View Full Version : Femoral bleedout - Warning *GRAPHIC*
Here is a video showing a suspect take a single 7.62 to the thigh, with following femoral bleeding:
http://www.youtube.com/watch?v=7e8gGXZDRY0
It is hard to assess how long the casualty maintained consciousness, as the video is slightly edited. I am also not sure if the casualty is actually dead by the end of the video, or unconscious with late stage shock (Level II-III).
I think that the video shows two things, albeit paradoxical observations:
1. You have some time to attend to an arterial bleed
2. You need to stop arterial bleeds quickly, as things can go south fast if you don't.
Here is a video showing a suspect take a single 7.62 to the thigh, with following femoral bleeding:
http://www.youtube.com/watch?v=7e8gGXZDRY0
It is hard to assess how long the casualty maintained consciousness, as the video is slightly edited. I am also not sure if the casualty is actually dead by the end of the video, or unconscious with late stage shock (Level II-III).
I think that the video shows two things, albeit paradoxical observations:
1. You have some time to attend to an arterial bleed
2. You need to stop arterial bleeds quickly, as things can go south fast if you don't. I am curious to know the actual time it took.
You'd think putting direct pressure on it would be almost an instinct, but obviously not. Same thing happens in the video from Columbine. Kid got shot through the abdomen and just kinda sat down and put his head on the table like he already accepted he was going to die. It probably wouldn't have done a whole lot for either of these guys since no one else is really around to help, but its better than nothing.
I watched the unedited version as part of a class. Caught my instructor today (different class) and video is 4 min total. Dies (no movement) around 3 min mark.
I am curious to know the actual time it took.
My assessment is that the guy isn't dead yet, just unconcious and circling the drain.....if he is in irreversible shock is hard to say.
Hot Holster
09-30-13, 09:12
My assessment is that the guys isn't dead yet, just unconcious and circling the drain.....if he is in irreversible shock is hard to say.
I tend to agree, though he's pretty close to death. If you look close at his back/chest area just before the video ends, I think there is a very shallow breath movement.
Is a gunshot wound in that zone common or rare in combat? How large is the zone that can be hit by the bullet and sever that artery? I mean, I know the bullet will flip and yaw, but with as much emplasis as it takes to get a spinal coloumn hit, does the same apply to the femoral zone, or is it if you just hit the upper thigh with a rifle caliber it will likely be damaged?
Anterior view:
http://www.bartleby.com/107/Images/large/image550.gif
As to how common/easy it is to injure the femoral artery, that is hard to say. Vessels can expand and contract quite a bit, especially arteries, and are considered elastic tissue.
I don't think it is realistic to intentionally aim for it, and expect to hit it.
Failure2Stop
09-30-13, 11:37
I don't think it is realistic to intentionally aim for it, and expect to hit it.
It's a decent target for an edged weapon, not so much for current non-explosive projectile weapons.
Is a gunshot wound in that zone common or rare in combat? How large is the zone that can be hit by the bullet and sever that artery? I mean, I know the bullet will flip and yaw, but with as much emplasis as it takes to get a spinal coloumn hit, does the same apply to the femoral zone, or is it if you just hit the upper thigh with a rifle caliber it will likely be damaged?
My experience is that groin/femoral wounding not so much from a direct hit from a bullet but rather shrapnel either from an explosion or a bullet hitting something else and splintering.
I worked in a research lab for a few years, working on an off-the-shelf hemoglobin-based oxygen carrier, we used Yucatan pigs of 75 kilo's. We would slice the femoral artery before giving them "the product" or LR or NS (depending on the card we drew). It could take some of them a very long time to bleed to death.
Djstorm100
09-30-13, 14:06
My experience is that groin/femoral wounding not so much from a direct hit from a bullet but rather shrapnel either from an explosion or a bullet hitting something else and splintering.
I worked in a research lab for a few years, working on an off-the-shelf hemoglobin-based oxygen carrier, we used Yucatan pigs of 75 kilo's. We would slice the femoral artery before giving them "the product" or LR or NS (depending on the card we drew). It could take some of them a very long time to bleed to death.
