See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/258102754 Temporization of Penetrating AbdominalPelvic Trauma With Manual External Aortic Compression: A Novel Case Report ARTICLE in ANNALS OF EMERGENCY MEDICINE · OCTOBER 2013 Impact Factor: 4.33 · DOI: 10.1016/j.annemergmed.2013.09.026 · Source: PubMed DOWNLOADS VIEWS 46 128 3 AUTHORS, INCLUDING: Matthew Douma Royal Alexandra Hospital 6 PUBLICATIONS 0 CITATIONS SEE PROFILE Available from: Matthew Douma Retrieved on: 19 July 2015 TRAUMA/CASE REPORT Temporization of Penetrating Abdominal-Pelvic Trauma With Manual External Aortic Compression: A Novel Case Report Matthew Douma, RN, BSN; Katherine E. Smith, MD, BSc; Peter G. Brindley, MD, FRCPC A young civilian man experienced multiple gunshots to the lower abdomen, pelvis, and thigh. These were not amenable to direct compression by a single rescuer. This report outlines the first case in the peer-reviewed literature of manual external aortic compression after severe trauma. This technique successfully temporized external bleeding for more than 10 minutes and restored consciousness to the moribund victim. Subsequently, external bleeding could not be temporized by a second smaller rescuer, or during ambulance transfer. Therefore, we also gained insights about the possible limits of bimanual compression and when alternates, such as pneumatic devices, may be required. Research is needed to test our presumption that successful bimanual compression requires larger-weight rescuers, smaller-weight victims, and a hard surface. It is therefore unclear whether manual external aortic compression is achievable by most rescuers or for most victims. However, it offers an immediate and equipment-free life-sustaining strategy when there are limited alternatives. [Ann Emerg Med. 2013;-:1-3.] 0196-0644/$-see front matter Copyright © 2013 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2013.09.026 INTRODUCTION The priority after penetrating trauma to the major vessels of the abdomen, pelvis, and lower extremities is rapid surgical rescue.1 However, patients with life-threatening abdominal-pelvic hemorrhage also need to be temporized at the scene and maintained during transport. Unlike bleeding from the extremities, hemorrhage from the umbilicus to the proximal thigh is often not amenable to direct compression or to hemostatic dressings. Therefore, management of these injuries, referred to in military literature as junctional trauma, is difficult and mortality is high.2 Annually, gunshot wounds cause approximately 200,000 civilian deaths3 and more than 700,000 total deaths worldwide.4 Junctional trauma is the leading preventable cause of conflictzone death,5 and our case (as well as recent events in Aurora, CO, and Boston, MA) highlights that it is also a concern in civilian life. A study of abdominal gunshot wounds presenting to the emergency department (ED) reported 16% mortality.6 Another found that death increased 1% for every 3 minutes in the ED before laparotomy.7 In short, this is an important problem for out-of-hospital and ED staff. Further research and novel clinical ideas are sorely needed. We present a novel case of successful temporization with manual external aortic compression (Figure) that followed multiple gunshot wounds to the abdomen and lower extremity. A civilian patient was successfully temporized for more than 10 minutes by a single rescuer. Although perhaps intuitive, manual external aortic compression has not been previously described in the medical literature for penetrating or nonpenetrating trauma. CASE REPORT A young civilian man received multiple shots from a handgun at close range. He experienced wounds to the right lower Volume -, no. - : - 2013 abdomen, left flank, and right proximal thigh. All bled externally and profusely. This was witnessed by a nearby health care professional (M.D.), who responded immediately. The victim had an initial Glasgow Coma Scale (GCS) score of 6 (motor 4, verbal 1, eyes 1). Carotid pulses were faint, peripheral pulses were absent, skin was pale, and respirations were rapid and shallow. The rescuer (who weighed >200 lbs) applied direct pressure to the anterior abdominal wound, using a towel, which appeared to externally tamponade that single site. However, the victim continued to bleed profusely from the flank and thigh. These multiple wounds could not be