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Control of life-threatening haemorrhage from the neck: a new indication for balloon tamponade
Injury (1992) 23, (8), 557459
printed in Great Brifuin
557
Control of life-threatening haemorrhage from the neck: a new indication for balloon tamponade D. Gilroy, M. Lakhoo, D. Charalambides and D. Demetriades Department
of Surgery, Baragwanath
Hospital and University
of the Witwatersrand,
Johannesburg,
We report fke we of a Foley cafkefer, placed through fke wound, fo provide balloon famponade of major bleeding from fke neck and suprachvicukxr fossae. In 70 consecutive explorations for exsanguinating injury in fkese regions balloon famponade was used eight times, and was jua’ged fo be fully effecfive in four patients, parfly e$cfive in one, and ineffecfive in three patients
Introduction Injuries to major vessels in the neck and supraclavicular fossae have a high mortality, mainly related to haemorrhage. When major bleeding is present digital pressure may be employed in an attempt to minimize blood loss en rmfe to theatre, and during preparation for surgery. This is not only sometimes difficult and relatively ineffective, but can make skin preparation, draping, and dissection to expose the lesion awkward, as well as being potentially hazardous to the owner of the finger. We report the use of a Foley catheter placed through the wound to provide balloon tamponade in this situation.
Figure 1. Internal jugular wound.
Method of balloon use In essence, the technique is simple. If a suitable (i.e. not gaping, with wide open base) externally bleeding wound is present in the neck (Figure I), a Foley catheter (18 or 2oG) is introduced with a finger into the wound to the estimated or palpated source of bleeding. The balloon is then inflated with saline until the bleeding stops or moderate resistance is felt (Fipre 2 ). Generally 15-20 ml is sufficient. This will often stop the haemorrhage; however, if a deep wound is present or there is a long lesion in the vessel, the balloon may only be providing proximal control. In this case a second catheter is introduced and inflated to provide distal control (Figure 3). In wounds of the supraclavicular fossa, especially if the pleural cavity is penetrated, the catheter should be introduced as far as possible, past the lesion, the balloon inflated and the catheter pulled back firmly and held in place with a large artery clip (Figure 4). This has the effect of preventing bleeding into the chest and compressing the injured vessel onto the first rib or clavicle, depending on its relationship to the balloon. If external bleeding continues after this, a 0 1992 Butter-worth-Heinemann Ltd 0020-1383/92/080557-03
Figure 2. One balloon applied.
South Africa
55s
Injury: the British Journal of Accident Surgery (1992)
Vol. 23/No. 8
Figure 3. Two balloons applied.
second proximal balloon may again be inserted. Blood returning up the lumen of the catheter is an indication of
distal bleeding and, depending on the nature of the wound in question, should prompt adjustment or further inflation of the balloon or clamping of the catheter.
Patients and methods For the period June to September 1990, inclusive, patients admitted to one surgical service with exsanguinating injuries of the neck or supraclavicular fossa were identified prospectively, and use of balloon tamponade evaluated. Other neck explorations for this same period were identified restrospectively. The surgical service in question shares trauma admissions to our hospital with four other services. In this service a policy of selective conservatism is applied to penetrating neck injuries. In the absence of clinical signs of vascular or visceral damage the patient is observed. Angiography is seldom used and visceral contrast studies are only carried out when doubt exists. The cases reported in this series would represent, according to our audit, 25 per cent of the penetrating wounds of the neck or supraclavicular fossae admitted during the study period. Balloon tamponade is used in suitable wounds if brisk external bleeding is seen or if bleeding into the pleural cavity is occurring or is suspected.
Figure 4. One balloon applied to subclavian vein wound.
Balloon tamponade was judged fully effective if there was clinical evidence of haemorrhage before insertion and if haemorrhage was seen to recur after deflation peroperatively. It was judged possibly effective when external haemorrhage was seen which stopped with application of balloon, but in which brisk bleeding did not recur after peroperative deflation.