Something like this?
https://www.youtube.com/watch?v=TnqxNQmgcqg&oref=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DTnqxNQmgcqg&has_verified=1
It is very true that it takes time to bleed out, something that is seen in both pig testing and human patients.
The casualty in this video is still alive when the clip stops, and was transported to hospital where he later died of blood loss.
It is very true that it takes time to bleed out, something that is seen in both pig testing and human patients.
The casualty in this video is still alive when the clip stops, and was transported to hospital where he later died of blood loss.
Interesting to know where you got that info?
For those that haven't seen a femoral A., they're a bit smaller than a standard garden hose. Figure around the thickness of your thumb. Bleed out probably accurate at the 3-4 minute mark.
Figure your heart pumps 60x/minute (probably higher since "I just got shot!" adrenaline). Figure 50ml per beat (which is low, but it's easy math). In other words, at rest, your heart pumps around 3 liters per minute. Maybe 2/3 directed downwards, the other 1/3 towards arm, head, brain.
So 2 liters per minute in the lower half of body; 2 legs, so 1 liter/minuter per leg. Average person holds 5 liters of blood. So total exsanguination in 5 minutes. Probably less, when you factor in elevated heart rate and stroke volume, panic, etc.
The real problem with femoral shots is that it's a difficult place to obtain and maintain adequate pressure (remember Blackhawk Down?) Even TQ's are useless if it's high enough. Tons of pressure, combat guaze, fluids and rapid surgical intervention.
Interesting to know where you got that info?
For those that haven't seen a femoral A., they're a bit smaller than a standard garden hose. Figure around the thickness of your thumb. Bleed out probably accurate at the 3-4 minute mark.
Figure your heart pumps 60x/minute (probably higher since "I just got shot!" adrenaline). Figure 50ml per beat (which is low, but it's easy math). In other words, at rest, your heart pumps around 3 liters per minute. Maybe 2/3 directed downwards, the other 1/3 towards arm, head, brain.
So 2 liters per minute in the lower half of body; 2 legs, so 1 liter/minuter per leg. Average person holds 5 liters of blood. So total exsanguination in 5 minutes. Probably less, when you factor in elevated heart rate and stroke volume, panic, etc.
The real problem with femoral shots is that it's a difficult place to obtain and maintain adequate pressure (remember Blackhawk Down?) Even TQ's are useless if it's high enough. Tons of pressure, combat guaze, fluids and rapid surgical intervention.
The more you bleed out, the lower the blood pressure, so I don't believe the rate of flow will be linear...
The more you bleed out, the lower the blood pressure, so I don't believe the rate of flow will be linear...
Yes and no. Less volume, but the arteries will likely be contracting due to adrenaline, so the actual afterload will be the same initially. While I have no idea if the "stages" of shock hold across all time lines (ie, will the patient progress through all 4 stages if they bleed out in 5 minutes), according to the tables, BP is stable through 30% blood loss.
But, yes, you likely wouldn't have linear flow. Doesn't matter, since something like >40% blood loss is fatal.
Interesting to know where you got that info?
For those that haven't seen a femoral A., they're a bit smaller than a standard garden hose. Figure around the thickness of your thumb. Bleed out probably accurate at the 3-4 minute mark.
Figure your heart pumps 60x/minute (probably higher since "I just got shot!" adrenaline). Figure 50ml per beat (which is low, but it's easy math). In other words, at rest, your heart pumps around 3 liters per minute. Maybe 2/3 directed downwards, the other 1/3 towards arm, head, brain.
So 2 liters per minute in the lower half of body; 2 legs, so 1 liter/minuter per leg. Average person holds 5 liters of blood. So total exsanguination in 5 minutes. Probably less, when you factor in elevated heart rate and stroke volume, panic, etc.
The real problem with femoral shots is that it's a difficult place to obtain and maintain adequate pressure (remember Blackhawk Down?) Even TQ's are useless if it's high enough. Tons of pressure, combat guaze, fluids and rapid surgical intervention.
