Acute Life-threatening Hemorrhage Research Articles

Diagnosis and therapeutic strategies for small bowel vascular lesions.

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

Acute Life-Threatening Hemorrhage in Neonates With Severe Hemophilia A: A Report of 3 Cases.

Hemorrhagic shock is a rare, emergent condition that is often fatal in newborns. In this article, we report cases of 3 neonates presenting with acute, life-threatening hemorrhage who were subsequently diagnosed with severe hemophilia (<1% factor VIII). The first infant was tachycardic, pale, and had a precipitous drop in his hemoglobin secondary to a subgaleal hemorrhage. The second patient sustained a splenic rupture, a sequela that has been reported in only 4 other neonatal cases. The last infant presented with tonic-clonic seizures and respiratory distress. Head imaging demonstrated extracranial and intracranial hemorrhage, complications that can result in 20% mortality. All 3 patients were successfully treated with clotting factor concentrate and blood products. After normalization of factor VIII levels, the newborns did not develop any new hemorrhages and were discharged home within 3 weeks of birth. Pediatric providers should be aware that these signs and symptoms may be potentially lethal complications in neonates with severe factor VIII deficiency.

Acute life-threatening hemorrhage : Diagnostic workup and treatment possibilities are constantly improving

Acute life-threatening hemorrhage : Diagnostic workup and treatment possibilities are constantly improving

Conservative Management of Cervical Ectopic Pregnancy.

To evaluate the safety and effectiveness of conservative management for cervical ectopic pregnancies. We conducted a retrospective review of all cases of cervical ectopic pregnancy diagnosed at our tertiary care academic centre between January 2002 and July 2014. The diagnosis of cervical ectopic pregnancy was made using transvaginal ultrasound according to published criteria. Management decisions were made by individual clinicians. Cervical ectopic pregnancy was diagnosed in 27 women with a median age of 34 years. Two thirds of them were nulliparous, and 44% (12/27) reported infertility. The mean gestational age at diagnosis was seven weeks. The median serum human chorionic gonadotropin level was 11 300 IU/L (range 610 to 163 700). Fetal cardiac activity was present in 19 pregnancies (70%). Vaginal bleeding was the most common presentation, occurring in 23 cases (85%). Three women presented with acute life-threatening hemorrhage. All cases were successfully managed conservatively, allowing uterine preservation. Systemic methotrexate (single or multi-dose protocol) was the mainstay of therapy. Other minimally invasive interventions included ultrasound-guided injection of potassium chloride into the pregnancy, uterine artery embolization, vaginal ligation of cervical branches of the uterine arteries, and dilatation and curettage, with or without dilute vasopressin cervical infiltration and Foley catheter tamponade. Systemic methotrexate alone or in combination with other minimally invasive techniques can be effective conservative treatment for cervical pregnancies. A fertility-sparing approach is the optimal treatment for this patient population, which has high rates of infertility and nulliparity. We present a management algorithm based on our results to aid in standardizing the management of cervical ectopic pregnancies.

A Critical Review of the Literature and an Evidence-Based Approach for Life-Threatening Hemorrhage in Maxillofacial Surgery

