Randomised controlled trial of tourniquet associated pain generated in lower limb after exsanguination by Esmarch bandage versus limb elevation.

BACKGROUND: Tourniquets are common adjuncts in the operating theatre but can be associated with post-operative pain. This study was designed to compare what effect pre-tourniquet Esmarch bandage exsanguination has on pain, compared to pre-tourniquet exsanguination by elevation alone. METHODS: 52 volunteers (104 lower limbs) were included in this study with each volunteer acting as their own matched control. The primary outcome was patient reported pain, measured in both legs simultaneously using area under curve. Secondary outcomes were pain score during inflation and deflation, cumulative pain score, duration of recovery and blood pressure during testing. RESULTS: Pain after Esmarch was superior to elevation as measured by area under pain curve (68.9 SD 26.1 vs 77.2 SD 27.3, p = 0.0010), independent of leg dominance. Cumulative pain scores demonstrated the same superiority after inflation (50.7 SD 17.1 vs 52.9 SD 17.0, p = 0.026) but not after deflation (p = 0.59). Blood pressure was not significantly different. Time to full recovery of the lower limb was the same for both groups-7.6 min (SD 2.1 min, p = 0.80). CONCLUSION: Previous studies describe a positive effect on pain when Esmarch bandage was used prior to tourniquet inflation for upper limb. Our findings suggest the same benefit from Esmarch when it was used on lower limbs-particularly during inflation of tourniquet. In addition to pain profiles, surgeon preference and patient factors need to be considered when deciding between elevation and Esmarch bandage.

Comparing outcomes in patients with exsanguinating injuries: an Eastern Association for the Surgery of Trauma (EAST), multicenter, international trial evaluating prioritization of circulation over intubation (CAB over ABC).

INTRODUCTION: Hemorrhage is a major cause of preventable trauma deaths, and the ABC approach is widely used during the primary survey. We hypothesize that prioritizing circulation over intubation (CAB) can improve outcomes in patients with exsanguinating injuries. METHODS: A prospective observational study involving international trauma centers was conducted. Patients with systolic blood pressure below 90 who were intubated within 30 min of arrival were included. Prioritizing circulation (CAB) was defined as delaying intubation until blood products were started, and/or bleeding control was performed before securing the airway. Demographics, clinical data, and outcomes were recorded. RESULTS: The study included 278 eligible patients, with 61.5% falling within the "CAB" cohort and 38.5% in the "ABC" cohort. Demographic and disease characteristics, including age, sex, ISS, use of blood products, and other relevant factors, exhibited comparable distributions between the two cohorts. The CAB group had a higher proportion of penetrating injuries and more patients receiving intubation in the operating room. Notably, patients in the CAB group demonstrated higher GCS scores, lower SBP values before intubation but higher after intubation, and a significantly lower incidence of cardiac arrest and post-intubation hypotension. Key outcomes revealed significantly lower 24-hour mortality in the CAB group (11.1% vs. 69.2%), a lower rate of renal failure, and a higher rate of ARDS. Multivariable logistic regression models showed a 91% reduction in the odds of mortality within 24 h and an 89% reduction at 30 days for the CAB cohort compared to the ABC cohort. These findings suggest that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries. CONCLUSION: Post-intubation hypotension is observed to be correlated with worse outcomes. The consideration of prioritizing circulation over intubation in patients with exsanguinating injuries, allowing for resuscitation, or bleeding control, appears to be associated with potential improvements in survival. Emphasizing the importance of circulation and resuscitation is crucial, and this approach might offer benefits for various bleeding-related conditions.

Death from exsanguination due to power drill injuries in a complex suicide: a case report.

We present a case of a complex suicide of a 66-year-old man with a history of several psychiatric disorders. He attempted to commit suicide by inflicting cut wounds on his forearms, wrists, and neck but afterwards changed the method of suicide by using an electric power drill. After several unsuccessful attempts to drill a hole in either his head, thorax, or abdomen, he managed to perforate the common carotid artery on the right side of his neck and subsequently died from exsanguination.

[The application of a new type of sterile elastic exsanguination tourniquet in aspiration surgery for upper limb lymphedema].