Results In all, 14 patients were identified who underwent exploration of wounds of the neck or supraclavicular fossae, of which 10 were stab and four were due to gunshots. The age range was 17-36 years and 12 were male. One patient had a negative exploration. One had repair of an isolated laryngeal laceration and two had repairs of isolated oesophageal injuries. The remaining. 10 patients had lesions of blood vessels; details are shown in Tablel. Clinical evidence of
Table I. Summaryof patients
Injury GSW left subclavian vein Stab left internal jugular vein Stab left internal jugular vein Stab left trapezius muscular arteries and veins Stab left first intercostal artery and vein Stab left subclavian vein GSW left subclavian artery and vein GSW left subclavian artery and vein and apex of lung Stab left carotid artery GSW left carotid artery
Initial systolic pressure (mmHg)
Attempted ballon tamponade
0 90 70 110 80 0
Yes Yes Yes Yes Yes Yes
0
Yes Yes No
7: 0
No
Remarks on use of balloon tamponade Fully effective Fully effective Fully effective Fully effective Possibly effective Not effective, not properly applied Not effective Not effective Haematoma but no active bleeding Wound not suitable
Gilroy et al.: Control of haemorrhage from the neck
559
haemonhage, together with a suitable wound led to attempted balloon tamponade in eight of these cases. This was judged to be fully effective in four cases and partly effective in one. In one further case inadequate traction on the catheter prevented full effectiveness. Of the IO patients, three with Sascular injury died, all from the cumulative effects of blood loss.
nique. Additional advantages accrue in terms of ease of skin preparation and safety of the assistant. The presence of the inflated balloon can also aid identification of the wound track during dissection. We have also used balloon tamponade to advantage in other sites, such as the groin, and believe that this technique is a useful addition to the armamentarium of the trauma surgeon.
Discussion
Paper accepted
This small series shows balloon tamponade through the wound to be helpful in controlling life-threatening bleeding in some cases of penetrating injury of the neck, having been very effective in four of the eight cases in which it was used. Venous injuries seem particularly amenable to this tech-
14 April ‘19%.
Requestsfor reprints should be addressedto: Mr D. Gilroy, Department Queen’s University, Clinical Institute, Grosvenor Road, Belfast BT12 2BA, Northern Ireland, UK.
of Surgery,
printed in Great Brifuin
557
Control of life-threatening haemorrhage from the neck: a new indication for balloon tamponade D. Gilroy, M. Lakhoo, D. Charalambides and D. Demetriades Department
of Surgery, Baragwanath
Hospital and University
of the Witwatersrand,
Johannesburg,
We report fke we of a Foley cafkefer, placed through fke wound, fo provide balloon famponade of major bleeding from fke neck and suprachvicukxr fossae. In 70 consecutive explorations for exsanguinating injury in fkese regions balloon famponade was used eight times, and was jua’ged fo be fully effecfive in four patients, parfly e$cfive in one, and ineffecfive in three patients
Introduction Injuries to major vessels in the neck and supraclavicular fossae have a high mortality, mainly related to haemorrhage. When major bleeding is present digital pressure may be employed in an attempt to minimize blood loss en rmfe to theatre, and during preparation for surgery. This is not only sometimes difficult and relatively ineffective, but can make skin preparation, draping, and dissection to expose the lesion awkward, as well as being potentially hazardous to the owner of the finger. We report the use of a Foley catheter placed through the wound to provide balloon tamponade in this situation.
Figure 1. Internal jugular wound.
Method of balloon use In essence, the technique is simple. If a suitable (i.e. not gaping, with wide open base) externally bleeding wound is present in the neck (Figure I), a Foley catheter (18 or 2oG) is introduced with a finger into the wound to the estimated or palpated source of bleeding. The balloon is then inflated with saline until the bleeding stops or moderate resistance is felt (Fipre 2 ). Generally 15-20 ml is sufficient. This will often stop the haemorrhage; however, if a deep wound is present or there is a long lesion in the vessel, the balloon may only be providing proximal control. In this case a second catheter is introduced and inflated to provide distal control (Figure 3). In wounds of the supraclavicular fossa, especially if the pleural cavity is penetrated, the catheter should be introduced as far as possible, past the lesion, the balloon inflated and the catheter pulled back firmly and held in place with a large artery clip (Figure 4). This has the effect of preventing bleeding into the chest and compressing the injured vessel onto the first rib or clavicle, depending on its relationship to the balloon. If external bleeding continues after this, a 0 1992 Butter-worth-Heinemann Ltd 0020-1383/92/080557-03
Figure 2. One balloon applied.