Info is from this article about the incident:
http://www.dailymail.co.uk/news/article-2025287/Pakistani-soldier-sentenced-death-shooting-unarmed-man-video-shocked-world.html
Shah was eventually taken to a local hospital and died shortly after from blood loss
And you are incorrect about the time it takes to bleed to death; it takes time.
There are several defense mechanisms at work in the body when you start bleeding, that will significantly reduce the rate at which you lose blood after only a short while. In testing on pigs, a severed femoral initially bleeds at a rate of 1 liter per minute. After about 15 seconds, the rate will have slowed to about 250ml per minute. In a different test on pigs they sever two arteries and one vein in the groin, and wait 10 minutes before intervening, with a 100% survival rate. And in yet another test, they have drawn a lethal dose of blood from a pig, and if this blood volume is restored within 3 hours they had a 100% survival rate. Longer than that, and the percentage that dies is greater than the percentage that lives.
And how exactly do you only pump 3/5 of your blood volume in a single minute? Cardiac output is cardiac output....
With regards to the BHD incident where Jamie Smith dies, my understanding is that the medic did indeed control the bleed, but was seeking to apply a clamp because that was the protocol of the time. Granted, I was not there, but the information stems from a very reliable source in the military medical community in the US, who has spoken to the medic who treated Cpl. Smith.
ETA: I want to make it perfectly clear that this is not meant to detract from the excellent effort done by the Delta medic during that situation. He kept him alive for 3 hours under extremely difficult conditions.
Gutshot John
10-01-13, 13:01
Total exsanguination isn't necessary to be unrecoverable. Kidney failure especially occurs very rapidly, but it doesn't always lead to immediate death. I think most medics especially forget that its the subsequent and associated organ failures that kill. Exsanguination is a fatal outcome of shock, but so is partial exsanguination with organ shutdown.
I don't think pointing to some individual cases such as pigs and get anything meaningful is possible. There are simply too many factors at play and you need a far larger sample size. I think what it does illustrate is that extreme shock manifests itself in a variety of ways, and the amount of time you have before lethality varies greatly on circumstances.
I've seen positional shock take people very quickly that were otherwise stable, sometimes you have time, sometimes you don't.
It pays to think about the situation you have in front of you.
ETA: As a contemporary of the medic in question who received much of the same training, and certainly studied the actions of medical personnel on the ground, incorporating that very scenario into PHTLS/TCCC, my understanding of the death of Cpl. Smith was that the bleeding was NOT controlled and so he was trying to go back in and clamp it. If the patient was otherwise stable, and the medic decided to to go back in...well I would question the judgment of that call, that's not to say it wasn't the right call, just that it raises eyebrows...if that is what happened.
They didn't mention "positional shock" in paramedic school. Could you please describe the patho behind it?
I don't think pointing to some individual cases such as pigs and get anything meaningful is possible. There are simply too many factors at play and you need a far larger sample size. I think what it does illustrate is that extreme shock manifests itself in a variety of ways, and the amount of time you have before lethality varies greatly on circumstances.
Just to clarify, in case my original post left any doubt, these are not individual tests, but several tests done by a big actor in this industry.
But yes, there are a lot of factors at play; overall health is one. Most military personnell, for example, are healthy individuals and have been through some type of screening. Their ability to handle blood loss is most likely better than random civilians who can have any number of underlying issues complicating the issue and/or lowering chances of survival.
ETA: As a contemporary of the medic in question who received much of the same training, and certainly studied the actions of medical personnel on the ground, incorporating that very scenario into PHTLS/TCCC, my understanding of the death of Cpl. Smith was that the bleeding was NOT controlled and so he was trying to go back in and clamp it. If the patient was otherwise stable, and the medic decided to to go back in...well I would question the judgment of that call, that's not to say it wasn't the right call, just that it raises eyebrows...if that is what happened.
According to the doctor who explained this, the following was the protocol taught to 18D's of the time:
In case of junctional/inguinal bleeds, they were to cut down in order to find the bleed so they could clamp it. Live tissue training was done on goats, with a very different anatomy than humans, especially in regards to where the arteries and veins are located; much closer to the surface on goats.
According to the doctor, this type of tissue training led to a faulty protocol.
