Management Of Life-threatening Bleeding Research Articles

Pathophysiology of bleeding

Bleeding is associated with an increased morbidity and mortality. Anatomic and hemostatic causes play acentral role in the pathophysiology of bleeding, with anatomic causes being by far more common. While trauma and invasive procedures are the leading causes of bleeding in surgical disciplines, gastrointestinal bleeding is the major cause of bleeding in internal medicine. Major bleedings lead to secondary homeostatic changes, which in turn not only contribute to further bleeding, but also to the pathogenesis of organ dysfunction. Acquired coagulopathies due to antithrombotic treatment or an underlying disease also contribute to the extent and the dynamics of bleeding, while hereditary bleeding disorders are seldom. The balance between the physiological pro- and anticoagulant pathway plays asignificant role in the pathophysiology of bleeding and coagulation. Therefore, the pathophysiology of bleeding cannot be described by means of easily available laboratory coagulation workup. The aim of coagulation correction during the management of life-threatening bleeding is not to normalize coagulation, but rather to stop bleeding. Besides acareful clinical evaluation of the course of bleeding coupled with basic understanding of the physiology of coagulation, targeted laboratory coagulation workup can contribute to arational coagulation treatment concept.

Multicenter retrospective study of transcatheter arterial embolisation for life-threatening haemorrhage in patients with uncorrected bleeding diathesis

BackgroundWe retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis.Materials and methodsThis multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count < 50,000/mL) and/or International Normalized Ratio (INR) ≥2.0, and/or activated partial thromboplastin time (aPTT) > 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients’ 30-day survival rate, and procedure-related complications.ResultsIn total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%.ConclusionTAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making.

Stop the Bleed Training: Rescuer Skills, Knowledge, and Attitudes of Hemorrhage Control Techniques

BackgroundBystanders play a significant role in the immediate management of life-threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to evaluate the efficacy of STB training for rescuers from different backgrounds. We hypothesized that STB training would be appropriate to increase skills and knowledge of bleeding control techniques for all providers, regardless of level of medical training. Study designCourse participants anonymously self-reported confidence in six major areas. A five-point Likert scale was used to quantitate participant's self-reported performance. Results were stratified into medical rescuers (MR) and LRs. Students' ability to perform STB skills were objectively assessed using an internally validated 15-point objective assessment tool. Data were pooled and analyzed using Student's t-test and chi-Squared test with P < 0.05 considered significant. Results are presented as average with standard deviation (SD) unless otherwise stated. ResultsA total of 1974 participants were included in the study. Precourse confidence was lowest for both groups in management of active severe bleeding and ability to pack a bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core areas measured (P < 0.001). The most significant increases were reported in the two previous areas of lowest precourse confidence-management of active severe bleeding—LRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001—and ability to pack a bleeding wound—LR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD 0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated combined 99.3% proficiency on postcourse objective assessments. ConclusionsThis study provides quantitative evidence that Stop the Bleed training is effective, with both LRs and MRs demonstrating improved confidence and skill proficiency after a 1-h course. Future program development should focus on building a pool of instructors, continued training of LRs, and determining how often skills should be recertified.

Just the facts: Management of life-threatening bleeding with oral anticoagulant use in the emergency department.

Just the facts: Management of life-threatening bleeding with oral anticoagulant use in the emergency department.

Clinical manifestations and management of life-threatening bleeding in the largest group of patients with severe factor XIII deficiency.

Factor XIII (FXIII) deficiency is a rare hemorrhagic disorder for which the highest incidence occurs in southeast Iran. The aim of this study was to assess molecular characteristics, clinical manifestations and management of life-threatening diathesis in FXIII deficiency. This study was conducted on 190 patients with FXIII deficiency. Genotype analysis for the most frequent mutation of FXIII-A subunit gene in Iranian, Trp187Arg, was performed for all patients. Clinical manifestations and management of patients with intracranial hemorrhage (ICH), miscarriage and neonates with FXIII deficiency were documented. Neonates were divided in two groups: Group 1 received a standard dose of Fibrogammin P(®) (10-26IU/Kg) and group 2 received a high dose of this drug (60-80IU/Kg) for 36months. Bleeding episodes in both groups were recorded, and neonates of group 2 were regularly checked for thrombotic events. Molecular analysis revealed that all patients were homozygous for Trp187Arg mutation. Umbilical bleeding, hematoma and prolonged wound bleeding were common presentations. ICH was another common presentation leading to behavioral and developmental disorders and aphasia. ICH was managed by Fibrogammin P(®) at a dose of 10-26IU/Kg, and miscarriage was managed by Fibrogammin P(®) at a dose of 10IU/Kg every 2weeks during pregnancy, and the same dose administered as prophylaxis before gestation every 4weeks. Neonates of group 2 received 60-80IU/kg dose of Fibrogammin P(®). This higher dose did not trigger thrombotic events but significantly decreased bleeding episodes and prevented the occurrence of major bleeding. Trp187Arg is the most common mutation of FXIII-A subunit in Iran, and Fibrogammin P(®) is effective in the management of FXIII deficiency, and higher dose of this drug is safe and effective in neonates.

