Femoral bleedout - Warning *GRAPHIC*

**Arctic1** · 10-02-13, 01:47

Originally Posted by Caduceus

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.

**Caduceus** · 10-02-13, 05:38

Originally Posted by Arctic1

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.

**Arctic1** · 10-02-13, 06:24

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

Originally Posted by Texas42

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

Originally Posted by Caduceus

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.

**Arctic1** · 10-02-13, 08:52

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

Originally Posted by Arctic1

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"?

**Arctic1** · 10-02-13, 10:26

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

Originally Posted by Arctic1

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.