I might be confused about the bleeding part though, it has been a few years since the seminar. Come to think of it, the case might be that the bleed was not controlled, but he sought to control it via the clamp rather than try different measures.
Anyways, it was the opinion of this doctor, that the faulty protocol took too much focus away from other interventions that could have been tried.
Total exsanguination isn't necessary to be unrecoverable. Kidney failure especially occurs very rapidly, but it doesn't always lead to immediate death. I think most medics especially forget that its the subsequent and associated organ failures that kill. Exsanguination is a fatal outcome of shock, but so is partial exsanguination with organ shutdown.
I don't think pointing to some individual cases such as pigs and get anything meaningful is possible. There are simply too many factors at play and you need a far larger sample size. I think what it does illustrate is that extreme shock manifests itself in a variety of ways, and the amount of time you have before lethality varies greatly on circumstances.
I've seen positional shock take people very quickly that were otherwise stable, sometimes you have time, sometimes you don't.
It pays to think about the situation you have in front of you.
ETA: As a contemporary of the medic in question who received much of the same training, and certainly studied the actions of medical personnel on the ground, incorporating that very scenario into PHTLS/TCCC, my understanding of the death of Cpl. Smith was that the bleeding was NOT controlled and so he was trying to go back in and clamp it. If the patient was otherwise stable, and the medic decided to to go back in...well I would question the judgment of that call, that's not to say it wasn't the right call, just that it raises eyebrows...if that is what happened.
The organ failure is secondary to the Trauma Triad of Death, not necessarily because of the lack of the blood itself. If medics in the field are thinking that far ahead of the curve instead of using ALS (Accelerator Life Support) then they have bigger problems.
I would be careful to dismiss multiple and independent studies using animals. It's what we call "research" and "science," and from those studies we have an understanding of how much time an X-kilogram body will bleed an n-amount of blood before, in most cases, that line has been crossed. We all know the end-point and what occurs between injury and end-point; and you are right in that there are many variables, but really not THAT many. At some point the body regardless of pig or person crosses a line and that's that.
As far as sample size there are data bases (thanks to Vietnam and all points since including data from civilian trauma) that one can pool to find averages, so numbers are there for people who want to do the legwork.
As for your last point I generally agree, but it does sound suspiciously close to armchair quarterbacking, and I have seen enough of your posts to realize that you would not do that. Most of us who have been deployed and rendering care in austere and nasty places with bullets flying have I am certain made calls that, upon review, would "raise eyebrows."
I completely concur that it pays to think about the situation before you, and critical thinking is absolutely necessary.
Gutshot John
10-01-13, 16:02
They didn't mention "positional shock" in paramedic school. Could you please describe the patho behind it?
Sorry the more correct term is "positional hypotension."
It's typically found in extreme speed vehicle accidents.
While your body is in a certain position, your BP is maintained at or near normal...during extrication, changing of positioning (from say seated/bent to standing/elongated), will cause the patient to crash rapidly as pressure on an otherwise undetected bleed is removed. I had a particular case where an individual was essentially cut in half at the abdomen with a wholly crushed pelvis. He was alert and conscious until we moved him, than it was like someone flipped a switch, when we finally saw the injury we knew there was nothing we could have done.
Sorry the more correct term is "positional hypotension."
It's typically found in extreme speed vehicle accidents.
While your body is in a certain position, your BP is maintained at or near normal...during extrication, changing of positioning (from say seated/bent to standing/elongated), will cause the patient to crash rapidly as pressure on an otherwise undetected bleed is removed. I had a particular case where an individual was essentially cut in half at the abdomen with a wholly crushed pelvis. He was alert and conscious until we moved him, than it was like someone flipped a switch, when we finally saw the injury we knew there was nothing we could have done.
First time I saw this was in a similar situation (sad case where a cop in a chase lost control and hit someone, the guy he hit was the one who eventually bled to death once we cut him out of the car). Once you see this, you never forget.
Voodoo_Man
10-01-13, 16:10
It's a decent target for an edged weapon, not so much for current non-explosive projectile weapons.
I agree, I believe in the video it was just a "lucky shot" of sorts.
