The Use of External Counterpressure (G-Suit) in the Management of Traumatic Retroperitoneal Hemorrhage

Vol. 107, June

THE JOURNAL OF UROLOGY

Copyright

© 1972 by The Williams & Wilkins Co.

Printed in U.S.A.

1:'HE USE OF EXTERNAL COUNTERPRESSURE (G-SUIT) IN THE MANAGEMENT OF TRAUMATIC RETROPERITONEAL HEMORRHAGE A. P. MCLAUGHLIN, III,* D. L. MCCULLOUGH, W. S. KERR, JR.

AND

R. C. DARLING

From the Departments of Urology and General Surgery, Massachusetts General Hospital, Boston. Massachusetts

External counterpressure with a gravity suit (Gsuit)t has increased survival in experimental animals with traumatic large vessel lacerations by decreasing local blood loss and maintaining the blood pressure.1 Such external counterpressure controls blood loss by decreasing the vascular transmural pressure and the area of laceration. Central venous pressure, cardiac output and blood pressure are maintained by diverting the effective circulating blood volume to vital organs above the area of G-suit compression. Our successful clinical application of these physiologic principles in patients with massive retroperitoneal bleeding is presented herein. The use of external counterpressure has not been reported previously in the treatment of urologic and pelvic trauma. METHODS

The G-suit is a double layered vinyl plastic envelope which is laced around the patient and may extend from the xyphoid to below the knees. When inflated it exerts a uniform circumferential pressure on body surfaces. Pressure is regulated by an escape valve which leads to a column of water whose depth in centimeters regulates the external counterpressure (fig. 1). The G-suit was used in 3 patients with extensive pelvic trauma involving the urogenital tract. All patients required an operation to re-establish continuity between the bladder and urethra. Postoperatively they were transferred directly from the operating table into the gravity suit which was inflated with 25 mm. Hg pressure. The suit covered the patients from the subcostal margin to the lower legs. All patients remained on endotracheal tubes with ventilatory assistance for varying periods and all received 2 units of fresh whole blood upon arrival in the recovery room. Close monitoring of vital signs, blood chemistry studies and arterial blood gas values served as guidelines for supportive treatment. After 24 to 36 hours of external counterpressure, the G-suit was slowly deflated during a 4 to 6-hour period. A group of 3 patients with similar injuries served as retrospective controls. No injuries involved laceration of the iliac vessels. All patients were male subjects. Accepted for publication October 22, 1971. Read at annual meeting of American Urological Association, Chicago, Illinois, May 16-20, 1971. * Current address: Division of Urology, Department of Surgery, University Hospital of San Diego, San Diego, California 92103. t Kendall Company, Chicago, Illinois. 1 Gardner, W. J. and Storer, J.: The use of the G suit in control of intra-abdominal bleeding. Surg., Gynec. & Obst., 123: 792, 1966.

RESULTS

Extent of injury, treatment and results are summarized in table 1. Prolonged external counterpressure of 20 to 25 mm. Hg was extremely effective in controlling postoperative pelvic bleeding when compared to controls with similar injuries. Each patient in the test group was easily managed except as noted. The single death (case 3) followed multiple complications culminating in a vagotomy and total gastrectomy. Pulmonary function is not compromised by the G-suit and metabolic acidosis has not been a problem (table 2). Gradual release of external counterpressure did not result in re-bleeding. Case 6 illustrates several important diagnostic and therapeutic points. With pelvic fractures, if intraperitoneal visceral injury is suspected, peritoneal aspirations should be made in the upper abdominal quadrants. Since the inferior peritoneal reflexion is usually elevated by pelvic hematoma, lower quadrant aspirations are almost always extraperitoneal and give falsely positive results. Preoperatively, this patient had a positive lower quadrant aspiration and at laparotomy no intraperitoneal bleeding was noted. Although no major arterial or venous injury involving the iliac vessels was suspected, pelvic exploration was carried out resulting in uncontrollable bleeding and death. The pelvic hematoma forms a natural tamponade when major vessels are intact and should not be disturbed. Application of external counterpressure therapy was inappropriate, poorly timed and ineffectual in a terminal patient whose clotting factors were grossly abnormal following more than 60 transfusions. PHYSIOLOGY OF EXTERNAL COUNTERPRESSURE

