Temporary Control Of Bleeding Research Articles

Feasibility of a Portable Abdominal Insufflation Device for Controlling Intraperitoneal Bleeding After Abdominal Blunt Trauma.

Uncontrolled bleeding contributes to 30% to 40% of trauma-related deaths and is the leading cause of potentially preventable deaths. Currently, there is no effective method available to first responders for temporary control of noncompressible intraabdominal bleeding while patients are transported to the hospital. Our previous studies demonstrated that abdominal insufflation provides effective temporary bleeding control. The study aims to prove the feasibility (insufflation to a target pressure) and safety (cardiovascular and respiratory effects) of a novel portable abdominal insufflation device (PAID) designed to control the intraperitoneal bleeding caused by abdominal trauma. The PAID prototype is based on a patented design and manufactured via additive manufacturing. PAID contains a 16-g CO2 cartridge and an electronic pressure transducer. PAID was tested on a bench top and a swine animal model. For the animal model study, the intraperitoneal pressure as well as cardiorespiratory parameters (hearth rate, SpO2 [peripheral capillary oxygen saturation], and blood pressure) were continuously monitored during the insufflation procedure. The prototype functioned according to specifications on both bench top and animal models. CO2 insufflation of the peritoneal cavity was delivered up the target 20 mm Hg and maintained for 30 minutes from 1 or 2 cartridges in the swine model. No intraoperative incidents were registered, and all the recorded physiological parameters were within normal limits. The PAID prototype is a feasible, easy to use device that provides quick, controlled, and safe insufflation of the peritoneal cavity. Future studies will focus on testing the next-generation, semiautomatic PAID prototype in a severe intraabdominal injury model.

Severe Venous Injury in Acute Trauma Setup – Is There a Role for Endovascular Treatment?

Background: The role of endovascular treatment of acute traumatic venous injuries (ATVI) remains controversial. Endovascular resuscitation and hybrid trauma management (EVTM) concepts, which constitute the combination of conventional and endovascular capabilities in the treatment of vascular injuries continue to evolve, yet published reports of traumatic venous injuries treated by endovascular means remain confined to sporadic case reports.Methods: The medical literature from 1990 to 2017 using Pubmed and OVID Medline databases was reviewed to search for reports on the endovascular treatment of ATVI. No publications were excluded due to the small number of publications available. Sixteen reports were found. The manuscripts were analyzed regarding the mechanism, location, and type of injury; endovascular techniques utilized; and both clinical and radiographic outcomes.Results: Endovascular treatment was reported in only 16 patients with ATVI during the study period. Most cases (10/16; 62.5%) were secondary to blunt trauma, while the rest (6/16; 37.5%) were secondary to penetrating injuries equally divided between gunshot wounds and stab wounds. Endovascular stent or stent graft utilization was employed in 12 of these cases, 2 cases were treated by endovascular embolization and in 2 cases endovascular balloons were used for temporary hemorrhage control to facilitate open surgical exposure and intervention. No mortalities related to the endovascular interventions were reported.Conclusion: The experience with endovascular treatment of ATVI remains very limited. The results currently available, although very limited in numbers, appear promising. Additional study will prove essential in defining the optimal employment of EVTM concepts in the management of venous injuries, particularly as technology continues to advance and experience with these modalities increases.

Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

514 - Laparoscopic Vascular Injury Repair-How Can We Avoid Conversion to Emergency Laparotomy?

Since 1998 we have experienced 1100 laparoscopic or robotic retroperitoneal lymphadenectomies including para-aortic and pelvic dissection. 28 of these cases required vessel repair for inadvertent injury. We will present techniques for safe and sequel-free vascular injury repair. Case 1- Right external iliac artery was injured during robotic pelvic lymphadenectomy. Case 2- Left external iliac artery was injured during laparoscopic pelvic lymphadenectomy. Case 3- Avulsion injury to the left external iliac vein. Case 4- Avulsion injury to the left renal vein during a left-sided para-aortic dissection. Case 5- IVC was injured during right-sided para-aortic lymphadenectomy. All these cases required temporary bleeding control with vascular clamps, atrumatic forceps, vascular tape and/ or pressure application with sponge. All cases were administered with high molecular heparin and holes closed with 4.0–6.0 proline suture. No blood transfusions or emergency conversions to laparotomy were required. Laparoscopic suturing techniques are vital to the safety of retroperitoneal lymphadenectomy.