New Oral Anticoagulants

The approval of the new target specific oral anticoagulants provides clinicians with alternatives to warfarin. This review focuses on dabigatran, a direct thrombin inhibitor and rivaroxavan, a direct factor Xa inhibitor. These new oral anticoagulants have favourable pharmacological properties that overcome many of the problems associated with warfarin use. Their efficacy and safety have also been shown in large Phase III randomized studies in VTE prevention in major orthopedic surgery, treatment of acute VTE and prevention of stroke and systemic embolism in atrial fibrillation. Although bleeding is an anticipated side effect, this risk can be prevented or minimized by appropriate prescribing. Specifically, the oral new anticoagulants should only be used within licensed indications, clinicians should have basic knowledge of their pharmacological properties, particularly their dependence on renal clearance and restrict eligible patients to those with a similar profile as patients included in the original studies. The management of life-threatening bleeding is presently empirical due to the lack of good quality data and specific reversal antidotes are not currently available. All hospitals should develop clinical practice guidelines and have systems in place to ensure the safe and appropriate use of these new anticoagulants.

Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care

Children in the cardiac intensive care unit (CICU) with congenital or acquired heart disease are at risk for hematologic complications, both hemorrhage and thrombosis. The overall incidence of hematologic complications in the CICU is unknown, but risk factors and target groups have been identified where the essential physiologic balance between bleeding and clotting has been disrupted. Although the best management of life-threatening bleeding and clotting is prevention, the cardiac intensivist is often faced with managing life-threatening hematologic events involving patients from within the unit or those who present from outside. Part I of this review deals with the propensity of children with congenital and acquired heart disease to complications of both bleeding and clotting, and includes discussions of perioperative bleeding, thromboses in single-ventricle patients, clotting of Blalock-Taussig shunts and thrombotic complications of mechanical valves. Part II deals with the subject of stroke in children with heart disease. Part III reviews monitoring the effectiveness of anticoagulation and thrombolysis in the CICU. Currently available diagnostics modalities, medications and management strategies are reviewed and future directions discussed.

Rotational thromboelastometry analysis and management of life-threatening haemorrhage in isolated craniofacial injury

Massive haemorrhage from facial fractures is rare but the associated mortality rate is high. Here, we describe a case in which thromboelastometry [rotational thromboelastometry (ROTEM)]-guided administration of prothrombin complex concentrate and fibrinogen concentrate was effective in correcting coagulopathy in a 68-year-old man with serious craniofacial trauma and massive haemorrhage. The patient, a cyclist who collided with a car, was transferred to the emergency department of our hospital with signs of shock and significant bleeding from multiple fractures and soft tissue injuries to the face. Blood gas analysis and standard laboratory tests revealed the presence of anaemia and acidosis, and our massive haemorrhage protocol was initiated. E-FAST and total-body computed tomography scans excluded the possibility of bleeding from other sites. All efforts were directed towards stopping bleeding from craniofacial lesions, but the surgeon experienced difficulty in maintaining haemostasis. ROTEM analysis revealed severe coagulopathy and was indispensable in guiding transfusion: 2 g tranexamic acid, followed by 1000 IU prothrombin complex concentrate, 5 g fibrinogen and 2 U platelet concentrate. Two hours later, ROTEM analysis showed that coagulopathy had been corrected, and haemostasis was confirmed by cessation of bleeding. This report highlights the potential for using ROTEM to guide treatment with fibrinogen and prothrombin complex concentrates in the presence of profuse multifocal bleeding and severe coagulopathy.