For an edged weapon, as you stated, it is a pretty massive target.
Gutshot John
10-01-13, 16:15
The organ failure is secondary to the Trauma Triad of Death, not necessarily because of the lack of the blood itself. If medics in the field are thinking that far ahead of the curve instead of using ALS (Accelerator Life Support) then they have bigger problems.
The broader point was that saying that one has "time" to address the bleed because it takes 5 mins+ for TOTAL exsanguination misses the point, you can die due to far less blood loss for a variety of reasons. Organ failure, if memory serves, is the cause of most "shock" deaths.
I would be careful to dismiss multiple and independent studies using animals. It's what we call "research" and "science," and from those studies we have an understanding of how much time an X-kilogram body will bleed an n-amount of blood before, in most cases, that line has been crossed. We all know the end-point and what occurs between injury and end-point; and you are right in that there are many variables, but really not THAT many. At some point the body regardless of pig or person crosses a line and that's that.
I don't think I was dismissing them, the point was that because this particular pig died or lived, it ultimately doesn't change the dynamics of how aggressively shock needs to be identified and treated.
I'm a huge believer in keeping as much blood in the system as possible represents the best chance of survival. I don't care how long it takes to bleed out, the more blood I keep inside the system the better.
As for your last point I generally agree, but it does sound suspiciously close to armchair quarterbacking, and I have seen enough of your posts to realize that you would not do that.
Go back and re-read what I wrote.
It's only armchair quarterbacking if I agreed that the medic took an otherwise stable patient and then starting trying to clamp a wound on a controlled bleed as was described by Arctic1.
This would be contraindicated based on my understanding of protocols at the time and of the incident itself. You would not attempt to do an arterial cutdown on an othewise stable patient...IF that is what he did.
My understanding of the incident, however, was that the medic did NOT have a stable patient NOR a controlled bleed - ergo his actions strike me as necessary as Cpl. Smith was likely going to die anyways.
Most of us who have been deployed and rendering care in austere and nasty places with bullets flying have I am certain made calls that, upon review, would "raise eyebrows."
I totally agree with that, just because it might raise some eyebrows, it might absolutely have been medically necessary. But if you're opening a controlled bleed on a stable patient without a reasonable expectation of improving the outcome, I would be still be skeptical.
The broader point was that saying that one has "time" to address the bleed because it takes 5 mins+ for TOTAL exsanguination misses the point, you can die due to far less blood loss for a variety of reasons. Organ failure, if memory serves, is the cause of most "shock" deaths.
Not really the point I was trying to make, and I do not disagree with your statement you made about adressing bleeds as soon as possible in order to prevent further blood loss.
My point was to illustrate that people do not bleed out in seconds, it actually takes some time. Not to take your time in treating the patients.
I don't think total exsanguination is even possible, due to the decreased blood pressure.
Sorry the more correct term is "positional hypotension."
It's typically found in extreme speed vehicle accidents.
While your body is in a certain position, your BP is maintained at or near normal...during extrication, changing of positioning (from say seated/bent to standing/elongated), will cause the patient to crash rapidly as pressure on an otherwise undetected bleed is removed. I had a particular case where an individual was essentially cut in half at the abdomen with a wholly crushed pelvis. He was alert and conscious until we moved him, than it was like someone flipped a switch, when we finally saw the injury we knew there was nothing we could have done.
I believe you're actually talking more about the body having a tamponade - something acting like MAST trousers, that maintain the BP. Once released, the afterload drops and BP along with it.
To Arctic 1:
While I agree "total exsanguination" is not super likely, as stated above, you don't need to lose all of it to die. Shock is a metabolic state; start hypoperfusion of small capillary beds, start making free radicals and ultimately cell death, and you start having problems. Even if you rapidly fluid resuscitate, you can get a second-hit/reperfusion type effect and continue with organ death. This is one reason why rapid isotonic fluid boluses are starting to be supplemented w/ colloids and blood products (and ATLS reflects this) - no use replacing volume with salt water.
Not to mention coagulation defects and delayed DIC, hypothermia as part of the triad, etc. And in older folks, you have to worry about already compromised organ systems; I've heard of people having fatal MI's while having orthostatic vitals taken (I assume that counts as "Positive").