managed with direct compression by the single rescuer. Therefore, he applied maximal bimanual force to the patient’s epigastrium to compress the abdominal aorta proximal to all wounds. This involved pressing the right fist (bolstered by his left hand) between the xiphoid and umbilicus (Figure). Within 30 seconds of manual external aortic compression, external bleeding stopped. Concurrently, the patient regained consciousness, began moving, opened his eyes, and verbalized (GCS 14). As such, presumably, major internal bleeding was also stemmed. Additional lay responders arrived and manual external aortic compression was demonstrated and handed off to a rescuer of smaller build (<150 lbs). External bleeding resumed within 30 seconds and the patient again became unconscious. Therefore, the initial rescuer resumed maximal manual external aortic compression. Bleeding once again appeared to stop, and the victim awakened, verbalized, and moved all limbs (GCS 14). Paramedics responded but were held back for 10 minutes by police. Bimanual compression was maintained by the single rescuer throughout. When emergency medical services arrived, roadside compression was successfully handed off to a male ambulance paramedic (>200 lbs). Manual compression was interrupted to transfer the patient to an ambulance stretcher and again as he was Annals of Emergency Medicine 1 Penetrating Abdominal-Pelvic Trauma and Manual External Aortic Compression Figure. Bi-manual external aortic compression. loaded into the ambulance. The patient became obtunded both times. The maneuver was resumed but, subjectively, required more manual effort on the stretcher compared with the roadside. During transport, it was abandoned to obtain vital signs, intravenous access, and a cervical collar. Within minutes, the patient again bled externally and became unresponsive. Four minutes into the 9-minute transfer, he had a pulseless electrical activity cardiac arrest, presumed a result of severe hypovolemia. Advanced cardiac life support resuscitation was initiated and continued for the remaining 5-minute transfer to the ED. In the ED, a multidisciplinary trauma team responded immediately. An anterolateral thoracotomy and pericardotomy revealed no pericardial or pleural blood, and the thoracic aorta was cross-clamped. A chest tube and subclavian central venous catheter were placed, 2 L of crystalloid and 4 units of blood were rapidly infused, and open cardiac massage was performed. The patient had return of spontaneous circulation and was rushed to the operating room for an urgent midline laparotomy. Surgeons evacuated a large volume of blood and located an expanding retroperitoneal hematoma, splenic and gastric injuries, and lacerations to the inferior vena cava and abdominal aorta. Intraoperatively, the patient received 14 units of packed RBCs, 3 units of fresh frozen plasma, and 1 pool of platelets. Intraoperative blood testing showed a hemoglobin level of 4.7 g/dL (normal 14 to 18 g/dL), platelet level less than 40,000/mL (normal 150,000 to 400,000 mL), partial thromboplastin time 146 seconds (normal 30 to 50 seconds), international normalized ratio 2.9 (normal 0.8 to 1.2), and lactate level of 14 mmol/L (normal 0.5 to 1 mmol/L). Death occurred 105 minutes after ED arrival with extreme acidosis, refractory cardiac dysrhythmias, and inability to repair the aorta. Family consented to this case report on condition of anonymity. DISCUSSION Injuries to the abdominal aorta and iliac and common femoral arteries often preclude tourniquets and hemostatic agents.8 Therefore, sophisticated devices such as a novel abdominal 2 Annals of Emergency Medicine Douma, Smith & Brindley tourniquet have been developed.2 However, these are not always available in the civilian out-of-hospital system. In addition, they require training, experience, and time to deploy. Meanwhile, patients can die within a few minutes of major abdominal-pelvic trauma. Manual external aortic compression offers a cost-free, equipment-free, easy-to-teach, and immediately available technique. Therefore, it is intuitively appealing. Moreover, our first responder’s experience shows it can successfully temporize a severe lower-extremity bleeding event. Our second responder’s lack of success also shows that the technique has limitations. However, this also provided useful insights about how manual external