Management of major trauma haemorrhage: treatment priorities and controversies

The severely injured trauma patient often arrives in the emergency department bleeding, coagulopathic and in need of a blood transfusion. The diagnosis and management of these patients has vastly improved with a better understanding of acute traumatic coagulopathy (ATC). In the emergency setting, traditional laboratory coagulation screens are of limited use in the diagnosis and management of life-threatening bleeding. Whole blood assays, such as thrombelastography (TEG) and rotational thrombelastometry (ROTEM) provide a rapid evaluation of clot formation, strength and lysis. Rapid diagnosis of ATC and aggressive haemostatic transfusion strategies utilizing early high doses of plasma are associated with improved outcomes in trauma. At present there is no accurate guide for transfusion in trauma, therefore blood and clotting products are administered on an empiric basis. Targeted transfusion therapy for major trauma haemorrhage based on comprehensive and rapid measures of coagulation e.g. TEG/ROTEM may lead to improved outcomes while optimizing blood utilization. Evidence for the clinical application of TEG and ROTEM in trauma is emerging with a number of studies evaluating their ability to diagnose coagulopathy early and facilitate goal-directed transfusion. This review explores current controversies and best practice in the diagnosis and management of major haemorrhage in trauma.

PP-63. Management of life-threatening hemorrhage in neonatal patients with DIC secondary to sepsis: An alternative approach

PP-63. Management of life-threatening hemorrhage in neonatal patients with DIC secondary to sepsis: An alternative approach

Stent-grafts in the management of life-threatening hemorrhage following inadvertent femoral catheterization in high-risk patients: report of two cases and review of the literature

Bleeding related to inadvertent femoral catheter insertion is an infrequent but morbid complication. We report two cases of acute life-threatening bleeding after attempts at femoral vein catheterization. Both patients were morbidly obese, had multiple comorbidities, and were at high risk for surgical intervention. Aggressive resuscitation failed to stabilize the patients. Emergency digital subtraction angiography diagnosed the site of the femoral artery bleeding. In one patient, the site of injury was the right profunda femoris artery. Both bleeding sites were controlled successfully with endovascular covered stent placement, without complication. Although prior publications have reported the concept of endovascular repair in femoral artery injuries, to the best of the author’s knowledge, covering the profunda femoris artery with no complications has not been described previously. In critically ill patients with life-threatening hemorrhage following inadvertent femoral catheterization, management with endovascular covered stents is safe and effective.

Role of CT angiography and embolisation in the management of life-threatening haemorrhage following microvascular head and neck reconstruction

Post-operative haemorrhage in the head and neck cancer patient can have a catastrophic outcome either for the patient or the free flap if microvascular reconstruction has been performed. The life of the patient always takes priority over the flap; however the pedicle can be at risk when the patient is returned to theatre for arrest of the haemorrhage. CT angiography is a good non-invasive method of determining the source of bleeding and facilitating superselective embolisation, minimizing risk to the flap pedicle. We present a case which this treatment was successfully used with a good result and would recommend its use when similar situations occur.

Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature

There are many reasons for hypotension in trauma patients. Life-threatening hemorrhage associated with maxillofacial trauma is considered rare. Here, we present a 25-year-old patient with maxillofacial trauma complicated by life-threatening hemorrhage after a traffic accident. At the emergency department, massive epistaxis was noted. Nasal packing and blood transfusion were performed, but vital signs of the patient were still unstable. Cerebral angiography revealed contrast extravasation from the left superficial temporal and internal maxillary arteries of the left external carotid artery. After transarterial embolization was performed, the hemorrhage immediately stopped. When common treatment such as nasal packing, correction of coagulopathy, reduction of fractures, and arterial ligation fails to control the hemorrhage, transarterial embolization can offer a safe alterative to surgical exploration.

The management of life-threatening haemorrhage following blunt facial trauma

Life-threatening bleeding is uncommon following blunt facial trauma. There have been few reports in the literature describing its optimal management and a clear approach to treatment is yet to be defined. Reported strategies for control of facial haemorrhage include oro-nasal packing, external carotid artery ligation, transantral ligation of the internal maxillary artery, maxillary reduction and angiographic embolisation. Advances in angiography and selective vessel embolisation have made this the treatment of choice in cases of bleeding following penetrating facial injury. Its use in the management of bleeding following blunt facial trauma is unclear. The combined experience of the facial trauma teams at Harborview Hospital, Seattle, USA and Liverpool Hospital, Sydney, Australia yielded four cases of severe life-threatening haemorrhage following blunt trauma that underwent angiography. The roles of various management strategies were evaluated to generate a preferred management pathway in treating severe bleeding following blunt facial trauma.

