Damage Control for Severe Pelvic Haemorrhage in Trauma
Mansoor Khan, David Nott in Fundamentals of Frontline Surgery, 2021
The pelvis is a ring that rarely breaks in one place alone. Structures in proximity to the fractures can be injured, especially the thin-walled pelvic veins. The pelvic cavity pressure is lower than the venous pressure, creating a large potential retroperitoneal space for haemorrhage and clot to fill. The pelvic organs are readily compressed or displaced upwards into the abdomen, allowing further haemorrhage into the enlarged potential space as it dissects away from the bony pelvis. Exsanguinating pelvic haemorrhage is typically associated with additional arterial bleeding. The pelvic bones and ligaments are sturdy structures and, therefore, require a significant amount of energy to break (e.g., high energy motor vehicle collision [MVC], falls >2 m, pedestrian versus motor vehicle). There are three broad patterns of severe pelvic fracture:Lateral compression (Figure 9.2a)Anterior–posterior (A-P) compression (‘open book’) (Figure 9.2b)Vertical shear (Figure 9.2c)
Genital injuries in children and adolescents
Joseph S. Sanfilippo, Eduardo Lara-Torre, Veronica Gomez-Lobo in Sanfilippo's Textbook of Pediatric and Adolescent GynecologySecond Edition, 2019
Blunt forceful penetrating vaginal injuries can include lateral vaginal wall and posterior fornix lacerations, and a tear may extend along the vagina and enter the peritoneal cavity, avulsing the cervix from its attachment to the vagina. This is called vaginal rupture, or colporrhexis, and while it is rare, examples have been described.6 In such cases, the bowel, omentum, or fallopian tubes may eviscerate through the laceration (Figure 9.6). These patients present with vaginal bleeding and may be at risk of morbidity or death from exsanguination if not properly diagnosed and managed. If it is necessary to inspect the vagina of a trauma victim and a standard speculum is too large for a prepubertal child or young adolescent, vaginoscopy may be done. In this case, it is important to monitor the fluid deficit to avoid filling the abdomen or peritoneal cavity with saline through an unseen laceration extension. Perforations into the rectum or peritoneal cavity mandate an exploratory laparotomy or laparoscopy to determine whether other structures, such as the bowel or blood vessels, have been injured. Rectal injuries above the sphincter may mandate need for a diverting colostomy, and consultation with a pediatric surgeon is warranted.
The Chest
Kenneth D Boffard in Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
In urban trauma centres, cardiac injuries are most common after penetrating trauma, and constitute about 5% of all thoracic injuries. The diagnosis of cardiac injury is usually obvious. The patient presents with exsanguination, cardiac tamponade and, rarely, acute heart failure. In addition to the well described globular heart shape on x-rays, a straight left heart border has been associated with the presence of a haemopericardium. Patients with tamponade owing to penetrating injuries usually have a wound in proximity, decreased cardiac output, increased central venous pressure, decreased blood pressure, decreased heart sounds, narrow pulse pressure, and occasionally paradoxical pulse. Immediate clinician performed eFAST will usually demonstrate the presence of pericardial fluid, but in cases where the diagnosis of pericardial tamponade cannot be confirmed on clinical signs and on eFAST, formal echocardiogram is useful.
Comparison of Three Junctional Tourniquets Using a Randomized Trial Design
Published in Prehospital Emergency Care, 2019
Micah J. Gaspary, Gregory J. Zarow, Michael J. Barry, Alexandra C. Walchak, Sean P. Conley, Paul J.D. Roszko
Exsanguination remains a leading cause of potentially preventable death in both civilian (1) and military trauma care (2). Many cases involve traumatic junctional wounds of the proximal leg that are not amenable to treatment with traditional tourniquet techniques (1, 3), and junctional hemorrhage control has been noted as an important area for research in both military and civilian settings (4, 5). Junctional tourniquets (JTQs) are designed to control hemorrhage by applying direct pressure over the femoral artery just distal to the inguinal ligament at the junction of the lower limb and torso. At the time of our study design, 3 JTQs had been cleared by the FDA for junctional hemorrhage control: The Combat Ready Clamp (CRoC®), the Junctional Emergency Treatment Tool (JETT™), and the SAM® Junctional Tourniquet (SJT).
Massive transfusion in upper gastrointestinal bleeding: a new scoring system
Published in Annals of Medicine, 2019
Yi-Chuan Chen, Chen-Ju Chuang, Kuang-Yu Hsiao, Leng-Chieh Lin, Ming-Szu Hung, Huan-Wen Chen, Shung-Chieh Lee
In current literature, there is no available validated predictive scoring system to assess the need for MT and guide the determination of MT protocol activation in patients with non-trauma bleeding. Gastrointestinal bleeding is one of the major bleeding contexts requiring massive transfusion, ranging from 17.3% to 25% [32,33]. In UGIB, transfusions are definitely indicated in massive, exsanguinating haemorrhage and can be lifesaving; however, the most effective transfusion strategy is controversial because the majority of UGIB cases are minor bleeding without haemodynamic instability [34,35]. One recent (2013) randomized trial demonstrated that a restrictive transfusion strategy at lower transfusion thresholds had better outcomes in patients with UGIB [25]. However, patients with massive exsanguinating bleeding were excluded in this study, thus an optimal transfusion strategy in UGIB patients with massive haemorrhage remains unclear.
Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma
Published in Expert Review of Anticancer Therapy, 2018
Javier González, Jeffrey J. Gaynor, Mahmoud Alameddine, Manuel Esteban, Gaetano Ciancio
Intraoperative estimated blood loss (IEBL) varies widely among series with mean values ranging from 350 to 4300 cc [65,66], while exsanguination following uncontrollable hemorrhage has been reported in up to 7.5% of RCC and TT cases [64]. The potential for important hemorrhage during or after RN and TT depends on the particular features of the operating field, which in turn is dictated by the amount of intravascular tumor burden (i.e. level and degree of venous occlusion), extent and distribution of the collateral venous network generated in response to IVC obstruction, and characteristics of local spreading of the disease (i.e. quantity and quality of neighboring structures invasion) [67].