aortic compression might be optimized when there are few alternatives. These insights should also help direct ongoing research. Our case supports but does not prove the intuitive assumption that larger-weight rescuers are more likely to succeed. In a small but ingenious study, 9 healthy volunteers had dumbbell weights placed on a rolled towel, which was placed over the abdomen. Eighty to one hundred twenty pounds was required to occlude blood flow in the common femoral artery (as measured by Doppler ultrasonography).9 The need for such a large force may explain why our smaller rescuer was unsuccessful. Although a victim’s vertebral column should provide posterior compression, performing manual external aortic compression on a harder surface (ie, the cement or the floor of the ambulance, or by adding a backboard, as with cardiac chest compressions) may increase effectiveness. This presumption also needs to be formally studied. In our case, manual external aortic compression was also difficult to maintain during transfer to the ambulance. It was also not maintained during transport because of prioritization of other, more conventional, interventions. Bimanual compression might also be limited by patient factors. For example, our victim weighed less than 90 kg. Bimanual compression (and pneumatic devices) may be limited by ineffectiveness (or discomfort) in those with increased abdominal girth.9,10 Although this remains to be studied, it may be an important limitation, given increasing rates of worldwide obesity. Fortunately, health care workers (and many lay public) have already been taught a bimanual technique for performing cardiac chest compressions. Therefore, minimal education should be required. This assumption is supported by the ease with which our first rescuer handed off manual external aortic compression on 2 occasions. Presumably, manual external aortic compression would also be relatively easy to describe to a rescuer by telephone dispatch. This should further minimize delays compared with devices. As is the case for cardiac chest compressions, our experience also supports the intuitive benefit of extending elbows and positioning the upper body above the hands. This increased transfer of upper body strength may be why compression seemed easier on the roadside compared with the raised ambulance stretcher. To our knowledge, manual external aortic compression has not been described in the peer-reviewed literature after either penetrating or nonpenetrating trauma. It is also not part of any published trauma guidelines. Given that manual external aortic Volume -, no. - : - 2013 Douma, Smith & Brindley Penetrating Abdominal-Pelvic Trauma and Manual External Aortic Compression compression may seem intuitive, we also reviewed nonmedical sources, military gray literature, and Internet forums. We used the key words “external aortic compression,” “junctional trauma,” “penetrating trauma,” “dismounted complex blast injury,” “abdominal hemorrhage,” and “abdominal/pelvic/ junctional gunshot wound.” We also used the assistance of the assistant of a medical librarian to ensure rigor. We found only a Web site discussing a manual external aortic compression10 and a newspaper article recommending one fist above the wound and one below the injury.11 Outside of trauma, manual external aortic compression has been reported after rupture of an abdominal aortic aneurism12 and for postpartum hemorrhage.13 A study in 20 nonbleeding postpartum patients used manual external aortic compression to obliterate femoral pulses in 55% and significantly reduce pulses in 65% (P<.01).14 It has also been associated with decreased mortality and morbidity after postpartum hemorrhage in the developing world15 and has been adopted by the Queensland ambulance service for this use.16 Manual external aortic compression has also been used successfully to increase cardiac afterload after severe cyanosis in a 3-month-old with tetralogy of Fallot.17 Instead of manual compression, the US military has promoted the use of pneumatic devices after trauma.2 An abdominal aortic tourniquet has been shown to successfully arrest femoral artery flow in 15 of 16 volunteers, as determined by ultrasonographic Doppler.18 Our lack of success with 2 of 3 rescuers using manual compression means that devices (when present) may be preferable, especially with