Basic Management of Pelvic Fractures

The management and treatment of complex pelvic fractures require knowledge of the initial evaluation of a trauma patient, pertinent anatomy, and techniques available for hemorrhage control. Trauma patients with complex pelvic fractures are at high risk for hemorrhage and require thoughtful and expeditious management. A multidisciplinary team including a trauma surgeon, an orthopedic surgeon, and an interventional radiologist is required for optimal treatment of these complex injuries. The team must be managed by the trauma surgeon to guide ongoing resuscitation as the patient may travel throughout the hospital to undergo several interventions to control hemorrhage. A number of techniques can be emergently implemented for fracture stabilization and hemorrhage control, including temporary application of a pelvic binder, preperitoneal pelvic packing, external fixation, and angioembolization. The patient’s clinical status, fracture pattern, and bleeding source must be considered when deciding which hemorrhage control techniques should be performed. New temporary hemorrhage control interventions, such as resuscitative endovascular balloon occlusion of the aorta, have shown early success in control of pelvic fracture–related hemorrhage and require further investigation. Pelvic fractures are associated with a number of neurovascular and genitourinary injuries, which can carry long-term morbidity. This review discusses the diagnosis, management, and treatment of complex pelvic fracture and associated hemorrhage. This review contains 5 figures, and 55 references. Key words: angioembolization, pelvic fixation, pelvic fracture, preperitoneal packing, resuscitative endovascular balloon occlusion of the aorta

Ultrasound-Guided Resuscitative Endovascular Balloon Occlusion of the Aorta in the Resuscitation Area

BackgroundIn trauma resuscitation with resuscitative endovascular balloon occlusion of the aorta (REBOA), urgent and accurate placement of the catheter in the resuscitation area without fluoroscopy can shorten the time from admission to REBOA, allowing rapid, temporary control of bleeding. DiscussionThe experience-based protocol in our center for ultrasound-guided REBOA in the resuscitation area without fluoroscopy is as follows: the femoral artery is punctured and a guidewire inserted; sonography is used to verify that the guidewire is in the abdominal aorta; the position of the balloon is confirmed with ultrasound after estimating the distance to the clavicle, and the pressure in the radial artery and sheath is used to monitor correct positioning; connect the pressure transducer to the catheter sheath for continuous monitoring of the blood pressure in the sheath, and inflate the balloon until the blood pressure tracing at the sheath has disappeared; check the pulse in the left radial artery, and withdraw the catheter slightly if the pulse in the radial artery is not palpable or is decreased (if this pulse is not palpable or decreased, the balloon is in the aortic arch). In this retrospective review of our REBOA protocol, between April 2012 and March 2016, 34 patients were enrolled. Two patients had complications, including dissection of the femoral artery in one and difficult percutaneous vascular access in another. Median time needed to complete the procedure was 8 min. Overall, 24 of 34 patients survived more than 24 h (72%), and overall mortality was 47%. Patients who lived more than 24 h, and then died had severe traumatic brain injury or septic shock. ConclusionsUltrasound-guided REBOA is presented. Monitoring the blood pressure in the left radial artery allows us to determine adequate positioning of the balloon, and the blood pressure in the catheter sheath located in the femoral artery should also be monitored to prevent aortic injuries caused by the overinflation of the balloon.

Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis

BackgroundNoncompressible truncal hemorrhage is a leading cause of potentially preventable death in trauma and acute care surgery patients. These patients are at high risk of exsanguination before potentially life-saving surgical intervention may be performed. Temporary aortic occlusion is an effective means of augmenting systolic blood pressure and perfusion of the heart and brain in these patients. Aortic occlusion temporarily controls distal bleeding until permanent hemostasis can be achieved. The traditional method for temporary aortic occlusion is via resuscitative thoracotomy with cross clamping of the descending aorta. While effective, resuscitative thoracotomy is highly invasive and may worsen blood loss, hypothermia, and coagulopathy by opening an otherwise uninjured body cavity. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary aortic occlusion using an occlusive balloon catheter that is introduced into the aorta via endovascular access of the common femoral artery. For this reason it is thought that REBOA could provide a less-invasive method for temporary aortic occlusion. Our purpose is to describe our experience with the implementation of REBOA at our Level 1 trauma center. MethodsA retrospective case series describing all cases of REBOA performed at a prominent level 1 trauma center between October 2011 and September 2015. The study inclusion criteria were any patient that received a REBOA procedure in the acute phases after injury. There were no exclusion criteria. Data were collected from electronic medical records and the hospital's trauma registry. ResultsA total of 31 patients underwent REBOA during the study period. The median age of REBOA patients was 47 (interquartile range [IQR] = 27 to 63) and 77% were male. A majority (87%) of patients sustained blunt trauma. The median injury severity score was 34 (IQR = 22 to 42). The overall survival rate was 32% but varied greatly between subgroups. Balloon inflation resulted in a median increase in systolic blood pressure of 55-mm Hg (IQR 33 to 60), in cases where the data were available (n = 20). A return to spontaneous circulation was noted in 60% of patients who had arrested before REBOA (n = 10). Overall, early death by hemorrhage was 28% with only 2 deaths in the emergency department before reaching the operating room. ConclusionsREBOA is an effective method for achieving temporary aortic occlusion in trauma patients with noncompressible truncal hemorrhage. Balloon inflation correlated with increased blood pressure and temporary hemorrhage control in a vast majority of patients.

New device for temporary hemorrhage control in penetrating injuries to the ventricles.

BackgroundThe best way to control hemorrhage from cardiac injuries is through digital occlusion followed by suture. However, this is difficult to accomplish in the emergency department (ED) setting. Generally, temporary control is obtained in advance of definitive treatment in the operating room. Despite safety and efficacy concerns, balloon Foley catheter insertion through the injury is still an option following ED thoracotomies. We developed a new device for temporary hemorrhage control in cardiac injuries and compared it to the Foley.Methods6 adult swine (n=6) underwent full-thickness (1.5 cm) injury along the longitudinal axis of the right ventricle (RV). After 5 s of bleeding, hemorrhage control was attempted with either the device or the Foley, and blood loss quantified. Subsequently, the wound was sutured and mean arterial pressure was restored to baseline with lactated Ringer's infusion. Subsequently, another injury 2 cm apart in the same ventricle was managed with apparatus not employed in the first injury. The same followed in the LV totaling 4 injuries per animal, 2 in each ventricle. Intraoperative echocardiogram, laboratory test and final wound sizes assessed.ResultsThe device resulted in less bleeding than the Foley; RV 58.7±11.3 vs 147.7±30.9 mL, LV 81.7±11.9 vs 187.5±40.3 mL (p<0.05). Percent change in tricuspid regurgitation was less with the device than FO, 66.6% vs 400%. Mitral regurgitation increased 16% with Foley, but remained unchanged with the device. Changes in stroke volume and LV ejection fraction were less with the device than with Foley; SV 2.09% vs 12.48%, left ventricular ejection fraction 0.46% vs 5.45%. Foley insertion enlarged the wounds. Platelet count, complete blood count, prothrombin time, activated prothrombin time and fibrinogen decreased, whereas troponin and lactate increased compared with baseline, underscoring the magnitude of shock.ConclusionsCardiac hemorrhage was effectively controlled with the new device. The low-profile collapsible blocking membrane interfered less with cardiac function than did the balloon of the Foley, an important asset in the context of shock.