Recombinant activated factor VII in the management of life-threatening bleeding in cardiac surgery

Massive perioperative bleeding is a potential complication of cardiac surgery, and may persist despite conventional interventions. RFVIIa is being increasingly used as additional therapy, and the aim of the present study was to describe our experience with rFVIIa in the management of life-threatening bleeding in adult cardiac surgery. Retrospective chart review of 24 patients undergoing a variety of cardiac procedures was performed at Sahlgrenska University Hospital between January and August 2004. The patients developed life-threatening bleeding during or after surgery despite conventional medical therapy and transfusion of blood products, and received rFVIIa as additional therapy. RFVIIa was administered as a median bolus dose of 60 microg/kg. Nineteen patients received one dose of rFVIIa; the bleeding stopped or decreased in 18 of them. Five patients received repeated doses of rFVIIa. Fifteen patients were reexplored due to massive postoperative bleeding or cardiac tamponade and a surgical source of bleeding was identified in six of these patients. A statistically significant reduction in chest drain losses after administration of rFVIIa was demonstrated. No adverse reactions were noted. RFVIIa was successfully used as an additional therapy both during and after cardiac surgery, when bleeding was refractory to conventional methods. Bleeding stopped eventually in all patients and none of the patients exsanguinated.

Endovascular therapy in the emergent management of intractable hemorrhage associated with head and neck neoplasms

To evaluate the feasibility, safety, and efficacy of endovascular interventions in the emergent management of life-threatening hemorrhage associated with head and neck neoplasm. Over the past 5 years, 4 patients were subjected to emergent angiography to identify the sources of intractable bleeding and to endovascular interventions in an attempt to stop bleeding and salvage patient life. Selective bilateral CCA, ICA, and ECA arteriographies were initiated to document the underlying pathology and transcatheter arterial embolization with various embolic agents and stent deployment were carried out for cessation of intractable bleeding. The overall technical success rate is 75% (3/4). Two patients with buccal carcinoma were successfully treated with gelatin sponge pledgets and polyvinyl alcohol particles embolizations. One patient with a bulky ruptured RICA pseudoaneurysm associated with neurofibromatosis was successfully embolized with a 2–4 mm fibered platinum coil. The remaining patient with a wide-neck LCCA pseudoaneurysm resulted from IAIC for left buccal carcinoma was treated with two superimposing Easy Wallstents in the distal LCCA-LICA followed by 10 platinum coils embolizations due to non-availability of stent-graft (Covered stent). Unfortunately, despite sluggish flow leading to the pseudoaneurysm appreciated on fluoroscopy, the fragile pseudoaneurysm ruptured approximately 8 minutes thereafter while waiting for complete thrombosis. With the stents in place at LCCA-LICA, the vascular surgeon was able to ligate the LCCA and LICA to exclude the psendoaneurysm. No complications were encountered in all patients. Endovascular therapy with various embolic agents and stent deployments were feasible, safe, and efficacious in the acute management of intractable hemorrhage associated with head and neck neoplasms.

The management of coumarin-induced over-anticoagulation Annotation.

The management of coumarin-induced over-anticoagulation Annotation.

The role of endoscopic therapy in the treatment of bleeding varices

The role of endoscopy in bleeding varices is both diagnostic and therapeutic. While sclerotherapy of oesophageal varices remains an established modality, ligation has, in view of its higher safety margin, turned out to be superior in recent years. The excellent initial results of ligation are, however, tainted by a higher recurrence rate in the long term. Since the end-point of treatment is the achievement and maintenance of variceal eradication, the addition of low-dose sclerotherapy following initial eradication by ligation seems to be the optimal method to combine the best of both techniques. In the management of life-threatening bleeding from oesophageal varices and gastric varices, cyanoacrylate remains the only promising non-surgical option. Primary endoscopic prophylaxis is still under evaluation. It is only justified in high-risk patients with large varices bearing red colour signs and in the presence of an intolerance of or contra-indication to propranolol. When indicated, ligation seems to be preferable, and the addition of low-dose sclerotherapy after initial variceal eradication may maintain the benefits accrued in such high-risk patients. The present review examines the available evidence regarding the above issues in the recent literature.

Intrathoracic Muscle Flaps in the Surgical Management of Life-Threatening Hemorrhage from the Heart and Great Vessels

Intrathoracic Muscle Flaps in the Surgical Management of Life-Threatening Hemorrhage from the Heart and Great Vessels

Intrathoracic muscle flaps in the surgical management of life-threatening hemorrhage from the heart and great vessels.

Ten patients with real or threatened hemorrhage from either the heart or the great vessels secondary to infection or radiation necrosis (or both) underwent vascular closure techniques followed by reinforcement using an intrathoracic muscle flap. Three patients died during initial hospitalization, two from recurrent bleeding. The other seven patients survived a median of 23.7 months, and none had evidence of infection or bleeding. In patients who have real or impending hemorrhage from the heart or great vessels associated with infection, strong consideration should be given to the intrathoracic transposition of an extrathoracic muscle.