Objective: To evaluate the effect of a new type of sterile elastic exsanguination tourniquet (SEET) in aspiration surgery for upper limb lymphedema. Methods: The clinical data of 159 patients who underwent aspiration surgery for upper limb lymphedema from January 2017 to June 2022 in the Beijing Shijitan Hospital, Capital Medical University were retrospectively analyzed. Among them, 54 patients were treated with SEET (SEET group), while 105 patients were not treated with SEET (No-SEET group). The propensity score matching method was used, and the surgical indicators and complications were compared between the two groups. The factors affecting intraoperative bleeding volume were analyzed through multiple linear regression analysis. Results: A total of 49 pairs of patients were successfully matched by the propensity score method. The age of patients in the SEET and No-SEET groups was (57.7±8.9) years and (56.8±9.1) years, respectively. Compared with the Non-SEET group, the SEET group had less bleeding volume [(311±164) ml vs (437±173) ml, P<0.001]. The results of multiple linear regression analysis showed that the factors affecting intraoperative bleeding volume included age (ß=-0.142, P=0.041), using the SEET (ß=-0.249, P=0.002), surgical time (ß=0.195, P=0.010) and the amount of fat mixture sucked out (ß=0.464, P<0.001). Conclusions: The clinical application of the SEET in aspiration surgery for upper limb lymphedema is safe, and can significantly reduce the bleeding volume and alleviate blood shortage.

Advances in trauma care to save lives from traumatic injury: A narrative review.

ABSTRACT: Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment.As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.

A Case of Fatal Exsanguination by a Japanese Short Sword.

ABSTRACT: We report a rare case of fatal exsanguination by a wakizashi , a Japanese short sword ( shinken ). A man in his 60s was found lying on his back on his bed. He was in cardiopulmonary arrest when the ambulance crew arrived and was pronounced dead on arrival at the hospital. A wakizashi with blood stains on the blade was found on the floor, and blood was present on the bed sheets on which the man was found. Autopsy revealed an incised wound extending diagonally from superolaterally to inferomedially on the anterior left thigh as the only injury. The wound appeared mostly straight, approximately 44 cm long and 9 cm deep, with smooth walls. The left femoral artery and vein had been cleanly severed, and the cause of death was determined to be blood loss from the severed blood vessels. The wakizashi (blade length, 45 cm) was large enough to have caused the wound, and the left thigh was presumed to have been incised by a downward slash from the sword.

Exsanguination from ruptured femoral artery pseudoaneurysm - A fatal complication of groin heroin injection.

Intravenous drug users (IDUs) eventually encounter a common problem- a need to turn to a new vessel to inject drugs. Whether it is because no other spot is available due to scarring or convenience, the groin is the preferred spot for some. Chronic puncture of femoral vessels can lead to a rare but significant complication- femoral artery pseudoaneurysm (FAP). Its fatal consequence- rupture and bleeding is well recognized, but the forensic literature on this subject is limited. We present eight cases of exsanguination due to the ruptured FAP in IDUs who share most or all the following characteristics: long-term heroin use and/or pronounced drug use stigmata, chronic groin injection-related lesions, absence of significant precipitating pseudoaneurysm trauma, and no or minimal concentrations of heroin metabolites in blood. The FAP presentation varied greatly, from palpable fist-sized mass or slight elevation under the skin defect to infundibular arterio-cutaneous fistula that ruptured through the skin induration. In some, surrounding skin or soft tissue showed signs of inflammation but without suppuration. The most prominent FAP characteristic was smooth-surface cavitation on cross-sections. We performed microscopic evaluation in two cases and verified disruption of the artery wall (i.e., pseudoaneurysm) with elements of acute and chronic inflammation and fibrosis; foci of fibrinoid necrosis were noticed on the arterial wall. All subjects were pale, with faint hypostasis and organ anemia, consistent with reported massive hemorrhage. Because such sudden, unwitnessed, and suspicious deaths may raise the question of injury infliction, proper autopsy evaluation is crucial, for which we propose guidelines.

Exsanguination From Superficial Lower Extremity Trauma.

ABSTRACT: Deaths related to exsanguination are not rare; however, most are related to large-caliber blood vessel or organ disruption. This article reports 2 deaths from external hemorrhage arising from superficial lower extremity trauma in persons with peripheral vascular disease and anticoagulant therapy. The first involved a 78-year-old woman who was found unconscious in her home by a relative, with a plastic bag tied around her left foot and evidence of profuse hemorrhage arising from a left great toenail partial avulsion injury. The second involved a 48-year-old male resident of an adult group home who was involved in a physical altercation with a group home employee, who reportedly kicked the decedent in the right shin, resulting in extensive hemorrhage and death. The cases highlight the fact that lethal exsanguination can occur from superficial trauma. Persons with peripheral vascular disease and those taking anticoagulants may be at particular risk for such deaths.

Extra Peritoneal Packing for Exsanguinating Pelvic Hemorrhage: Should We Do It in the Emergency Department?

BACKGROUND: Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage. OBJECTIVES: To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR). METHODS: Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008-2018. RESULTS: Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038). CONCLUSIONS: EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT.

A rare suicide case involving fatal bleeding from varicose veins.

