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Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, such as external aortic compression which has been identified as an immediately applicable maneuver to address the leading cause of battlefield mortality: junctional hemorrhage. However, it is currently unclear how to optimize this technique.  Methods:  This prospective, block-randomized, cross-over simulation study of compression optimization was performed on a model of central vessel compression that recorded weight (lbs) and pressure (mmHg). Forty participants simulated external aortic compression on the ground as well as a stretcher with and without a backboard. Participants were blinded to compression weight and pressure, as well as the purpose of the study, to minimize preparation bias. Manoeuvres were performed in alternating order to control for skill acquisition and fatigue. Scripted instructions were followed to compress with 1 then 2 hands, and to apply “sustainable effort” and then “maximal effort”.  Results:  The greater the compressor's bodyweight the greater their mean compression (Pearson’s correlation 0.9342). Using one-hand, a mean of 28% participant bodyweight (95%CI, 26% - 30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased rescuer bodyweight transmission by 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p&lt;0.001). Adding a backboard increased transmission of rescuer bodyweight 7%-15% (p&lt;0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4%-9% (p &lt; 0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p &lt;0.001).  Conclusion:  Efficacy is maximized with larger-mass, two hands, and compression on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). This study demonstrates the feasibility of indirect pressure as a potential temporizing measure for life-threatening haemorrhage not amenable to direct compression.

P035: Optimization of indirect pressure to temporize life-threatening haemorrhage: a simulation study