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Control of bleeding

Question Type:
Intervention
Full Question:
Among adults and children with severe, external bleeding, (P), does application of ice, elevation of an injured extremity and/or application of pressure over proximal pressure points, with or without simultaneous direct pressure (I), compared with direct pressure alone (C), change overall mortality, hemostasis, hospital length of stay, major bleeding, complications (O)?
Consensus on Science:
For the critical outcome of mortality, we identified no evidence. For the critical outcome of hemostasis, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 RCT(King 2008, 205) showing a benefit in the reduction of femoral hematoma formation in post-PCI patients receiving cold pack (vasoconstriction) compared with sandbags (compression). This study enrolled 50 patients and reported a statistically significant reduction in femoral hematoma formation, but no quantitative data were provided to calculate the MD and CI. The publication included an illustration suggesting that cold compression reduced the size of the hematoma by approximately 20 cm2 over 180 minutes in the cold compression group and by less than approximately 10 cm2 in the compression-only group. For the critical outcome of major bleeding, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 RCT,(Levy 1993, 174) which enrolled 80 patients who underwent total knee arthroplasty and reported an MD in calculated total body blood loss in the cold compression group of 610 mL (95% CI, 415.6–804.4) and an MD in extravasation of 357 mL (95% CI, 184.6–529.3). For the important outcome of complications, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 RCT(Levy 1993, 174) showing a nonsignificant reduction in complications of the occurrence of deep vein thrombosis in the cold compression group (1/60 knees) compared with the non–cold compression group (2/40 knees). For the important outcome of hospital length of stay, we identified no evidence.
Treatment Recommendation:
We suggest that localized cold therapy with or without pressure may be beneficial in hemostasis for closed bleeding in extremities (weak recommendation, very-low-quality evidence). There is inadequate evidence to make a treatment recommendation concerning the use of proximal pressure points, localized cold therapy for external bleeding, or the elevation of an extremity for control of bleeding. Values, Preferences, and Task Force Insights In making this weak recommendation, we do so cautiously because we are generalizing results from the healthcare setting to the first aid setting. Public comments on this topic expressed concern about the application of localized cold therapy to pediatric patients and the risk of hypothermia. The task force thought that local application of cold therapy to an area of closed bleeding, such as a bruise or hematoma, is intended to be directed at a relatively small, limited-size injury and would not result in hypothermia (eg, an instant cold pack applied to a bruise).
CoSTR Attachments:
2015 01 31 SOF bleeding control.doc    
2015 10 13 FA530 bleeding control inclusion_exclusion.docx    

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