Analysis of surgical treatment of tibial fractures fractures during the antiterrorist operation

Objective: To analyze the surgical procedures performed at all levels of medical care in the wounded with gunshot fractures of the tibia and severed limbs during the anti-terrorist operation (ATO). Methods:it is analyzed medical care in 118 wounded (May 2014–April 2015) with tibial gunshot fractures in 111 (94.07 %) and severed limbs — 7 (5.93 %).Results: in the wounded with tibial gunshot fractures and severed limbs temporary bleeding control, aseptic bandage application, pain management transport immobilization with improvised means provided at the primary and I medical care levels with following evacuation to the II level of the medical care. Beginning from the II level, all wounded underwent primary surgical treatment (PST). Osteosynthesis with external fixation device (EFD) performed in 76.27 % patients, revision surgical treatment (ST) — in 72.03 %, fasciotomy — in 23.73 %, free autodermoplasty — in 15.25 %, Ilizarov device osteosynthesis — in 15.25 %, amputation — in 10.17 %, nailing — in 8.47 %, plating — in 5.93 %, autogenous prosthesisng — in 5.08 %, VAC therapy — in 4.24 %, revision surgical treatment — 3.38 %. At the II level of medical care PST, final bleeding control, fasciotomy and stable fixation with external fixation device performed mainly. At the III and IV levels revision ST with VAC-therapy and ultrasound cavitation executed. After the soft tissue healing with the inflammation signs absence in 14.40 % patients external fixation device changed to the plate or nail. After 6–12 month good functional results obtained in 54.31 % of patients, satisfactory — in 30,17 %, unsatisfactory — in 15.52 %. Organizational, treatment and diagnostic mistakes were analyzed.

Management of Intra-Abdominal Hemorrhagic Shock Using REBOA

Hemorrhage is the leading cause of potentially preventable death after a traumatic injury. 1 Scott DJ Eliason JL Villamaria C et al. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma Acute Care Surg. 2013; 75: 122-128 Crossref PubMed Scopus (104) Google Scholar , 2 Brenner ML Moore LJ DuBose JJ et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013; 75: 506-511 Crossref PubMed Google Scholar , 3 Norii T Crandall C Terasaka Y Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015; 78: 721-728 Crossref PubMed Scopus (141) Google Scholar Noncompressible torso hemorrhage (NCTH), which is a disruption of the vascular activity of the axial torso vessels, pulmonary parenchyma, solid organs, or the bony pelvis, accompanied by shock, 4 Morrison JJ Stannard A Rasmussen TE et al. Injury pattern and mortality of noncompressible torso hemorrhage in UK combat casualties. J Trauma Acute Care Surg. 2013; 75: S263-S268 Crossref PubMed Scopus (79) Google Scholar has an associated mortality of approximately 45%. 5 Kisat M Morrison JJ Hashmi ZG et al. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013; 184: 414-421 Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar A significant number of these deaths often occur because of the delay in definitive hemorrhage control in an operative theater or interventional radiology suite. Therefore, a need for adjunct hemorrhage control is paramount to attaining temporary control of bleeding until definitive hemostasis can be achieved. 3 Norii T Crandall C Terasaka Y Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015; 78: 721-728 Crossref PubMed Scopus (141) Google Scholar , 4 Morrison JJ Stannard A Rasmussen TE et al. Injury pattern and mortality of noncompressible torso hemorrhage in UK combat casualties. J Trauma Acute Care Surg. 2013; 75: S263-S268 Crossref PubMed Scopus (79) Google Scholar , 5 Kisat M Morrison JJ Hashmi ZG et al. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013; 184: 414-421 Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar A key to improving outcomes in patients with NCTH is a “bundle” of measures that can facilitate early diagnosis, rapid control of hemorrhage, systemic and topical hemostatic support, and a short time at the scene. In the past decade a paradigm shift has occurred in treatment strategies and transfusion algorithms, with emphasis on hemostatic or damage control resuscitation. 2 Brenner ML Moore LJ DuBose JJ et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013; 75: 506-511 Crossref PubMed Google Scholar , 6 Stannard A Eliason JL Rasmussen TE Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011; 71: 1869-1872 Crossref PubMed Scopus (355) Google Scholar Jennifer Adamski is Assistant Professor, Clinical Track, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.

A small case series of aortic balloon occlusion in trauma: lessons learned from its use in ruptured abdominal aortic aneurysms and a brief review.

