Bleeding Management of the Severely Injured

The authors believe this has relevant patient management implications which are not discussed in emergency medicine literature or training.

Clinical Implications from an Observational Report

We offer this clinical observation following an occurrence during bleeding management instruction at a recent procedural course within the Centre for Emergency Health Sciences (a bio-skills/research facility) in Texas. The authors believe the following account has relevant patient management implications which are not discussed in emergency medicine literature or national training initiatives.

Background

During fresh (non-fixed/non-frozen) human cadaver-based bleeding instruction, the authors of this report engaged a 91-year-old male human specimen (6’ 1” / 151 lbs. [185.4 cm /68.49 kg.] at room temperature) with an estimated body mass index of 19.9 (low normal), and cardiac arrest listed as cause of death. For purposes related to this course, and the creation of our standard bleeding model, several routine procedures were undertaken.

Related

A distal femur surgical amputation (six centimeters proximal to the knee) was performed with a #20 scalpel and a Stryker® System 6 Sagittal Saw. Additionally, preparations for this perfused extremity consisted of a 10-centimeter vertical “cut-down” incision – beginning two centimeters inferior to the inguinal ligament – with reflection and identification of the inguinal neurovascular bundle (Fig A).

Fig. A Right inguinal neurovascular bundle
Fig. B Transected proximal femoral artery
Fig. C Transected distal femoral artery

Upon exposure of the inguinal neurovascular bundle, and palpation of the femoral artery, significant atherosclerotic plaque was identified. (Retrospectively, the authors reviewed this specimen’s history but were unable to identify the root cause of his advanced disease.)

Atherosclerosis is a leading cause of vascular disease worldwide and one that is readily linked to smoking, obesity, high blood pressure, high cholesterol, and diabetes mellitus. 

Herrington, W. Et al.

Following exposure, we attempted the insertion of a 7 Fr Cordis Prelude® (Merit Medical), but the authors appreciated significant atherosclerotic plaque preventing catheter placement. This finding necessitated a complete transection of the femoral artery (Fig B, Fig C) to enable placement of the catheter (something which is typically accomplished with a modified Seldinger approach). Following cannulation of the artery, distal flow was achieved with a blood analog and utilization of a LifeFlow® (410 Medical) hand pump, which can manually generate pulsatile circulation when actuated. Once distal flow was confirmed, the Cordis was sutured into position and the inguinal window was packed and closed.

Identified Clinical Challenge

During the hemorrhage control demonstration, digital compression of the artery was attempted, followed by the immediate application of a C.A.T.® Tourniquet (Composite Resources, Inc.). Both highly experienced faculty immediately noted that even with digital arterial compression, and a correctly applied tourniquet, brisk hemorrhage continued. The tourniquet was further tightened; however, no decrease in bleeding was noted.

A second C.A.T.® Tourniquet was applied immediately distal to the initial tourniquet but also failed to achieve hemostasis. Upon close inspection of the anatomy, we noted that digital pressure did not sufficiently compress the femoral artery. Interrogation with ultrasound confirmed that tourniquet occlusion of the femoral artery could not be achieved. The authors collectively concluded that this bleeding control failure was specifically related to a non-compressible artery, likely the result of significant circumferential atherosclerosis.

Observational Conclusion

Select patient populations may present unique challenges to bleeding control.1,2 Emergency medical providers should be aware that a subset of patients (those with a diagnosis of, or history related to atherosclerosis) may present bleeding management challenges – possibly related to non-compressible arteries – which may not be mitigated by the application of a tourniquet. In these situations, albeit rare and one that may only become obvious after abject failure of a tourniquet, aggressive wound packing and continuous pressure may be the only viable option. Our wound packing conclusion (in the absence of other realistic recommendations) stems from collective understanding of junctional wound packing or the frank alternative of death. The authors make this observation public, in the absence of a formalized study, given its relevance to select populations (agreeably less prevalent), and those who are responsible for their care.

The authors, given their experience in the laboratory, field, and clinical settings, further postulate that there may be other potential bleeding related challenges not currently addressed in various first-aid programs. For example, Stop the Bleed© is a national program designed to teach hemorrhage control to the general public in an effort to reduce death from controllable bleeding.  Our clinical observations demonstrate that there are some patients for which tourniquets may be ineffective despite proper application. Bleeding control courses should consider modifying some content to include bleeding management for patients with whom standard methodologies or equipment fail.

Acknowledgements

The authors would like to acknowledge the men and women who donate their remains to support medical research and procedural development. Without their precious gift, untimely death and needless suffering would prevail. We would also like to thank the UTSW Willed Body Program and staff for their tireless efforts to enhance the medical arts beyond walls and borders. Lastly, we would like to extend our gratitude to laboratory technicians, Elizbeth Dillard, BS, NREMT, Jenna Dixon, and Daisey Bermes for their work during this effort.

References

  1. Jeyaseelan S, Stevenson TM, Pfitzner J. Tourniquet failure and arterial calcification. Case report and theoretical dangers. Anaesthesia. 1981 Jan;36(1):48-50. doi: 10.1111/j.1365-2044.1981.tb08599.x. PMID: 7468962.
  2. Barr L, Iyer US, Sardesai A, Chitnavis J. Tourniquet failure during total knee replacement due to arterial calcification: case report and review of the literature. J Perioper Pract. 2010 Feb;20(2):55-8. doi: 10.1177/175045891002000202. PMID: 20192092.

The conclusions in this report are those of the authors and do not necessarily reflect the position or opinion of SAUSHEC, the U.S. Army or the U.S. Department of Defense.

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