Life-threatening facial hemorrhage in Maxillofacial Surgery (MFS) has an approximate incidence of 1% in the trauma patient and in elective surgery. The treatment of acute life-threatening hemorrhage in MFS to prevent hypovolemic shock or airway obstruction forms the basis of emergency care and necessitates the need for further analysis given the multitude of options proposed for treatment. A systematic review of the literature was undertaken to formulate an evidence-based approach to the treatment of life-threatening hemorrhage in MFS. A comprehensive search of journal articles was performed using PubMed and Ovid databases. Keywords and phrases used were "life threatening facial hemorrhage," "life threatening facial bleeding," "external carotid artery ligation," and "external carotid artery embolization." Our search yielded 1441 articles. In an attempt to focus on hemorrhage exclusively from traumatic and operative events, articles that cited hematological disorders as the underlying cause of bleeding were excluded from the study. There were 40 articles which met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There was 1 Level II, 21 Level III, 12 Level IV, and 6 Level V papers. Seven Level III evidence-based studies noted a high association between midface injuries, particularly Lefort III fractures and massive oronasal hemorrhage. One Level II study, 8 Level III studies, and 3 Level IV studies concluded that the internal maxillary artery was most frequently associated with intractable posttraumatic hemorrhage. One Level II, 16 Level III, 3 Level IV, and 3 Level V articles cited anterior and posterior nasal packing and conservative measures as the first attempt to manage traumatic hemorrhage. Subsequently, 8 Level III studies re-enforced the importance of temporary reduction of facial fractures as an effective means to control massive hemorrhage early in the algorithm. Seven Level III studies, 4 Level IV, and 2 Level V studies documented the importance of ligation of arteries as one of the absolute measures to manage facial hemorrhage, whereas 1 Level II, 14 Level III, 2 Level IV, and 3 Level V studies alluded to embolization as the most reliable technique for control of the hemorrhage. In orthognathic surgery, the internal maxillary artery was most frequently the source of massive hemorrhage according to 2 Level III, 4 Level IV, and 1 Level V studies. Two Level III, 5 Level IV, and 1 Level V study proposed packing as the first attempt to tamponade the hemorrhage. Two Level IV and 1 Level V study cited pseudoaneurysm as a potentially life-threatening vascular complication after elective surgery. Management of facial hemorrhage should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for posttraumatic and elective life-threatening hemorrhage in MFS based on this critical review of the literature is presented and discussed.

Acute Life-Threatening Hemorrhage in Patients with Head and Neck Cancer Presenting with Carotid Blowout Syndrome: Follow-Up Results after Initial Hemostasis with Covered-Stent Placement

CSP in patients with HNC presenting with CBS can provide immediate hemostasis to prevent exsanguination. We evaluated the safety and efficacy of CSP to control acute life-threatening hemorrhage in patients with HNC presenting with CBS. We retrospectively reviewed 10 patients (7 men, 3 women; mean age, 59 years) with HNC presenting with acute life-threatening hemorrhage from CBS that was treated with CSP. We studied patient demographics, presentations, procedures, initial and delayed complications, and technical and clinical outcomes on follow-up. All patients achieved immediate hemostasis following CSP. Periprocedural complications consisted of groin hematomas (n=2), acute limb ischemia requiring thrombectomy, and an asymptomatic temporal lobe hemorrhage. Imaging and clinical follow-up were available for a mean of 17.7 months (range, 1-60 months). Two patients remained asymptomatic with a patent stent and no evidence of rebleeding at 17 and 21 months, respectively. Recurrent hemorrhages requiring retreatment were encountered in 3 patients secondary to stent infections (30%) at mean duration of 8 months. Neurologic morbidity resulted from stent thrombosis and stroke at 8 months in a single patient. Mortality was unrelated to CSP but was a result of palliative hospice care (n=3) at a mean of 2 months or natural disease progression (n=1) with documented patency of the stent at 6 months. Acute life-threatening hemorrhage from CBS related to advanced HNC can be safely and effectively treated with CSP. However, potential delayed ischemic or infectious complications are common in the exposed or infected neck.

Stent-grafts placement for treatment of massive hemorrhage from ruptured hepatic artery after pancreaticoduodenectomy

To present a series of cases with life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm after pancreaticoduodenectomy (PD) treated with placement of stent-grafts. Massive hemorrhage from ruptured hepatic artery pseudoaneurysm after PD in 9 patients (6 men, 3 women) at the age of 23-75 years (mean 48 years), were treated with placement of percutaneous endovascular balloon-expandable coronary stent-grafts. All patients were not suitable for embolization because of a non-patent portal vein. One or more stent-grafts, ranging 3-6 mm in diameter and 16-55 mm in length, were placed to exclude ruptured pseudoaneurysm. Follow-up data, including clinical condition, liver function tests, and Doppler ultrasound examination, were recorded at the outpatient clinic. Immediate technical success was achieved in all the 9 patients. All stent-grafts were deployed in the intended position for immediate cessation of bleeding and preservation of satisfactory hepatic arterial blood flow. No significant procedure-related complications occurred. Recurrent bleeding occurred in 2 patients at 16 and 24 h, respectively, after placement of stent-grafts and treated with surgical revision. One patient died of sepsis 12 d after the interventional procedure. The remaining 6 patients were survived when they were discharged. The mean follow-up time was 10.5 mo (range 4-16 mo). No patient had recurrent bleeding after discharge. Doppler ultrasound examination verified the patency of hepatic artery and stent-grafts during the follow-up. Placement of stent-grafts is an effective and safe procedure for acute life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm.