EndoVascular and Hybrid Trauma Management (EVTM) is an emerging concept for the early treatment of trauma patients using aortic balloon occlusion (ABO), embolization agents and stent grafts to stop ongoing traumatic bleeding. These techniques have previously been implemented successfully in the treatment of ruptured aortic aneurysm. We describe our very recent experience of EVTM using ABO in bleeding patients and lessons learned over the last 20years from the endovascular treatment of ruptured abdominal aortic aneurysms (rAAA). We also briefly describe current knowledge of ABO usage in trauma. A small series of educational cases in our hospital is described, where endovascular techniques were used to gain temporary hemorrhage control. The methods used for rAAA and their applicability to EVTM with a multidisciplinary approach are presented. Establishing femoral arterial access immediately on arrival at the emergency room and use of an angiography table in the surgical suite may facilitate EVTM at an early stage. ABO may be an effective method for the temporary stabilization of severely hemodynamically unstable patients with hemorrhagic shock, and may be useful as a bridge to definitive treatment of the bleeding patients. EVTM, including the usage of ABO, can be initiated on patient arrival and is feasible. Further data need to be collected to investigate proper indications for ABO, best clinical usage, results and potential complications. Accordingly, the ABOTrauma Registry has recently been set up. Existing experiences of EVTM and lessons from the endovascular treatment of rAAA may be useful in trauma management.

Efficacy of a prehospital self-expanding polyurethane foam for noncompressible hemorrhage under extreme operational conditions.

Noncompressible abdominal hemorrhage is a significant cause of battlefield and civilian mortality. We developed a self-expanding polyurethane foam intended to provide temporary hemorrhage control and enable evacuation to a definitive surgical capability, for casualties who would otherwise die. We hypothesized that foam treatment would be efficacious over a wide range of out-of-hospital operational conditions. The foam was tested in an established lethal, closed-cavity hepatoportal injury model in four groups as follows. Group 1 involved baseline conditions, wherein foam was deployed from a pneumatically driven, first-generation delivery device at room temperature (n = 6). Group 2 involved foam deployment from a field-relevant, handheld delivery prototype (n = 12). Group 3 involved foam components that were conditioned to simulate 1-year shelf-life (n = 6). Group 4 involved foam that was conditioned to a range of temperatures (10 °C and 50 °C; n = 6 per group). In all studies, survival was monitored for up to 180 minutes and compared with an ongoing and accumulating control group with no intervention (n = 14). In Group 1 with a first-generation delivery system, foam treatment resulted in a significant survival advantage relative to the control group (p < 0.001), confirming previous results. In Group 2 with a handheld delivery system, survival was also improved, 83% at 3 hours, compared with 7% in the control group (p < 0.001). In Group 3, survival was 83% at 3 hours (p = 0.002). In Group 4 at temperature extremes, 3-hour survival was 83% (p = 0.002) and 67% (p = 0.014) in the low- and high-temperature groups, respectively. Temperature extremes did not result in hypothermia, hyperthermia, or thermal injury. In all studies, the bleeding rate in foam groups was significantly lower than in the control group (p < 0.05). Under a range of military operational conditions, foam treatment resulted in a survival advantage relative to the control group. This supports the feasibility of foam treatment as a prehospital hemostatic bridge to surgery for severely bleeding causalities.

Remote Telementored Ultrasound-Directed Compression to Potentially Accelerate Hemostasis in Exsanguinating Junctional Vascular Injuries.

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; http://innovativetraumacare.com). This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.

A Unique Case of Noncirrhotic Portal Hypertension Secondary to Extrahepatic Sarcoidosis