As for cardiac output is cardiac output ... well, CO= SV x HR. Tachycardia can make up for the decrease in SV as your total volume drops. In a healthy athlete, I'm sure it's entirely possible for the heart to be pumping more than entire volume per minute (70ml x 150 bpm = 10,500). As I said in my OP, the numbers were rounded for easy math.
Out of curiosity, have you done pig labs personally? Yes, arteries tend to spasm and slow blood flow. Ultimately though, they relax. In addition, ragged edges decrease the effectiveness of this mechanism. This can buy time, but I'm absolutely certain there are ways to exsanguinate in 5 minutes (complete transection of the femoral A., ruputured aorta, etc)
Some interesting abstracts:
http://www.ncbi.nlm.nih.gov/pubmed/21514772
http://www.ncbi.nlm.nih.gov/pubmed/23816260 (appears most of deaths were not acute, based on other cited sources)
Gutshot John
10-01-13, 20:23
I believe you're actually talking more about the body having a tamponade - something acting like MAST trousers, that maintain the BP. Once released, the afterload drops and BP along with it.
Except it's not really the blood itself as maintaining the pressure which is what I think of as tamponade, and the crash occurs very rapidly, but sure I'll buy that as a distinction.
As the chuckman said, when you see it, you never forget it.
Except it's not really the blood itself as maintaining the pressure which is what I think of as tamponade, and the crash occurs very rapidly, but sure I'll buy that as a distinction.
As the chuckman said, when you see it, you never forget it.
I see what youre saying (cardiac tamponade, right?) but its a similar mechanism.
Total exsanguination isn't necessary to be unrecoverable. Kidney failure especially occurs very rapidly, but it doesn't always lead to immediate death. I think most medics especially forget that its the subsequent and associated organ failures that kill. Exsanguination is a fatal outcome of shock, but so is partial exsanguination with organ shutdown.
I don't think pointing to some individual cases such as pigs and get anything meaningful is possible. There are simply too many factors at play and you need a far larger sample size. I think what it does illustrate is that extreme shock manifests itself in a variety of ways, and the amount of time you have before lethality varies greatly on circumstances.
I've seen positional shock take people very quickly that were otherwise stable, sometimes you have time, sometimes you don't.
It pays to think about the situation you have in front of you.
ETA: As a contemporary of the medic in question who received much of the same training, and certainly studied the actions of medical personnel on the ground, incorporating that very scenario into PHTLS/TCCC, my understanding of the death of Cpl. Smith was that the bleeding was NOT controlled and so he was trying to go back in and clamp it. If the patient was otherwise stable, and the medic decided to to go back in...well I would question the judgment of that call, that's not to say it wasn't the right call, just that it raises eyebrows...if that is what happened.
Actually, I think the order of events would be:
hypotension and anemia would eventually cause cardiac arrest, likely asystole.
Renal failure, shock liver, mesenteric ischemia/infarction, ARDS, ect aren't that big of an issue at that point.
And in a hospital, you aren't dead under someone with an MD says you are dead. :D
To Arctic 1:
While I agree "total exsanguination" is not super likely, as stated above, you don't need to lose all of it to die. Shock is a metabolic state; start hypoperfusion of small capillary beds, start making free radicals and ultimately cell death, and you start having problems. Even if you rapidly fluid resuscitate, you can get a second-hit/reperfusion type effect and continue with organ death. This is one reason why rapid isotonic fluid boluses are starting to be supplemented w/ colloids and blood products (and ATLS reflects this) - no use replacing volume with salt water.
Not to mention coagulation defects and delayed DIC, hypothermia as part of the triad, etc. And in older folks, you have to worry about already compromised organ systems; I've heard of people having fatal MI's while having orthostatic vitals taken (I assume that counts as "Positive").
Concur, and I never stated otherwise. I am not implying that casualties with femoral injuries will walk it off.
