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Hemorrhage

Medical Science Publication No. 4, Volume 1

WEDNESDAY MORNING SESSION
21 April 1954

MODERATOR
MAJOR WILLIAM H. MERONEY, MC


HEMORRHAGE*

LIEUTENANT COLONEL CARL W. HUGHES, MC

It would be presumptuous of me to discuss with this group the classification of hemorrhage and methods of control, but in order to present a number of the observations made in Korea, some of the basic teachings relative to hemorrhage will be mentioned. The conclusions reached here are drawn from observations made at the surgical hospital level.

Hemorrhage by definition is loss of blood from a blood vessel and, as such, is a major contributing factor to shock. Hemorrhage may be classified as primary or secondary and may occur from a lacerated or severed vessel. It may be external or internal, arterial or venous, or both.

Primary

The majority of hemorrhagic problems reaching the surgical hospital were in those patients with wounds of major vessels of one or more of the extremities and wounds of lesser vessels of the abdominal and thoracic viscera. Often, extremity wounds were multiple and complicated by abdominal or thoracic hemorrhage. Most of those patients with wounds of the great vessels of the thoracic and abdominal cavities bled to death before reaching the hospital.

External. Although wounds of major vessels of the extremities were usually accessible to control by tourniquet, observations made from a group of 75 patients with 79 injuries to major vessels of the extremity showed that 47 percent of this group were admitted with a tourniquet in place and 40 percent were in shock. This percentage of patients in shock is indicative of the seriousness of hemorrhage from a major vessel even when in a location where it can be controlled.

Since the severed artery tends to contract, retract and form a clot, it was interesting to speculate whether or not shock might be less prevalent in the patient with a completely severed artery than in the patient with a lacerated or partially severed artery, which is held apart and continues to hemorrhage. Observation of 202 patients with extremity wounds involving major vessels showed that 113, or 56


*Presented 21 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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percent, had a lacerated artery and 89, or 44 percent, had a severed artery. Using data from only a limited number (32) of this group arriving in shock, an attempt was made to correlate the occurrence of shock with a specific type of arterial injury. Of those studied in shock, it was found that 53 percent had laceration of the artery and 47 percent had a severed artery, showing that shock occurred in the patient with a severed major artery about as readily is in the patient with a lacerated major artery. Although several of these patients had multiple injuries, the gross hemorrhage was from the major vessel involved.

While in general, primary, gross hemorrhage was the immediate problem, continued ooze also proved to be a problem in many instances. Artz, Sako and Howard at the 46th Surgical Hospital (1) reported 20 deaths among 138 severely injured patients requiring 5 or more pints of blood each. Of these 20 deaths, 7 died of uncontrolled hemorrhage, 4 from uncontrolled postoperative oozing, and 3 from uncontrolled major vessel hemorrhage.

We have also observed patients continue to ooze and die postoperatively from massive muscle wounds, liver wounds and pelvic wounds. Such continued oozing was particularly evident following multiple transfusions. Dextran was administered alone to some patients and to others in ratios of 1:1 of blood and 1:2 of blood until some received a total of 2,500 to 3,000 cc. of dextran. No increased bleeding was attributed to use of the dextran, although such has been reported since the war.

Internal. While most primary hemorrhage is external and is obvious or visible hemorrhage, internal hemorrhage is often the more serious problem especially if in the abdomen or chest. Although we usually think of internal hemorrhage as abdominal or thoracic, it often occurs in the presence of comminuted fractures, especially fractures of the femur. Following such hemorrhage, a patient may show signs of severe shock without evidence of external bleeding. Another hidden form of internal hemorrhage is the pulsating hematoma. Following injury to an artery, the blood may be retained between fascial and muscle planes or in the soft tissue forming a pulsating hematoma. The center of the hematoma communicates with the hole in the artery and contains liquid blood while the peripheral portion of the hematoma tends to laminate and clot, forming a false sac, the beginning of a false aneurysm. If both artery and vein are injured and the clot is contained in a similar manner, then an arteriovenous fistula is likely to develop.

Blood flow distal to such pulsating hematomas will vary depending on the severity of the injury to the artery, the number of collaterals destroyed, the size of the hematoma, the pressure exerted by the hema-


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toma, and the peripheral resistance. When the extremity distal to the site of vascular damage has ample blood supply and the hematoma is self-contained and uninfected, it may be expedient to allow the pulsating hematoma to develop an arteriovenous fistula or false aneurysm which may be operated on at a later date. This is particularly true of carotid and high subclavian artery injuries. Surgery for a pulsating hematoma in either of these locations may result in profuse hemorrhage before control can be obtained. Clamping of the damaged carotid artery for only the length of time required to repair it may lead to a fatality at this time.