The effects of external counterpressure are exerted locally at the area of injury and systemically on the circulatory system. Animal experimentation, involving lacerations made in large and small veins, conclusively demonstrated a marked decrease in blood loss and an increased survival in dogs placed in the gravity suit. External counterpressure decreased blood loss in these cases by producing a reduction in the size of the laceration and decreasing regional blood flow. 2 A uniform circumferential pressure is exerted which decreases the diameter of the internal lumen of the vessel and counteracts the hydrostatic pressure exerted by blood flow which itself tends to pull the vessel walls apart (transmural pressure) 2 Ludewig, R. M. and Wangensteen, S. L.: Effect of external counterpressure on venous bleeding. Surgery, 66: 515, 1969.

940

94:l

USE OF G-SUIT IN MANAGEMENT OF RETROPERITONEAL HEMORRHAGE

Fm. 1. G-suit is vinyl plastic bag which laces around patient. Air is introduced. through inlet tube and pressure is adjusted. by height of water column in escape bag. Redrawn from Gardner .1 TABLic

1. Treatment results Transfusion Requirement (cc)

Case

Pt. Age

Operation

Extent of Injury

Preop.

Intraop.

Postoo.

Laparotomy, passage of urethral catheter, suprapubic cystotomy Same as case 1

4,500

4,500

1,000'

2,000

6,000

2,000-r

Same as case 1

6,000

8,000

2, ooot

1,500

5,000

5,000

3,000

8,000

20,000

10, 000§

Injuries treated with external counterpressure

1-MGH 1621996

19

2-MGH 1634698

24

3-MGH 1612239

27

4-MGH 1566973

17

5-MGH 1587835

17

6-MGH 1676377

75

Multiple comminuted pelvic fractures, transection prostatic urethra Fracture pubic rami bilaterally, transection of prostatic urethra, bilateral hemothorax Fracture pubic rami bilaterally and left ilium. Massive scrotal hematoma, transection of urethra

Iniuries treated without external counterpressure Fractures right superior and inferior pubic rami with dislocation right hip, partial transsection of urethra Multiple pelvic fractures including right acetabulum, fracture left femur Fractures right ilium, right acetabulum and right pubic rami

Closed reduction right hip

Repair right sciatic nerve

Exploratory laparotomy, evacuation pelvic hematoma

Data not available

2,500

"' According to protocol. ·f 1,000 cc whole blood given postoperatively following evacuation of 2,800 cc hemothorax. t Death from pulmonary fat emboli, upper gastrointestinal bleeding and acute tubular necrosis. § Death with severe metabolic and respiratory acidosis anuria and shock with hematocrit 20 per cent. G-suit applied terminally with no effect.

(fig. 2). The transmural pressure is decreased in proportion to the intraperitoneal pressure (G-suit pressure) and results in a significantly slower rate of leakage as indicated by the Bernoulli equation. Angiography has documented a reduction in the diameter of the inferior vena cava by 40 per cent and a decrease in the area of the vascular bed beneath the gravity suit. 3 These factors as well as a fall in regional blood flow up to 30 per cent shorten the duration of bleeding from experimental venous lacerations and aid in clotting hemostasis. 3 Wangensteen, S. L., Ludewig, R. M. and Eddy, D. M.: The effect of external counterpressure on the intact circulation. Surg., Gynec. & Obst., 12'i: 253, 1968.

Experience with arterial lacerations in the abdominal aorta and femoral vessels in animals in the G-suit also indicates an increased survival in these test animals. The volume of blood lost in test animals with arterial lacerations and the rate of bleeding are less when compared to control animals not treated with external counterpressure. 4 • 5 Shaftan, in his experiments with arterial hemorrhage, showed clearly that cessation of bleeding occurs 4 Wangensteen, S. L., Ludewig, R. M., Cox, J. M. and Lynk, J. N.: The effect of external counterpressure on arterial bleeding. Surgery, 64: 922, 1968. 6 Wangensteen, S. L., Eddy, D. M. and Ludewig, R. M.: The hydrodynamics of arterial hemorrhage. Surgery, 64: 912, 1968.