lower-strength rescuers, when patients cannot be removed rapidly, when rescuers cannot be positioned properly, and during prolonged transportation. Similarly, manual external aortic compression may be used only while awaiting a device. Although further study is required, the use of a single knee9 may also be preferable (and less fatiguing) than using hands. CONCLUSION Our case suggests that manual external aortic compression may provide an immediate and equipment-free life-sustaining strategy. Our experience also emphasizes that manual external aortic compression has limitations. Further study is warranted to ascertain whether it can be further optimized and whether it has widespread applicability. Supervising editor: Judd E. Hollander, MD Author affiliations: From the Lawrence S. Bloomberg Faculty of Nursing, Masters of Nursing, Nurse Practitioner Program Student and Collaborative Program in Resuscitation Science, Faculty of Medicine at the University of Toronto, Toronto, Ontario, Canada (Douma); and the Department of Emergency Medicine (Smith) and Division of Critical Care Medicine (Brindley), University of Alberta, Edmonton, Alberta, Canada. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict Volume -, no. - : - 2013 of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Publication dates: Received for publication August 8, 2013. Revision received September 11, 2013. Accepted for publication September 18, 2013. Address for correspondence: Peter G. Brindley, MD, FRCPC, E-mail Peter.Brindley@albertahealthservices.ca. REFERENCES 1. Mattox K, Moore E, Feliciano D. Trauma. 7th ed. New York: McGrawHill; 2013. 2. Kragh JF, Murphy C, Dubick MA, et al. New tourniquet device for battlefield hemorrhage control. US Army Med Dep J. 2011;(April-June): 38-55. 3. Me A, Bisogno E, Malby S. Global Study on Homicide 2011. Vienna, Austria: United Nations Office on Drugs & Crime; 2011. 4. Geneva Declaration Secretariat. Global Burden of Armed Violence. Geneva, Switzerland: Geneva Declaration Secretariat; 2008. 5. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (20012011). J Trauma Acute Care Surg. 2012;73:S431-S437. 6. Chamisa I. Civilian abdominal gunshot wounds in Durban, South Africa: a prospective study of 78 cases. Ann R Coll Surg Engl. 2008;90:581-586. 7. Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to laparotomy for intraabdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma Acute Care Surg. 2002;52:420-425. 8. Rhee P, Brown C, Martin M, et al. QuikClot use in trauma for hemorrhage control: case series of 103 documented uses. J Trauma. 2008;64:1093-1099. 9. Blaivas M, Shiver S, Lyon M, et al. Control of hemorrhage in critical femoral or inguinal penetrating wounds—an ultrasound evaluation. Prehosp Disaster Med. 2006;21:379-382. 10. Mattox K. External aortic compression in abdominal stab wounds. [Internet]. Trauma.org. 2006. Available at: http://www.trauma.org/ index.php/community/list/url/http:list.ftech.net/pipermail/traumalist/2006-July/032949.html. Accessed October 9, 2013. 11. Espiner H. These simple steps could save stabbing victims’ lives. Guardian [Internet]. London, England; May 24, 2006. Available at: http://www.guardian.co.uk/commentisfree/2006/may/24/comment. ukcrime/print. Accessed October 9, 2013. 12. Kin N, Hayashida M, Chang K, et al. External manual compression of the abdominal aorta to control hemorrhage from a ruptured aneurysm. J Anesth. 2002;16:164-166. 13. Keogh J, Tsokos N. Aortic compression in massive postpartum haemorrhage—an old but lifesaving technique. Aust New Zealand J Obstet Gynaecol. 1997;37:237-238. 14. Riley D, Burgess R. External abdominal aortic compression: a study of a resuscitation manoeuvre for postpartum haemorrhage. Anaesth Intensive Care. 1994;5:1-5. 15. Soltan MH, Sadek RR. Experience managing postpartum hemorrhage at Minia University Maternity Hospital, Egypt: no mortality using external aortic compression. J Obstet Gynaecol Res. 2011;37:1557-1563. 16. Queensland Government. Queensland Ambulance Service Field Reference Guide. Queensland Government; 2011. 17. Roekens VNC, Zuckerberg AL. Emergency management of hypercyanotic crises in tetralogy of Fallot. Ann Emerg Med. 1995;25:256-258. 18. Taylor D, Coleman M, Parker P. The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower limb haemorrhage. Bone Jt J. 2013;95-B(suppl 26):8. Annals of Emergency Medicine 3