Abdominal wounds...interesting concept

[Hmac]

I haven't seen any studies on this device and it's not on the market yet, but it's an intriguing concept.

Anybody here have any practical experience with this "abdominal tourniquet"?

http://gizmodo.com/5876064/this-new-army-tourniquet-is-going-to-save-a-bunch-of-lives?utm_medium=referral&utm_source=pulsenews&fb_source=message

I can see the potential in the military for a bunch of mesomorphic soldiers, but given the USA's truly impressive obesity epidemic, I have reservations about the device's broad application in the civilian population.


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[panzerr]

Interesting idea. I suppose if you position it below the navel you would most likely just push that wedge through the small intestines to occlude the AA (where it bifurcates,) and IVC. There would still be bleeding from the anastomosed arteries and veins but at least you wouldn't have large diameter arterial bleeding. I could see a guy shitting himself because of the increased IAP but I would rather shit myself and deal with the pain of one of these devices than bleed out in some backwater shithole.

[Sensei]

This appears to share similar concepts with the (in)famed MAST Trousers. The big difference being this device situated at the umbilicus as opposed to the leg / pelvic portions of the MAST device.

There are other minimally-invasive aortic occlusive devices out there. A colleague of mine at VCU/MCV in Richmond (Kevin Ward) patented one that is inserted in the esophagus: http://www.google.com/patents/US5716386

I believed that he collected some data using a swine model of hemorrhagic shock, but I do not think that the outcomes were favorable.

[Hmac]

This appears to share similar concepts with the (in)famed MAST Trousers. The big difference being this device situated at the umbilicus as opposed to the leg / pelvic portions of the MAST device.



I don't think so. This point of this device appears to be actual aortic occlusion whereas the point of MAST was venous compression (and pelvic stabilization, I guess :rolleyes:), and compression/occlusion of lower extremity arteries would certainly be unhelpful in intra-abdominal hemorrhage.

If I emergently explore the abdomen in someone in hemorrhagic shock, the first thing I do is slide in the aortic compressor (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1927277/). Obviously, aortic compression has always had to wait for laparotomy (or thoracotomy). This looks to be a device that can be applied pre-hospital. If it works, it could definitely save lives in penetrating trauma.

[ICANHITHIMMAN]

In what situation would one apply this?

[Hmac]

In what situation would one apply this?

My guess would be pre-hospital, hemorrhagic shock with penetrating trauma to the abdomen or in the ER while getting ready to move the patient to the OR. I recently had a young man who shot himself in the abdomen with a .22. Took out the left iliac artery, he became unstable as soon as he hit the ER doors. Aortic occlusion with the aortic compressor (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1927277/) describe above in the OR after opening him up likely saved his life, but I'm glad it didn't take any longer than it did to get him there. That situation strikes me as one where applying an external aortic "tourniquet" device as described in the Gizomdo article as soon as his vital signs started to tank might be useful.

[MAJK]

I'd like to test it but don't think its a great idea. Good thought but I'd like to know how it would affect someone's breathing. I would think airway pressures would increase and TV decrease. There isn't any point in stopping the bleeding if the person can't ventilate. I would like to see an injectable hemostatic agent like celox being used.

ER docs usually dont have a good concept of abdominal hemorrhage control or surgical/trauma critical care. The best thing to do is a thoracotomy w/ cross clamp which isn't really that hard to do but you do need some experience with it.

I'd like to see how it works out but the best thing is getting him to the surgeon (not ER Doc) ASAP. ER docs should really stick with what they know how to do best in a trauma situation...CALL THE TRAUMA SURGEON!!! heheheh

[Hmac]

I'm going to presume that adequate ventilation was high on their list of things to take into account when they designed the device.

That said, your concern reflects my concern about applicability in a population that leads the world in the incidence of obesity. Externally compressing an obese abdomen certainly can't help diaphragmatic excursion, but does it impair it enough to affect the usability of the thing? How about if PPV is being used? We'll see, I guess.

[MAJK]

I'm going to presume that adequate ventilation was high on their list of things to take into account when they designed the device.

That said, your concern reflects my concern about applicability in a population that leads the world in the incidence of obesity. Externally compressing an obese abdomen certainly can't help diaphragmatic excursion, but does it impair it enough to affect the usability of the thing? How about if PPV is being used? We'll see, I guess.

PPV doesnt matter if you restrict a persons lung capacity. Even with out being obese it will be hard to compress the abdomen that much to stop the bleeding. If the wound is under a soldiers plate the vascular injury is distal ... meaning the iliac artery and pelvic wounds. Your not going to compress that area. EDIT Proximal control would help if it does compress the aorta. Pelvic binder is for open book fractures and helps with venous bleeding. An injectable hemostatic agent would be my choice as long as it didn't make the abdomen into a big cement block.