South Africa
55s
Injury: the British Journal of Accident Surgery (1992)
Vol. 23/No. 8
Figure 3. Two balloons applied.
second proximal balloon may again be inserted. Blood returning up the lumen of the catheter is an indication of
distal bleeding and, depending on the nature of the wound in question, should prompt adjustment or further inflation of the balloon or clamping of the catheter.
Patients and methods For the period June to September 1990, inclusive, patients admitted to one surgical service with exsanguinating injuries of the neck or supraclavicular fossa were identified prospectively, and use of balloon tamponade evaluated. Other neck explorations for this same period were identified restrospectively. The surgical service in question shares trauma admissions to our hospital with four other services. In this service a policy of selective conservatism is applied to penetrating neck injuries. In the absence of clinical signs of vascular or visceral damage the patient is observed. Angiography is seldom used and visceral contrast studies are only carried out when doubt exists. The cases reported in this series would represent, according to our audit, 25 per cent of the penetrating wounds of the neck or supraclavicular fossae admitted during the study period. Balloon tamponade is used in suitable wounds if brisk external bleeding is seen or if bleeding into the pleural cavity is occurring or is suspected.
Figure 4. One balloon applied to subclavian vein wound.
Balloon tamponade was judged fully effective if there was clinical evidence of haemorrhage before insertion and if haemorrhage was seen to recur after deflation peroperatively. It was judged possibly effective when external haemorrhage was seen which stopped with application of balloon, but in which brisk bleeding did not recur after peroperative deflation.
Results In all, 14 patients were identified who underwent exploration of wounds of the neck or supraclavicular fossae, of which 10 were stab and four were due to gunshots. The age range was 17-36 years and 12 were male. One patient had a negative exploration. One had repair of an isolated laryngeal laceration and two had repairs of isolated oesophageal injuries. The remaining. 10 patients had lesions of blood vessels; details are shown in Tablel. Clinical evidence of
Table I. Summaryof patients
Injury GSW left subclavian vein Stab left internal jugular vein Stab left internal jugular vein Stab left trapezius muscular arteries and veins Stab left first intercostal artery and vein Stab left subclavian vein GSW left subclavian artery and vein GSW left subclavian artery and vein and apex of lung Stab left carotid artery GSW left carotid artery
Initial systolic pressure (mmHg)
Attempted ballon tamponade
0 90 70 110 80 0
Yes Yes Yes Yes Yes Yes
0
Yes Yes No
7: 0
No
Remarks on use of balloon tamponade Fully effective Fully effective Fully effective Fully effective Possibly effective Not effective, not properly applied Not effective Not effective Haematoma but no active bleeding Wound not suitable
Gilroy et al.: Control of haemorrhage from the neck
559
haemonhage, together with a suitable wound led to attempted balloon tamponade in eight of these cases. This was judged to be fully effective in four cases and partly effective in one. In one further case inadequate traction on the catheter prevented full effectiveness. Of the IO patients, three with Sascular injury died, all from the cumulative effects of blood loss.
nique. Additional advantages accrue in terms of ease of skin preparation and safety of the assistant. The presence of the inflated balloon can also aid identification of the wound track during dissection. We have also used balloon tamponade to advantage in other sites, such as the groin, and believe that this technique is a useful addition to the armamentarium of the trauma surgeon.
Discussion
Paper accepted
This small series shows balloon tamponade through the wound to be helpful in controlling life-threatening bleeding in some cases of penetrating injury of the neck, having been very effective in four of the eight cases in which it was used. Venous injuries seem particularly amenable to this tech-
14 April ‘19%.
Requestsfor reprints should be addressedto: Mr D. Gilroy, Department Queen’s University, Clinical Institute, Grosvenor Road, Belfast BT12 2BA, Northern Ireland, UK.
of Surgery,