942

MCLAUGHLIN AND ASSOCIATES TABLE

2. Arterial blood gas values

MGH 1621996

FO,

p02 --

Intraoperatively 2 hours postoperatively (Bird respirator) 9 hours postoperatively (Briggs-JO L flow) 12 hours postoperatively (extubated face mask 02) 24 hours postoperatively (extubated G-suit deflated)

pC02

pH

CVP*

Hct.

-- -- -- - -

.3 .8

155 535

42 37

7.41 7.52

37 39

12 6

.5

355

49

7.38

37

7

.5

366

50

7.39

36

10

.5

412

47

7 .46

36

5

* CVP-central venous pressure.

THE LAW OF LA PLACE

B

A

After G-Suit

Before G-Suit

t ,_-

Laceration

T@ T

p

X

p\'(( r~~~~:~n

fw

p',,..

T'

R

\

,p I

(P-P') X R'

T = tension P

=

Transmural f>ressure (intraluminal - extraluminal pressure)

R = Radius of Vessel

F1G. 2. Uniform circumferential pressure exerted by G-suit decreases tension in vessel wall by lowering transmural pressure (P-P') and by reducing radius (R'). External counterpressure slows rate of leakage from blood vessel wall by decreasing area of laceration and transmural pressure. This is calculated by Bernoulli equation:

Q=

A

°V

(6.P/p)+

y2

where Q rate of leakage, A = area of laceration, 6-P = transmural pressure, p = density of fluid and V = velocity. when a soft, extramural clot forms at the end of the severed artery. This event took place only after a mean drop in arterial pressure of 35 mm. Hg. Vasoconstriction and intramural thrombosis are late, secondary events in the control of arterial hemorrhage. 6 External counterpressure in arterial injuries produces similar circumferential or hoop forces around the lacerated artery but these forces may be less effective because of the decreased compressibility of the high pressure arterial system. It does promote a decrease in the rate of bleeding and increased 6 Sha.ftan, G. W., Chiu, C., Dennis, C. and Harris, B.: Fundamentals of physiological control of arterial hemorrhage. Surgery, 68: 851, 1965.

survival by allowing clotting hemostasis to occur at a higher blood pressure equivalent to the increment of artificial extramural pressure applied. Elegant proof of this was demonstrated in heparinized animals with arterial lacerations placed in the gravity suit. There was no difference in survival between this group and the untreated control animals. 7 The effects of pneumatic compression on cardiovascular dynamics after hemorrhage was clearly documented by Ferrario and associates in 75 experimental dogs. 8 Sixty of the dogs were bled an average of 30 cc blood per kg. while 15 dogs were not phlebotomized and served as controls. After bleeding, arterial pressures, stroke volume, central venous pressure and cardiac output decreased while the total peripheral resistance increased proportionately. These changes were reversed by applying the G-suit at a pressure of 30 mm. Hg for 1 hour. Arterial pressures, stroke volume, cardiac output and mean carotid flow increased, while the mean femoral arterial blood flow decreased. The inferior vena cava and intraperitoneal pressures rose in proportion to the G-suit pressure. The authors concluded that the effectiveness of circumferential pneumatic pressure is due to an increase in the circulating blood volume in the area outside of the gravity suit. This autotransfusion maintains vital cardiopulmonary function without deleterious effect (fig. 3). Renal function may be altered with G-suit compression. Results suggest an increase in renal vascular resistance, resulting in decreased renal perfusion and a fall in the glomerular filtration rate. However, renal tubular function remains unaltered and salt and water absorption are enhanced. 9 Because these experiments were not controlled and since contradictory evidence by Skinner and associates suggests that there is no change in renal blood flow in kidneys subjected to external counterpressures of 15 to 40 mm. Hg, the effect of the G-suit on renal function remains unanswered.1° Pulmonary function may be slightly altered in the gravity suit as suggested by Espinosa who noted an increased respiratory rate and a decrease in the vital capacity by 18 per cent in healthy volunteers. 11 Conversely, Gardner and Dohn reported no change in vital capacity in their study group. 12 7 Ludewig, R. M. and Wangensteen, S. L.: Aortic bleeding and the effect of external counterpressure. Surg., Gynec. & Obst., 128: 252, 1969. 8 Ferrario, C. M., Nadzam, G., Fernandez, L. A. and Gardner, W. J.: Effects of pneumatic compression on the cardiovascular dynamics in the dog after hemorrhage. Aerospace Med., 41: 411, 1970. 9 Shenasky, J. H., II and Gillenwater, J. Y.: The effects of external abdominal counterpressure on renal function. Surg. Forum, 21: 528, 1970. 10 Skinner, S. L., McCubbin, J. W. and Page, I. H.: Control of renin secretion. Circ. Res., 16: 64, 1964. 11 Espinosa, M. H. and Updegrove, J. H.: Clinical experience with the G-suit. Arch. Surg., 101: 36, 1970. 12 Gardner, W. J. and Dohn, D. F.: The antigravity suit (G-suit) in surgery. Control of blood pressure in the sitting position and in hypotensive anesthesia. J.A.M.A., 162: 274, 1956.