This case report deals with a sharp force suicide case, which may challenge the experience of many forensic pathologists as well as the studies published to date. An overview of the published cases shows that sharp force suicides account only for 1.6%-3% of all suicides and the self-inflicted injuries are usually localized on the body parts easily accessible with one's hand including the neck, thorax, or upper extremities, as well as in locations of major vascular bundles or vital organs. Reported, however, is a case in which the victim relied on the knowledge of her medical condition and used a kitchen knife to incise her varicose veins, which resulted in fatal bleeding. The case is rare on a number of grounds: incision of varicose veins is rarely the method of choice in suicide cases, injuries of peripheral veins are rarely fatal, and so are injuries of isolated veins where no damage to arteries is suffered.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature.

INTRODUCTION: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. METHODS: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. RESULTS: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. CONCLUSIONS: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature / Uso de torniquete nas hemorragias de extremidades na população civil: revisão sistemática da literatura

ABSTRACT Introduction: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. Methods: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. Results: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. Conclusions: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

RESUMO Introdução: o uso de torniquete em extremidades (TQ) aumentou no ambiente civil; os resultados benéficos observados nas forças armadas influenciaram a aceitação por equipes de pré-hospitalar (PH) assim como pela população leiga. Esta revisão teve como objetivo analisar os tipos de TQ de extremidades usados em ambiente civil, local da lesão, indicações e complicações. Métodos: revisão sistemática foi conduzida com base em artigos originais publicados no PubMed, Embase e Cochrane seguindo as diretrizes do PRISMA de 2010 a 2019. Extração de dados focada no uso de TQ de extremidade para controle de hemorragia em ambiente civil, dados demográficos, tipo de estudo e duração, mecanismo de lesão, indicações de uso, local da lesão, tipo de TQ, tempo de TQ e complicações. Resultados: dos 1.384 artigos identificados, 14 foram selecionados para revisão com total de 3.912 vítimas civis com hemorragia nas extremidades e 3.522 colocações de extremidades TQ analisadas. A maioria foi aplicado em pacientes do sexo masculino (79%), com trauma contuso ou penetrante. Entre as indicações estavam choque hemorrágico, suspeita de lesões vasculares, sangramento contínuo e amputações traumáticas parciais ou completas. A aplicação na extremidade superior foi o local de aplicação mais comum (56%), quase todos aplicados a uma única extremidade (99%), e apenas 0,6% requereram aplicações nas extremidades superior e inferior. 80% dos TQs aplicados eram dispositivos comerciais e 20% improvisados. Conclusões: o uso de TQ em ambientes civis está associado a traumas. Os TQs comerciais são mais utilizados, com tempo menor que uma hora de uso e poucas complicações.

Fatal rooster attack.

A 76-year-old woman was attacked by a domestic rooster on her rural property while collecting eggs. The bird pecked her lower left leg causing significant hemorrhage with collapse and death. The decedent's past medical history included treated hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus and varicose veins. At autopsy the major findings were limited to the lower left leg which was covered with adherent dried blood. Two small bleeding lacerations were present, one of which was located immediately over a perforated large varix. Death was therefore due to exsanguination from bleeding varicose veins following an attack by a rooster. This case demonstrates that even relatively small domestic animals may be able to inflict lethal injuries in individuals if there are specific vascular vulnerabilities present.

Thoracic Visceral Compression-A Useful Technique for Demonstrating Small Bleeding Points in the Dissected Neck at Autopsy.

A 29-year-old man died at the scene of an altercation from a stab wound to the left side of the neck. At autopsy, careful in situ examination of the common carotid artery did not reveal any evidence of hemorrhage or apparent vascular injury. However, applying pressure to the chest wall and underlying thoracic viscera (lungs and heart) resulted in filling of the collapsed vessel with blood causing hemorrhage from a small incision on the medial aspect of the common carotid artery. Release of pressure and drying of the dissection field enabled the artery to be opened and the small defect to be identified. This technique may be used to temporarily restore blood to a vessel to help identify a small bleeding point that may otherwise be difficult to detect.

Right Ventricle Rupture After Open Heart Surgery.

The potential complications of cardiac surgery with sternotomy include mediastinitis and major bleeding, events that are infrequent but carry high mortality.We report a unique complication of median sternotomy. A 71-year-old man underwent coronary artery bypass grafting complicated by sternal dehiscence on postoperative day 7. One week after discharge, he presented with purulent drainage from the sternal wound bed and was diagnosed as having mediastinitis. Irrigation, debridement, and sternal reconstruction were performed. Two days later, bleeding was observed in the wound, and during surgical exploration, a tear in the right ventricle was discovered, and the patient exsanguinated and died. Autopsy findings included focal adhesions connecting the posterior sternum to the right ventricle wall, as well as microscopic evidence of focally extensive fatty infiltration along the rupture margin of the myocardium.Pertinent aspects of the case are reviewed, with particular attention to the possible microbial etiology of mediastinal infection and most likely mechanisms of injury contributing to the fatal right ventricular rupture.