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Thread: Femoral bleedout - Warning *GRAPHIC*

  1. #21
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    Quote Originally Posted by Gutshot John View Post
    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.

  2. #22
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    Quote Originally Posted by Hizzie View Post
    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.

  3. #23
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    Quote Originally Posted by Gutshot John View Post
    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.

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    Quote Originally Posted by Failure2Stop View Post
    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.

  5. #25
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    Quote Originally Posted by chuckman View Post
    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.

  6. #26
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    Quote Originally Posted by Gutshot John View Post
    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.
    It's not about surviving, it's about winning!

  7. #27
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    Quote Originally Posted by Gutshot John View Post
    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)
    Last edited by Caduceus; 10-01-13 at 21:07.

  8. #28
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    Quote Originally Posted by Caduceus View Post
    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.

  9. #29
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    Quote Originally Posted by Gutshot John View Post
    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.

  10. #30
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    Quote Originally Posted by Gutshot John View Post
    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.

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