs.
Of the remaining alternative ways to stop bleeding, the most promising is finger pressure and other techniques similar to the mechanism of action. Researchers believe that the simplest and most effective method of temporarily stopping major bleeding of the extremities, head and neck in the order of both self- and mutual assistance is finger pressing of the artery. Next, a hemostatic tourniquet or turnstile is used, an individual dressing package, MGC in powder form, a Z-folded bandage.
The advantages of the finger pressure technique are:
• rapid stop of bleeding;
• the possibility of application in anatomically complex areas (head, neck, axillary, subclavian, inguinal area);
• prevention of massive blood loss;
It should be borne in mind that, like any other method of stopping bleeding, it has its drawbacks:
• the time of effective impact on the pressure point is limited by the physical capabilities of the first aid provider;
• with this method, the rescuer and the wounded become immobile;
• when the vessel is pressed with fingers, the nerve trunks located next to it and the very sensitive periosteum are squeezed, which is quite painful;
• using this method significantly reduces the intensity of bleeding, but does not completely stop it due to collateral blood flow;
• due to the anatomical features of the location of a number of arteries or the complex nature of their damage, the use of the method of finger pressing is ineffective or impractical [1].
The purpose of the work
To analyze the current state of the problem of temporary bleeding arrest in tactical conditions.
Materials and methods of research.
The analysis of modern domestic and foreign literature devoted to the problem of temporary bleeding arrest, experience and results of the application of the methods used to stop blood flow in tactical conditions is carried out.
The results of the study. Bleeding is the main cause of death in injuries. In addition, in recent years, there has been an increase in the severity of injuries and mortality from bleeding due to injuries. This necessitates the timely provision of PP in the conditions of the "red" zone in the order of self- and mutual assistance. At the same time, the currently existing methods of temporary stopping bleeding are insufficiently effective in the "red" zone, do not have the tactical advantages that are so important in modern armed conflicts, have a short-term positive effect, and are inaccessible to wide segments of the population, including military personnel due to different physical and professional development.Conclusion. Thus, the problem of stopping bleeding is widespread all over the world. All of the above indicates the relevance of studying this problem and finding a solution. There is no consensus on the use of alternative methods to temporarily stop bleeding, since this topic has not been sufficiently disclosed and studied in the works of domestic and foreign scientists, and therefore it is of interest.

About the authors

Bogdan Andreevich Strizhakov

S.M. Kirov Military Medical Academy

Email: strizhakov.bogdan@yandex.ru
ORCID iD: 0009-0008-5847-2306
SPIN-code: 8709-5825

4th year cadet of the 3rd Faculty (training of doctors for the Aerospace Forces)

Russian Federation, 6 Akademika Lebedeva Street, Saint Petersburg, 194044, Russia

Nikita Igorevich Myasnikov

S.M. Kirov Military Medical Academy

Email: per.asper@mail.ru
ORCID iD: 0000-0002-1943-2829
SPIN-code: 3801-0559

Deputy Head of the Center (Tactical Medicine of the Armed Forces of the Russian Federation)

Russian Federation, 6 Akademika Lebedeva Street, Saint Petersburg, 194044, Russia

Georgy Alexeyevich Byrdin

S.M. Kirov Military Medical Academy

Author for correspondence.
Email: byrdineg@yandex.ru
ORCID iD: 0009-0001-6232-5340

4th year cadet of the 3rd Faculty (training of doctors for the Aerospace Forces)

Russian Federation, 6 Akademika Lebedeva Street, Saint Petersburg, 194044, Russia

References

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