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Prehospital hemorrhage management in low- and middle-income countries: A scoping review
Ashwin J Kulkarni1,2,3, Amber Batra2,4, Zachary J Eisner1,2,3
1University of Michigan Medical School, Ann Arbor, Michigan, USA.
Insights
Hemorrhage management (HM) training for first responders in low- and middle-income countries (LMICs) shows significant knowledge improvement. Prioritizing HM resources is crucial for reducing injury deaths in these regions.
Area of Science:
- Emergency Medicine
- Public Health
- Global Health
Background:
- Low- and middle-income countries (LMICs) bear a disproportionate burden of injury-related deaths, with hemorrhage accounting for a significant portion.
- Prehospital care in LMICs is often inadequate, exacerbating mortality from severe bleeding.
- Effective hemorrhage management (HM) is a critical, yet under-summarized, component of prehospital care in LMICs.
Purpose of the Study:
- To review the current literature on prehospital hemorrhage management (HM) practices in LMICs.
- To evaluate the impact and outcomes of first responder HM training programs in LMICs.
Main Methods:
- A systematic literature review was conducted using PMC, MEDLINE, and Scopus databases (January 2000 - January 2023).
- PRISMA-ScR guidelines were followed for article identification and selection.
- Inclusion criteria focused on first responder training programs for prehospital HM, with quality assessed using the Newcastle-Ottawa scale.
Main Results:
- Twenty studies from 16 countries met inclusion criteria, encompassing various study designs.
- Basic HM curricula were present in 15 studies, and advanced curricula in six.
- First responders reported using HM skills in 55%-76% of encounters, with notable knowledge gains (23-58 percentage points) in techniques like tourniquet application post-training.
Conclusions:
- This review synthesizes the existing evidence on prehospital HM in LMICs, covering epidemiology, interventions, and outcomes.
- There is a clear need to prioritize and further develop hemorrhage management resources and training for first responders in LMICs.
Introduction:
Low- and middle-income countries (LMICs) account for 90% of deaths due to injury, largely due to hemorrhage. The increased hemorrhage mortality burden in LMICs is exacerbated by absent or ineffective prehospital care. Hemorrhage management (HM) is an essential component of prehospital care in LMICs, yet current practices for prehospital HM and outcomes from first responder HM training have yet to be summarized.
Methods:
This review describes the current literature on prehospital HM and the impact of first responder HM training in LMICs. Articles published between January 2000 and January 2023 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for HM. Relevant articles were assessed for quality using the Newcastle-Ottawa scale.
Results:
Of the initial 994 articles, 20 met inclusion criteria representing 16 countries. Studies included randomized control trials, cohort studies, case control studies, reviews, and epidemiological studies. Basic HM curricula were found in 15 studies and advanced HM curricula were found in six studies. Traumatic hemorrhage was indicated in 17 studies while obstetric hemorrhage was indicated in three studies. First responders indicated HM use in 55%-76% of encounters, the most frequent skill they reported using. Mean improvements in HM knowledge acquisition post-course ranged from 23 to 58 percentage points following training for pressure and elevation, gauze application, and tourniquet application.
Conclusions:
Our study summarizes the current literature on prehospital HM in LMICs pertaining to epidemiology, interventions, and outcomes. HM resources should be a priority for further development.
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