Femoral bleedout - Warning *GRAPHIC*

**Djstorm100** · 09-30-13, 14:06

Originally Posted by chuckman

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=Tnqx...has_verified=1

**Arctic1** · 09-30-13, 16:37

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.

**Caduceus** · 10-01-13, 08:32

Originally Posted by Arctic1

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.

**Ironman8** · 10-01-13, 08:49

Originally Posted by Caduceus

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...

**Caduceus** · 10-01-13, 09:19

Originally Posted by Ironman8

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.

**Arctic1** · 10-01-13, 12:18

Originally Posted by Caduceus

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/arti...ked-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.

**Hizzie** · 10-01-13, 13:05

They didn't mention "positional shock" in paramedic school. Could you please describe the patho behind it?

**Arctic1** · 10-01-13, 13:15

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.

**Arctic1** · 10-01-13, 13:24

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.