As for cardiac output is cardiac output ... well, CO= SV x HR. Tachycardia can make up for the decrease in SV as your total volume drops. In a healthy athlete, I'm sure it's entirely possible for the heart to be pumping more than entire volume per minute (70ml x 150 bpm = 10,500). As I said in my OP, the numbers were rounded for easy math.
I understand the point you were trying to make, I just thought it was odd that you would list total blood volume as approx. 5 liters, and then use numbers that listed cardiac output as 3 liters for a person at rest. If I did not know better it could be confusing.
Out of curiosity, have you done pig labs personally? Yes, arteries tend to spasm and slow blood flow. Ultimately though, they relax. In addition, ragged edges decrease the effectiveness of this mechanism. This can buy time, but I'm absolutely certain there are ways to exsanguinate in 5 minutes (complete transection of the femoral A., ruputured aorta, etc)
I have not done pig labs that are focused on blood loss personally, no. That does not invalidate the data, and the data shows that even with complete femoral transections, survival rates can be high, even 100%.
Still, I did not intend to imply that this vid depicts how all upper thigh GSW's with femoral injuries will play out; it is a real situation that depicts a possible scenario for aid providers.
And aortic ruptures aren't really comparable to the type of bleeding we are discussing here, as mortality rates are incredibly high, for a number of reasons. But I'll concede that a person will die from a ruptured aorta pretty quickly ;)
Some interesting abstracts:
http://www.ncbi.nlm.nih.gov/pubmed/21514772
http://www.ncbi.nlm.nih.gov/pubmed/23816260 (appears most of deaths were not acute, based on other cited sources)
Thanks for the links.
Thanks for the links.
No problem.
Not sure your confusion on cardiac output - if you really want to hash it out we can go to PM's. But, "output" from the heart is simply a flow volume. Since the vasculature is supposed to be a closed system, fluid circulates. Cardiac output, therefore, should equal cardiac input. In high flow states, you can circulate the effective blood volume several times per minute. Kind of like a compressor in a refrigerator, or an oil pump. If that doesn't clear it up, like I said, I'll be more than happy to try and explain further.
Only reason I mentioned the pig lab is that protocols vary greatly. As I understand it, SF medic training used to entail shooting a goat (or similar) then saving it's life. Whereas most pig labs (I've only done 3), use a clean scalpel to lacerate/transect a vessel. Real life tends to be messier, however. Tumbling bullets, vasospasm, fragments, powder particles, etc. I'd consider the 18D training better for real life scenarios, though it's harder to scientifically replicate experiments when you introduce the fuzzy variables.
"Bleeding out" in 5 minutes, is of course, an ideal situation. As you pointed out, there are numerous variables, and while a GSW to the femoral A. isn't always fatal (especially "immediately"), it is typically a high morbidity event. On that I think we all agree.
Only reason I mentioned the pig lab is that protocols vary greatly. As I understand it, SF medic training used to entail shooting a goat (or similar) then saving it's life. Whereas most pig labs (I've only done 3), use a clean scalpel to lacerate/transect a vessel. Real life tends to be messier, however. Tumbling bullets, vasospasm, fragments, powder particles, etc. I'd consider the 18D training better for real life scenarios, though it's harder to scientifically replicate experiments when you introduce the fuzzy variables.
We usually shoot our pigs, thigh shot with rifle (5.56/7.62) and abdominal shot with handgun (9mm).
Not sure your confusion on cardiac output
No confusion on my part.
Gutshot John
10-02-13, 07:24
Renal failure, shock liver, mesenteric ischemia/infarction, ARDS, ect aren't that big of an issue at that point.
I completely disagree with that statement, and I've seen more than one medic make that mistake in the field.
Renal failure might not be the active pathology at that time, but pretending it isn't "that big of an issue" is nonsense. You are working to prevent it's occurrence as you would any other fatal pathology.
That said you totally missed the larger point.
My point was that death to hemorrhage can occur with somewhat less blood loss, than "total" exsanguination, and are just as fatal.
What's the difference between shock that results in organ failure, and death that results from near total exsanguination? To the patient? Zero difference. Dead is dead.
The only difference is from the paramedic perspective in that the patient dies in the ER/OR instead of your rig. That does NOT mean that the patient's death was not the result of your actions/inaction.
