Zones of hemorrhage: Defining vascular injury in military patients with complex pelvic fractures - A consensus panel review

Background Junctional extremity and noncompressible hemorrhage are difficult challenges facing the prehospital provider on the battlefield. The subset of casualties with pelvic or truncal vascular injury represents a challenge in hemorrhage control. Methods The Armed Forces Medical Examiner (AFME) System was queried for nonsurvivors with significant vascular injuries and an associated pelvic fracture. A panel of military experts in prehospital care, vascular surgery, and orthopaedic surgery reviewed all records. Zones of hemorrhage were categorized as Zone I, area of injury allowing tourniquet use; Zone II, area of injury compressible but not allowing tourniquet use; or Zone III, noncompressible. Currently available and emerging technologies for hemorrhage control were reviewed and potential applicability of each modality determined. Results An AFME database search yielded 49 nonsurvivors with pelvic fractures and associated vascular injuries. Zone I hemorrhage injuries were present in 21% of patients, Zone II in 19%, and Zone III in 60%, accounting for 115 total injuries. Thirty percent (n = 15) of patients had uncontrollable hemorrhage, 39% (n = 19) had hemorrhage potentially controllable by the battlefield prehospital provider, and 30% (n = 15) were deemed compressible with emerging technologies not available on the battlefield. Sixty-one percent (n = 30) had vascular injuries that were noncompressible using battlefield-available methods. Conclusions The majority of battlefield vascular injuries in nonsurvivors were not controllable using technology available to the prehospital responder. Classifying battlefield hemorrhage into zones of hemorrhage may allow us to focus future research and intervention development.