USE OF G-SUIT IN MANAGEMENT OF RETROPERITONEAL HEMORRHAGE

943

G-suit

j Transmural

G-suit

Bleeding

,fl

j Peripheral

,!;BP~ tPulse Vasoconstriction

f below to above diaphragm

i Carotid ! Femoral

•

Mean systemic filling pressure

i Venous

Autotransfusion from

pressure

resistance below diaphragm

return to heart

•

i Right atrial pressure i Stroke volume

artery flow

artery flow

Arterial pressure

~ i

I

Net Result ---

Arterial

BP

i Pulse

Fm. 3. Effect of external counterpressure on circulatory system THE MANAGEMENT OF EXTERNAL COUNTERPRESSURE THERAPY

When the use of external counterpressure is contemplated prior to an operation to control hemorrhage, careful planning is vital before the patient is placed in the gravity suit. Accurate diagnosis and thorough preparation with a urethral catheter and a nasogastric tube should be carried out before the G-suit is inflated. We know of 1 patient who did not have the nasogastric tube placed and subsequently died of vomiting and aspiration. Another patient mentioned by Espinosa had the gravity suit released for placement of a urethral catheter and suffered a fatal drop in blood pressure.U Radial artery catheters as well as central venous pressure lines are helpful. Wrapping the patient with a light cotton padding material similar to that used beneath casts is useful in avoiding skin maceration. Special pads over the heads of the fibula should prevent peroneal nerve injury. A source of continuous pressure in the suit, such as compressed air, is preferable since small leaks may be present in the plastic material. In cases requiring gTavity suit application preoperatively it would seem wise to release it only after the patient has received muscle relaxants in the operating room, since this often results in a precipitous drop in blood pressure. One should be ready to make the surgical incision promptly after removal of external counterpressure. Timing and thoughtful execution of the steps in diagnosis and therapy are vital. In our patients the gravity suit was applied immediately postoperatively to encompass the area of pelvic injury. Our treatment protocol includes prompt transfusion with 2 units of fresh blood to aid clotting homeostasis. Any tendency towards acidosis is easily treated with bicarbonate and mechanical respirator adjustments. Jf ventilation becomes compromised pneumo-hemothorax rather than G-suit problems should be suspected as illustrated by case 2. It has been advantageous to maintain our severely injured patients with ventilatory assistance for approximately 24 hours. Deflation of the gravity suit should be gradual to avoid. sudden changes in the

cardiovascular system and blood volume redistribution. DISCUSSION

Patients with severe pelvic trauma are a high risk group. Observers commenting on their management offer a variety of opinions concerning treatment. Ravitch advocated non-operative management until 10 L of blood had failed to resuscitate the patient. 13 Major vascular injuries should be suspected if sustained improvement in shock is not achieved blood transfusions equal to the estimated blood ume in l hour and especially when the fracture involves the sacro-iliac joints. 14 With arterial either direct repair or hypogastric artery ligation been recommended. 15 However, the efficacy of this surgical maneuver remains controversial.1 6 With major venous injuries, ligation of major veins may only increase bleeding from injured collateral veins and direct repair of major venous lacerations seems indicated.17 Opening of the posterior peritoneum destroys a valuable tamponade effect and has been disastrous on many occasions, as noted in our case 6. Unless major vessel injury is demonstrated or suspected, the retroperitoneal hematoma should remain undisturbed. If there is major vessel injury, intraperitoneal jury or documented bladder perforation with or without urethral transection, we believe ~u''""'U"" ploration is indicated. Hawkins and associates smnmarized other factors influencing the decision for laparotomy in patients with the crushed syndrome. He noted that suture ligature, hypogastric artery ligation, aortic cross clamping and 13 Ravitch, M. M.: Hypogastric artery ligation acute pelvic trauma. Surgery, 56: 601, 1964. 14 Motsay, G. J., Manlove, C. and Major venous injury with pelvic fracture. J.