Introduction: Sarcoidosis is a multisystem disease of unknown etiology characterized by the presence of non-caseating granulomas. Portal hypertension is a rare manifestation of sarcoidosis, first reported in 1949. Here we report the first case of extrahepatic sarcoidosis with granulomatous lymph node involvement at the porta hepatis, compression of portal vein leading to portal hypertension and recurrent episodes of gastrointestinal bleeding due to jejunal varices. A 57-year-old black female presented with pruritus, jaundice, elevated liver enzymes, and thrombocytopenia. Diagnosed with ophthalmic and pulmonary sarcoidosis in 1998, a mass at the porta hepatis causing intrahepatic dilation was now seen on CT abdomen. ERCP revealed a stricture at the proximal hepatic duct below the bifurcation, relieved by placing a biliary stent. Diagnostic exploratory laparotomy showed unresectable massive lymphadenopathy, extending from porta hepatis to the inferior aspect of liver, encroaching the vessels and bile ducts. Intrahepatic right bile duct choledoco-Roux-en-Y-jejunostomy was completed. Biopsy showed marked fibrosis and noncaseating granulomas of lymph nodes. Liver biopsy was free of sarcoidosis. Repeat episodes of pruritis and jaundice were treated with high-dose steroids and mycophenolate mofetil. Patient was readmitted with melena and severe anemia. Imaging showed slight decrease in size of the mass but effacement of extrahepatic portal vein, non-visualization of the left portal vein, and severe narrowing of right portal vein. Double balloon enteroscopy revealed large, bleeding perianastomotic jejunal varices. Endoscopic therapy failed and varices were surgically oversawn. Mycophenalate mofetil was restarted along with steroids. A year later recurrent episodes of severe bleeding developed. High-dose pulse steroid therapy was initiated and mycophenalte was increased. Mesocaval shunting was completed with temporary control of bleeding before occlusion. Patient was kept on high-dose steroids, mycophenalate, octreotide and nadolol. Later, CT abdomen revealed reduction in size of mass with partial visualization of the right branch of the portal vein. TIPS was completed via cannulation of the right portal vein, leading to resolution of portal hypertension and further episodes of GI bleed. Extrahepatic portal hypertension in the setting of porta hepatis sarcoidosis can be life threatening and very challenging to treat. Here we described how a combination immunosuppressant and radiologically placed shunt can be used successfully to treat recurrent episodes of GI bleed in such a patient.

Management of pseudoaneurysms of the internal carotid artery in postirradiated nasopharyngeal carcinoma patients

Massive epistaxis due to ruptured pseudoaneurysm of the internal carotid artery (ICA) is an often fatal complication of radiation treatment for patients with nasopharyngeal carcinoma. We review the clinical characteristics and predictors of survival in patients suffering from this serious complication after radiotherapy. Retrospective case series. Clinical records and radiological investigations of postirradiated NPC patients with ICA pseudoaneurysm diagnosed with digital subtraction angiography in Queen Mary Hospital from January 2003 to December 2012 were reviewed. Risk factors analyzed for survival included gender, size of initial tumor, history of second course of radiotherapy, history of previous maxillary swing nasopharyngectomy, presence of persistent disease, successful initial hemostasis, successful airway control, and endovascular treatment. Twenty-six were included in the analysis. Twenty-three patients underwent endovascular treatment, and 20 (87%) had successful control of the bleeding. Eighteen (69%) patients survived. Univariate analysis showed that successful temporary control of bleeding and airway control were associated with survival. Prompt bleeding control and airway management is necessary to improve survival. Endovascular treatment is a good definitive treatment option with a high success rate.

Use and complications of operative control of arterial inflow in combat casualties with traumatic lower-extremity amputations caused by improvised explosive devices

Proximal traumatic lower-extremity amputation has become the signature injury of the war in Afghanistan. Casualties present in extremis and often require immediate operative control of arterial inflow to prevent exsanguination. This study evaluated the use of this strategy and its complications. This is a retrospective analysis of case notes of UK service personnel, identified from the UK Joint Theatre Trauma Registry, who sustained traumatic lower-extremity amputation requiring suprainguinal vascular control, following improvised explosive device injury in Afghanistan, between July 2008 and December 2010. Fifty-one casualties were identified with a median Injury Severity Score (ISS) of 30. In 10 casualties, control was obtained via an extraperitoneal approach, and in 41, control was obtained via midline laparotomy and intraperitoneal (IP) approach. The most commonly controlled vessel in extraperitoneal control was the external iliac artery, and in IP control, the common iliac artery. Within the 41 patients who had IP control, 13 also required a therapeutic laparotomy, and 9 patients had bilateral injuries at the level of the proximal femur or higher. One patient, who had undergone IP control, experienced an injury to the common iliac vein, which was repaired. There were no other immediate complications recorded, and 39 casualties survived to discharge. This is the first study to characterize the methods of proximal control in high wartime lower-extremity amputees. Although some casualties will have abdominal injuries that necessitate laparotomy, the majority in our study did not; however, in the critically ill casualty, rapid proximal control is required. Novel methods of temporary hemorrhage control may reduce the need for, and burden of, cavity surgery. Epidemiologic study, level III; prognostic study, level IV.