Secondary

While the pulsating hematoma of arterial origin is more likely to expand and cause pressure on adjacent structures, both the arterial and the arteriovenous types of pulsating hematomas may bleed secondarily, especially in the presence of infection.

Secondary hemorrhage is usually arterial and may occur from a slipped ligature, from the faulty suture line of a repaired vessel, from slough of an injured vessel, or an overlooked vessel injury that has previously thrombosed. Infection predisposes to secondary hemorrhage. Such hemorrhage may occur from a severed or lacerated vessel as infection liquefies the clot. This is particularly true in the presence of pulsating hematomas. Russell (2) reported 59 cases of secondary hemorrhage developing at Tokyo Army Hospital in patients evacuated from Korea. He found that most secondary hemorrhage from war wounds occurred between the eighth and eighteenth days after wounding but varied from 5 to 44 days.

Control

A study of 79 major vascular injuries in extremities showed that 47 percent were admitted with a tourniquet in place which had been applied from 40 minutes to 141/2 hours previously, the average time being 4 hours. Tourniquets were found applied, covered by dressings and forgotten. Sometimes the presence of a tourniquet or the time of application was not noted on the field medical tag. Some tourniquets had cut deeply into the soft tissues. Others were applied at levels which required amputation of an extremity higher than was necessary for the injury alone.

It is believed that a tourniquet should be applied only tight enough to control hemorrhage and left in place until it can be removed by a medical officer with blood or plasma expander available to resuscitate the patient. When packs or pressure dressings will suffice, the tourniquet should be removed and the pressure dressing applied only tight enough to control hemorrhage. Dressing can be carelessly applied


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as tightly as a tourniquet. If applied properly, packs and pressure dressings will often control the major hemorrhage and allow some collateral vessels to function. Patients with pressure dressings must be observed carefully to make sure that bleeding does not recur as the blood pressure increases with resuscitation.

Now that the repair of acute vascular injuries is feasible, every effort should be taken to repair the damaged artery. Some patients with major artery injury will have hemorrhaged so severely that resuscitation becomes a major problem requiring prolonged use of a tourniquet. Continued use of the tourniquet during prolonged resuscitation may result in a nonviable extremity. In such cases with open wounds it may be practicable to clamp the injured artery as near the damaged site as possible preserving as much of the artery as possible for repair. In this manner, the remaining collateral vessels are free to function while resuscitation is being accomplished. This procedure is not without danger. If the tourniquet is removed during a critical stage of resuscitation, even after control of the damaged vessel, tourniquet shock may occur. If clamps are to be utilized to control the hemorrhage, they should be applied at the beginning of resuscitation, or when bleeding cannot be controlled by a tourniquet, or after the blood pressure is stabilized and it is evident there will be a prolonged delay before surgery.

Care must be taken to avoid tourniquet shock when loosening or removing tourniquets that have been in place for a number of hours. We observed, as an example, a patient admitted in profound shock with both legs mangled and with tourniquets high on his thighs. He received 19 pints of blood before a thin pulse became palpable. After receiving 5 more pints of blood and dextran, he developed a near normal blood pressure. Since his tourniquets had been in place for 6 hours it was decided to loosen them slowly and replace them distally in hopes of salvaging the knee joints. While this was done without any evidence of external hemorrhage, the patient's blood pressure dropped again and in spite of 4 more pints of blood given rapidly, the patient died, having received a total of 28 pints of blood.

Tourniquets should normally be applied as low as practicable to control hemorrhage but for traumatic amputations the tourniquet should be applied as low as possible on the stump, then it may be left in place indefinitely.

It may be well to mention here the availability of the artery for transfusion in traumatic amputations. Usually such patients have hemorrhaged severely and are in profound shock. Since the artery is a tough, elastic structure it can usually be easily identified in the mangled remains of the extremity. The exposed artery can be


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clamped, a large cannula or needle quickly inserted and the blood administered rapidly by the route through which it was lost.

In spite of availability of blood and plasma expanders, hemorrhage proved to be a problem in many instances. Artz, Sako and Howard (1) reported 89 severely wounded patients who required 15 or more pints of blood or plasma expander. Sixteen of the patients, or 18 percent, died of continued hemorrhage, most of them with abdominal injury (table l). The patient with intra-abdominal hemorrhage often cannot be resuscitated preoperatively and has to be taken to surgery for control of hemorrhage.