9: 343, 1969. 15 Miller, W. E.: Massive hemorrhage in fractures of the pelvis. Southern Med. J., 56: 933, 1963. 16 Quinby, W. C.: Pelvic fractures with hemorrhage (editorial). New Engl. J. Med., 284: 669, 1971. 17 Quinby, W. C., Jr.: Fractures of the pelvis and associated injuries in children. J. Pediat. 1; 353, 1966.

944

MCLAUGHLIN AND ASSOCIATES

packing have been fruitless in many cases of persistent pelvic bleeding. 18 We have used the gravity suit in similar patients with major pelvic and urogenital injuries following surgical exploration. Postoperative blood requirements were markedly reduced in patients placed immediately in the G-suit. Since 60 per cent of patients who die as a result of pelvic trauma die of blood loss, the use of the G-suit may be a clinical advancement in the treatment of these cases. External counterpressure of 20 to 25 mm. Hg up to 36 hours was sufficient to control pelvic bleeding and there was no evidence of significant re-bleeding following careful decompression. Cardiac output along with perfusion of vital structures above the area of G-suit compression including the kidney was maintained. All patients maintained normal renal function and had excellent urine outputs during treatment. Counterpressure has avoided the hazards of hypotension followed by acute renal failure which has been a serious complication in traumatic injuries. Respiratory acidosis and other metabolic problems were not encountered during external counterpressure therapy. Assisted ventilation was required because of the severity of these injuries and because large amounts of morphine with muscle relaxants were given intraoperatively. Patients who were extubated while still in the G-suit encountered no respiratory difficulty. Prolonged treatment with the G-suit inflated to 25 mm. Hg is safe without deleterious effects. 19 Other areas of application include the preoperative treatment of trauma to control blood loss temporarily and to allow sufficient time for medical resuscitation, in instances of major renal injury and in unusual circumstances in which 18 Hawkins, L., Pomerantz, M. and Eiseman, B.: Laparotomy at the time of pelvic fracture. J. Trauma,

10: 619, 1970. 19 Wangensteen, S. L., DeHoll, J. D., Ludewig, R. M. and Madden, J. J., Jr.: The detrimental effect of the G-suit in hemorrhagic shock. Ann. Surg., 170:

187, 1969.

transfusions are unavailable. Its efficacy in controlling pelvic bleeding following a vesical or prostatic operation or after renal transplantation is being explored. It might prove to be life saving in a hemorrhaging Jehovah's Witness, as mentioned by Gardner.20 One of us (R. C. D.) has been using the G-suit in the management of ruptured abdominal aortic aneurysms since 1967. It has been available for use in 27 patients. All patients had massive retroperitoneal blood loss and 17 were in profound shock at the time of hospitalization. With the use of the Gsuit, there have been no deaths in the emergency room or prior to induction of anesthesia. In the past about 66 per cent of deaths have been directly related to massive blood loss occurring at the time of rupture and half of these patients died on the way to the operating room. In the aortic aneurysm patients in shock, blood pressures rose significantly after application of the G-suit. One case is illustrative: J. F., an elderly woman, was in shock from an intraperitoneal rupture of an aortic aneurysm. The G-suit was placed with rapid restoration of vital signs to normal levels. With removal of the G-suit for an ill-advised reexamination of the abdomen, the patient again went into profound shock but responded once again following re-application of the G-suit. These statistics substantiate the clinical value of external counterpressure therapy in this group of patients. SUMMARY

This is the initial report concerning the use of the gravity suit as adjunctive therapy in the treatment of major pelvic trauma involving the urogenital tract. The physiological principles of external counterpressure on the cardiovascular system are presented and guidelines for using the gravity suit in patients with massive retroperitoneal bleeding are outlined. 20

Gardner, W. J.: Personal communication, 1967.