Recombinant activated factor VII (rFVIIa) treatment in infants with hemorrhage

Recombinant activated factor VII (rFVIIa) is approved by the FDA for the treatment of bleeding episodes in patients with hemophilia A or B with inhibitors to factor VIII or factor IX. In addition to the FDA-approved indications, rFVIIa has been anecdotally reported effective for profound bleeding episodes in adult patients without hemophilia, and proven beneficial for adults with intracranial hemorrhage. In the pediatric literature, case reports have been made with apparent clinical improvement seen after the use of rFVIIa for acute life-threatening bleeding; however, there are limited data regarding its use in infants<4 months of age. We report our experience with rFVIIa in nine infants with severe hemorrhage of diverse etiologies. This case series of infants under 4 months with coagulopathy and bleeding treated with rFVIIa was collected from two institutions. We report the age, weight and pre-rFVIIa laboratory values of the patients as well as the clinical scenario and outcomes. The nine infants all suffered acute life-threatening hemorrhage. Two patients were postoperative from cardiac surgery, two with Vitamin K deficiency and intracranial hemorrhage, three with suspected necrotizing enterocolitis and abdominal hemorrhage, and two with pulmonary hemorrhage. The patients ranged in age from 2 days to 4 months, (average age 1 month and average weight 3.3+/-1.0 kg). Seven of the nine patients had frozen plasma, cryoprecipitate, or platelet administration in failed attempts to correct the coagulation defect prior to receiving rFVIIa. The dose range used in this series was 90-100 microg.kg-1, with 90 microg.kg-1 being the most commonly used dose. The average pre-rFVIIa INR was 8.7+/-5.1. Four patients had an immeasurably high INR. All patients had clinical resolution of bleeding after receiving rFVIIa, and seven of nine patients survived. rFVIIa is a powerful hemostatic drug whose mechanism of action provides a theoretical specificity to sites of tissue injury. In addition to its FDA-approved uses in hemophiliac patients, this drug has a potential role in the treatment of life-threatening hemorrhage from multiple causes.

Surgical palliation of incurable urologic cancer

It is estimated that in 1995 urologic cancers will account for 44% of all new cancers in men and 4% of all new cancers in women. 1 In addition, it is estimated that these tumors will account for 19% of all cancer-related deaths in men and 3% of all cancer-related deaths in women. 1 Although advanced cancers are generally incurable and thus limit quantity of life, locally aggressive tumors may also be associated with significant symptomatic morbidity, which may affect quality-of-life issues as well. Locally advanced urologic cancers may cause pain related to invasion of tumor into surrounding tissues and obstruction of urinary outflow. The latter may result from either direct extension of tumor by hemorrhage with subsequent clot colic or compression by metastatic lymph nodes. Persistent bleeding, with resultant chronic anemia or acute life-threatening hemorrhage, may also be a consequence of locally advanced disease. In these instances, palliation of the local process, resulting in relief of symptoms, can lead to a significant improvement in quality of life. Benefiting quality of life may also lead to an increase in quantity of life without effecting cure of the primary cancer. However, the role of palliation is the relief of symptoms without expectation of cure, and judicious institution of invasive procedures requires weighing the potential benefits of palliation against the morbidity of the treatment itself. There are multiple therapeutic options for the treatment of locally extensive and symptomatic primary urologic cancers. They include arterial embolization, radiation therapy, chemotherapy, hormonal manipulation, urinary diversion, and radical ablative surgery Not all patients are candidates for all therapies, and this discussion will focus on the indications and options for the surgical management of locally extensive urologic tumors. The cancers that are most often associated with local spread and symptoms are renal cell carcinoma, transitional cell carcinoma, and prostate cancer. The therapeutic options for each of these cancers will be reviewed with the goal of delivering palliative treatment and subsequent improvement in quality of life.