Have someone stand on your stomach and take an opiate to further decrease your respiratory drive then see how you feel. The next thing these guys are going to invent is a tourniquet for your neck.:D

[Hmac]

PPV doesnt matter if you restrict a persons lung capacity. Even with out being obese it will be hard to compress the abdomen that much to stop the bleeding. If the wound is under a soldiers plate the vascular injury is distal ... meaning the iliac artery and pelvic wounds. Your not going to compress that area. Pelvic binder is for open book fractures and helps with venous bleeding. An injectable hemostatic agent would be my choice as long as it didn't make the abdomen into a big cement block.

Have someone stand on your stomach and take an opiate to further decrease your respiratory drive then see how you feel. The next thing these guys are going to invent is a tourniquet for your neck.:D

So....it's impossible that this thing will work, huh?

While we're on the subject of...er...questionable concepts, tell me more about pumping the peritoneal cavity full of Celox, especially the part about how it won't make the abdominal cavity into a cement brick.

:D at the concept of paramedics squirting Celox into the peritoneal cavity. Good one. Assuming you're joking, of course.

[MAJK]

So....it's impossible that this thing will work, huh?

While we're on the subject of...er...questionable concepts, tell me more about pumping the peritoneal cavity full of Celox, especially the part about how it won't make the abdominal cavity into a cement brick.

:D at the concept of paramedics squirting Celox into the peritoneal cavity. Good one. Assuming you're joking, of course.

I'd have to test it and see it first hand but I don't think it will work. I don't want to say without trying it but seems like a bad idea for the above reasons. An injectable hemostatic agent would be better at the role one CCP.

Not much else you can do...just get him to the surgeon (NOT ER DOC) ASAP. An ER Doc will not do anything different than a good medic/PJ/18D in the field. I know a few 18Ds also and they are very good at what they do. However, I did have a 3rd group 18D get sick while doing a BKA :laugh:

[Hmac]

I'd have to test it and see it first hand but I don't think it will work. I don't want to say without trying it but seems like a bad idea for the above reasons. An injectable hemostatic agent would be better at the role one CCP.

Not much else you can do...just get him to the surgeon (NOT ER DOC) ASAP. An ER Doc will not do anything different than a good medic/PJ/18D in the field. I know a few 18Ds also and they are very good at what they do. However, I did have a 3rd group 18D get sick while doing a BKA :laugh:

I'm not sure you have a complete grasp of the anatomy and physiology of the peritoneal cavity, nor of whats actually happening in intraabdominal hemorrhage. You keep talking about an "injectable hemostatic agent" as a means of controlling shock from intraabdominal hemorrhage. What are you talking about? Injecting what into what? How do you propose that's going to work exactly?

Compression is always the first line of controlling arterial hemorrhage, and, as a trauma surgeon, compressing the aorta is the first thing I do when entering the abdominal cavity for shock. If hemorrhagic shock can be identified pre-hospital ddand if this device can be applied pre-hospital before the patient gets to the trauma surgeon, it might save lives from penetrating trauma. Your concerns about not being able to ventilate with abdominal compression are likely unwarranted in normal BMI folks, maybe unwarranted in everyone. I'd have to see the data.

[MAJK]

I'm not sure you have a complete grasp of the anatomy and physiology of the peritoneal cavity, nor of whats actually happening in intraabdominal hemorrhage. You keep talking about an "injectable hemostatic agent" as a means of controlling shock from intraabdominal hemorrhage. What are you talking about? Injecting what into what? How do you propose that's going to work exactly?

Compression is always the first line of controlling arterial hemorrhage, and, as a trauma surgeon, compressing the aorta is the first thing I do when entering the abdominal cavity for shock. If hemorrhagic shock can be identified pre-hospital ddand if this device can be applied pre-hospital before the patient gets to the trauma surgeon, it might save lives from penetrating trauma. Your concerns about not being able to ventilate with abdominal compression are likely unwarranted in normal BMI folks, maybe unwarranted in everyone. I'd have to see the data.



you must know ... your the trauma surgeon

[Hmac]

I'd have to see it applied but putting pressure on the abdomen is going to be very hard to do. I guess its worth a try but I dont think its going to work. Creating an abdominal compartment syndrome might not be the best thing to do. However, as stated above I'd have to test it myself.

As far as injectable hemostatic agents ... I dont think there is one out good enough yet. I would think that would be the way to go.

Trust me I have a very good understanding or thoracic and abdominal anatomy. And I have seen tons of GSWs CONUS and OCONUS.

Your concepts regarding "injectable hemostatic agents" are impractical. Treating a groin wound with Celox or Quikclot doesn't translate to treating a penetrating injury to the aorta or iliac vessels. I'm not sure how practical an external aortic compressor is, but the concept is at least viable while "injectable hemostatic agents" blindly placed in the peritoneal cavity is not.

[MAJK]

as I try it myself with my hand it might work as long as its not compressing your entire abdomen. I guess I'd have to see it work in the field and the data.