Even if the injury occurs right in front of you...you do NOT have time to F^@K around with a severe arterial bleed.
Get on that S#!^.
Gutshot John
10-02-13, 07:28
I see what youre saying (cardiac tamponade, right?) but its a similar mechanism.
No a tamponade isn't specific to a place in the body, it's simply a blockage typified by blood that can occur anywhere, but yes cardiac tamponade is a form of it. Wound packing/Direct pressure would be a form of tamponade as well.
It's where you get the word tampon.
Even if the injury occurs right in front of you...you do NOT have time to F^@K around with a severe arterial bleed.
Get on that S#!^.
I don't think anyone has made an argument supporting this course of action....
Gutshot John
10-02-13, 09:44
I don't think anyone has made an argument supporting this course of action....
Huh? You don't think arterial bleeds should be treated aggressively?
The upshot of this thread was that you have more time than you think to treat a severe arterial hemorrhage, in my experience, you have less.
I don't know that anyone has made an argument that people die in seconds vs. minutes either.
The thing about these threads is that people walk away thinking 2-5 minutes is plenty of time to treat a severe arterial bleed based on exsanguination. It isn't, other factors come into play.
Time is short, 20-30% of BV can result in a fatality due to renal failure, depending on the size of the person this can be about 1-1.5 litres.
It doesn't take very long to lose that much blood...inside of a minute depending on circumstances. So that would be seconds right?
So when I hear things like "it takes some time", based on a video where the guy is clearly DRT by the 3 minute mark (assuming editing hasn't changed the time that much), where renal failure was likely to have been inevitable well before the 2 minute mark, I have to wonder how one comes to the conclusion that "it takes some time"?
No, I meant that I don't see anyone advocating being slow in treating an arterial bleed.
And the guy was not DRT, he died later in hospital, from blood loss. He is still breathing by the end of the clip. Read the article I linked to on the previous page.
Again, the point is that it takes time to bleed to death, so don't give up on a pt just because he has lost blood. It might not be too late to save him. My initial wording was a bit clumsy, but the point still remains: you can still save a pt even if you cannot stop the bleed immediately.
This is true in real life and in trials. Your comments about dying from renal failure do not add up when compared to what is being taught by people with very credible bona fides, in very advanced operational medicine courses regarding survival rates and blood loss.
The human body is an incredibly resiliant organism, and can take quite a beating.
Gutshot John
10-02-13, 11:07
Again, the point is that it takes time to bleed to death, so don't give up on a pt just because he has lost blood. It might not be too late to save him. My initial wording was a bit clumsy, but the point still remains: you can still save a pt even if you cannot stop the bleed immediately.
If that's your point than there is no dispute.
As for the guy, he was called at the hospital later, sure they worked him until they called it, but make no mistake that was a foregone conclusion.
As for the guy, he was called at the hospital later, sure they worked him until they called it, but make no mistake that was a foregone conclusion.
Yup, I think he went over the cliff long before arrival at the hospital.
Is a gunshot wound in that zone common or rare in combat? How large is the zone that can be hit by the bullet and sever that artery? I mean, I know the bullet will flip and yaw, but with as much emplasis as it takes to get a spinal coloumn hit, does the same apply to the femoral zone, or is it if you just hit the upper thigh with a rifle caliber it will likely be damaged?
http://www.youtube.com/watch?v=GGuPQ_oHrvA
It happened to a police officer in Las Vegas a couple years ago. He had a partner who knew what he was doing (former EMT) and saved his life.
St.Michael
02-23-14, 10:26
I am just a normal guy who likes to shoot as a hobby. These videos are always a real eye opener to what this "Hobby" is capable of. I don't know if I missed it, but why did no one help this fella? All those uniforms just standing around watching? I practice Kali so we do a lot of knife fighting and it's true this is a common target with an edged weapon and it's all too easy to hit. I have no experience with ever trying to "apply" this with anything other than a practice knife. Has anyone ever seen an edged weapon do this?
Powered by vBulletin® Version 4.2.5 Copyright © 2024 vBulletin Solutions, Inc. All rights reserved.