Self-Expandable Metal Stents in the Treatment of Acute Esophageal Variceal Bleeding

Acute variceal bleeding (AVB) is a life-threatening complication in patients with cirrhosis. Hemostatic therapy of AVB includes early administration of vasoactive drugs that should be combined with endoscopic therapy, preferably banding ligation. However, failure to control bleeding or early rebleed within 5 days still occurs in 15–20% of patients with AVB. In these cases, a second endoscopic therapy may be attempted (mild bleeding in a hemodynamically stable patient) or we can use a balloon tamponade as a bridge to definitive derivative treatment (i.e., a transjugular intrahepatic portosystemic shunt). Esophageal balloon tamponade provides initial control in up to 80% of AVB, but it carries a high risk of major complications, especially in cases of long duration of tamponade (>24 h) and when tubes are inserted by inexperienced staff. Preliminary reports suggest that self-expandable covered esophageal metallic stents effectively control refractory AVB (i.e., ongoing bleeding despite pharmacological and endoscopic therapy or massive bleeding precluding endoscopic therapy) with a low incidence of complications. Thus, covered self-expanding metal stents may represent an alternative to the Sengstaken-Blakemore balloon for the temporary control of bleeding in treatment failures. Further studies are required to determine the role of this new device in AVB.

Laparoscopic Vascular Injury Repair II during Pelvic Lymphadenectomy

Study Objective: Vascular injury is one of the most serious possible complications which can occur during pelvic lymphadenectomy. Two cases (one left external iliac artery and one right common iliac vein) which were repaired laparoscopically are presented. Materials and Methods: Temporary bleeding control is of paramount importance for accurate complication free repair. Tools and techniques for bleeding control as well as intracorporeal suturing skills will be shown. Results: Conversion to laparotomy was avoided.

Emergency management of iatrogenic injury of portal vein and superior mesenteric vein

Objective To explore the emergency management and prevention of iatrogenic injury of in-ferior vena cava. Methods A retrospective study was undertaken to investigate the operative procedure and post-operative outcome of 7 patients suffering from iatrogenic injury of inferior vena cava in the course of three nephrectomy, one fight adrenal gland tumor resection, one fight surgical kidney, one right upper retro-peritoneal tumor and one pancreaticoduodenectomy. The gross hemorrhage was controlled by local pressure. Then, abdominal incision was done. Firm pressure on the inferior vena cava was performed to right side for temporary control of hemorrhage. The bleeding part could be found when the hematocele was cleaned. And continuous suture should be done with 3-0 silk or absorbable suture after the crevasse was clamped. Results In these 7 cases, 1 died of hemorrhagic shock and the other 6 had significant effect postoperatively. The asso-ciated injuries were healed well except 1 case of slight edema of lower extremity. Conclusion Iatrogenic inju-ry of inferior vena cava can be treated successfully with correct procedure. Furthermore, the injury could be avoided with exactitude intraoperative procedure. Key words: Wounds and injuries; Injury of inferior vena cava; Iatrogenic; Operation; Management

Técnicas quirúrgicas complejas para el control de la hemorragia

Massive bleeding is a major cause of intraoperative death or death in the immediate postoperative period as a result of surgery. The present article describes the basic principles for the control of surgical bleeding as well as temporary and definitive maneuvers. Temporary control of bleeding can often be achieved with simple maneuvers, which may not be definitive, in which case damage control or planned reoperation are required. The surgeon's aim should always be to control the bleeding. If simple maneuvers fail, more complex procedures are required. The present article also describes these maneuvers to control bleeding (Pringle's maneuver, total vascular exclusion, atrial caval shunt, Mattox's maneuver, Cattel Braasch maneuver, Kocher's maneuver and aortic control maneuvers).