Table 1. Mortality of Casualties Requiring 15 or More Pints of Blood From the 46th Surgical Hospital

Injury

Number

Died

Mortality (percent)

Number dying of continued hemorrhage

Abdomen

24

19

79

11 (46 percent)

Abdomen and extremities

29

12

41

3 (10 percent)

Extremities

29

5

17

1 (3 percent)

Chest

7

3

43

1 (14 percent)


Total


89


39


44


16 (18 percent)

In order to control intra-abdominal hemorrhage in these patients whose shock could not be controlled by replacement of blood, a balloon catheter was tested as an intra-aortic tamponade in two critically wounded patients. It was arbitrarily decided that the catheter would be used only in moribund patients with intra-abdominal bleeding in which blood pressure could not be obtained after administration of 10 pints of blood. The catheter was utilized by inserting it through the femoral artery to the level of the diaphragm, then inflating the balloon with 20 cc.of sterile saline. The catheter was utilized in two moribund patients.

Case 1. The first patient was admitted 1 hour after injury with grenade wounds of the abdomen, thighs, leg and foot and a compound comminuted fracture of the right tibia and fibula. He had received 1,000 cc. of plasma prior to admission. On admission, his pressure was 40 systolic with a questionable diastolic level and pulse rate was 120. There was abdominal distention suggesting uncontrolled intra-abdominal bleeding. In the receiving ward he was given 2,000 cc. of whole blood and 500 cc. of dextran, and his blood pressure was read as 58 systolic with questionable diastolic pressure and pulse 120. He received 2,500 cc. more of blood without improvement. He was then taken to surgery in a moribund condition. There, no blood pressure


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could be obtained. The catheter was inserted and passed to the level of the diaphragm, where the balloon was inflated. The abdomen was then quickly opened and 1,500 to 2,000 cc. of free blood was aspirated. A bleeding external iliac vein was controlled and a massive laceration of the right lobe of the liver was packed and sutured.

After 15 minutes the catheter was slowly deflated, moved down to the bifurcation of the aorta, and reinflated to allow oxygenation of the kidneys, liver and spinal cord. This permitted multiple bleeding points in the bowel and mesentery and around the celiac axis to present themselves. With this bleeding, the blood pressure was again unobtainable and breathing became labored. The catheter was then replaced and inflated at the level of the diaphragm. The pressure was obtained at 78/50; then rose to 100/54, and respiration again improved. While the catheter at the diaphragmatic level controlled the bleeding and maintained a pressure, it also obscured the bleeding points so that they could no longer be found.

After 10 minutes at this level, the balloon was again slowly, partially deflated to expose the bleeding points, but the blood pressure was again lost. Re-inflation of the catheter balloon returned the blood pressure to 96/54, but again obscured the multiple bleeding points.

As the catheter was repeatedly deflated to demonstrate the bleeding points, the blood pressure continued to fall, and the patient's condition gradually became worse until he died on the operating table. It was feared that prolonged use of the high aortic tamponade might result in liver, renal or spinal cord damage from anoxia.

During surgery, the patient received 13 additional pints of whole blood and 1,000 cc. of dextran to total 22 pints of blood and 3 pints of dextran.

At autopsy, no damage to the celiac axis was demonstrated, but in addition to the damaged liver and iliac vein, there were multiple injuries to branches of the splenic artery, the mesenteric arteries, and a severed spermatic artery.

Case II. The catheter was utilized too late in the second patient for a blood pressure response. Although this patient received 24 pints of blood, he died almost simultaneously with insertion of the catheter.

The fear of harming a patient who might have been resuscitated without use of the catheter caused us to reserve it for use in absolutely moribund patients. Possibly these patients would have had a better chance for survival had it been used earlier. Although both patients died, the catheter was effective in temporarily restoring blood pressure in one patient and should be further evaluated experimentally and clinically.


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Summary

1. Primary gross hemorrhage was the usual immediate problem encountered in the wounded in Korea but continued ooze also proved to be a problem at times.

2. Secondary hemorrhage played an important role, especially hemorrhages resulting from pulsating hematomas and in the presence of infection. This was particularly observed during the mass evacuation of the early days of the war.

3. The control of hemorrage is discussed and the dangers of improper use of a tourniquet are discussed.

4. The use of an intra-aortic balloon catheter tamponade as a method of controlling intra-abdominal or intra-thoracic hemorrhage is presented.

References

1. Report of the Surgical Research Team from Korea-AMSGS, 1953.

2. Russell, J. P.: Secondary Hemorrhage in War Wounds. In: Symposium on Military Medicine in the Far East Command, pp. 73-77, Sept. 1951.