Control of major haemorrhage

EMERGENCY SURGERY

Control of major haemorrhage

Causes of major haemorrhage Trauma e Blunt injury e Penetrating injury

Kurian J Mylankal Michael G Wyatt

Iatrogenic Surgical e Primary e Reactionary e Secondary

Abstract Major haemorrhage defined as ‘life-threatening bleeding’ is associated with significant morbidity and mortality. Prompt and expeditious control of haemorrhage is essential to improve patient outcome and this requires a sound understanding of the fundamental principles of haemorrhage control. Knowledge of the mechanism of injury in trauma and a systematic approach to clinical examination and assessment of blood loss are essential to identify the patient with a life-threatening bleed. Permissive hypotension, correction of coagulopathy and avoidance of hypothermia are important during the resuscitation phase. Special investigations for major haemorrhage are reserved for the haemodynamically stable patient. There are some surgical principles which apply to the various scenarios of major haemorrhage and in particular the concept of damage control surgery is relevant here. Endovascular interventions have added a further dimension to our management strategy. This article aims to discuss some of the principles that govern the management of the patient with major haemorrhage.

Pathological

Box 1

trauma-related haemorrhage in the UK. Injury sustained during trauma may be penetrating, blunt or a combination of the two. A clear understanding of the pattern of tissue injury is critical in planning effective management strategies. Penetrating injury Stabbing and gunshot wounds are the common causes of penetrating injury. In stabbing, tissue damage ensues from transfer of low-level energy along the track created by the instrument. Damage is confined to this track and tissues away from this site remain unaffected. Major haemorrhage occurs from disruption of the solid organs and vasculature along the path of the instrument. Gunshot injury transfers kinetic energy from the projectile onto the tissue and the extent of damage is dependent on energy dissipated in the tissue before exit of the missile. This energy is displaced in a radial fashion producing a cavitation effect within the tissues. Vascular structures and solid organs produce a significant deceleration force on the missile with transfer of kinetic energy and destruction of the tissues.

Keywords Coagulopathy; damage control surgery; endovascular; haemorrhage control; life-threatening bleed; major haemorrhage; packing

Introduction Major haemorrhage in the surgical patient refers to a lifethreatening bleed. The Advanced Trauma Life Support (ATLS) programme introduced by the American College of Surgeons in 1997 defines major haemorrhage as blood loss greater than 40% (2 litres) of total circulating volume. Major haemorrhage is a direct cause for increased patient morbidity and mortality. Unexpected and uncontrolled major haemorrhage during surgery can increase the mortality from <1% to 20%.1 Hence it is imperative to have a good understanding of the fundamental principles of major haemorrhage control to improve overall patient outcome.

Kurian J Mylankal MBBS FRCS Edin FRCS Gen Surg MD is a Senior Registrar in the Department of Vascular and Endovascular Surgery at Fremantle Hospital, Perth, Western Australia. Conflicts of interest: none declared.

Blunt injury There is a combination of shearing and crushing forces involved in blunt injury. Shear forces act along tissue planes where there is a transition in fixation points of the organs. Displacing forces exert significant stress along these planes of weakness resulting in injury ranging from vessel wall intimal tear to organ rupture. The isthmus of the aorta which is the junction of the mobile ascending aorta and aortic arch, and the relatively fixed descending aorta is subject to significant stress during impact in road traffic accidents.2 The vascular pedicles of solid organs such as the liver, kidney and spleen are also liable to this effect. Crush injury is a direct compressive effect on the tissue sandwiched between external force and bone. The ensuing damage may range from tissue contusion to organ rupture. The pelvic ring is also prone to disruption from compressive forces, resulting in major haemorrhage from iliac artery and its branches and the venous plexuses.

Michael G Wyatt FRCS Eng MD is a Consultant Vascular Surgeon and an Honorary Reader at Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared.

Iatrogenic Laparoscopic surgery has revolutionized minimally invasive surgery. Although the incidence of iatrogenic injury to major

Causes of major haemorrhage (Box 1) Trauma Trauma is the most common cause of major haemorrhage, and road traffic accidents account for the vast majority of

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vasculature is rare in laparoscopic surgery, it can result in catastrophic haemorrhage. Endovascular interventions are central to the management of complex surgical conditions. Major haemorrhage can occur from percutaneous needle puncture sites for access vessels, rupture of vessels during balloon angioplasty and stent deployment.

removing all clothing is vital to avoid overlooking less obvious but critical injuries. In major haemorrhage unrelated to trauma, history of relevant past medical illness and anticoagulant use is sought.

Surgical bleeding Primary haemorrhage during surgery may be due to inadequate control of major blood vessels, clamp slippage or inadvertent trauma to adjoining vasculature and solid organs such as the spleen. Reactionary bleeding occurs within 24 hours of surgery and is due to technical faults or coagulopathy. Secondary haemorrhage is delayed bleeding, often within 5e10 days of the initial surgery and is as a result of infection or coagulation defects.3

Major haemorrhage amounting to blood loss of 40% of total body volume or 2 litres is immediately life threatening. The assessment of major haemorrhage is based on a combination of clinical findings of hypovolaemic shock with concurrent evidence of blood loss. Tachycardia, hypotension and tachypnoea are characteristics of major haemorrhage and are accompanied by features of inadequate perfusion to the vital organs with pallor, confusion and altered consciousness and oliguria (Table 1). Blood loss must be assessed and accurately measured when feasible. It must take into account both visible and non-visible blood loss into the thoracic cavity, intra-abdominal, pelvic and retroperitoneal spaces. In the operating theatre, it is mandatory to closely monitor blood loss in suction equipment, drapes and swabs.

Assessment of blood loss

Pathological causes This subgroup encompasses pathological processes that can result in major haemorrhage due to disease progression. Aortic aneurysm rupture is the classical case of major uncontrolled haemorrhage commonly encountered in the accident and emergency setting. Major bleeding from peptic ulcerations, angiodysplasia and diverticulosis of the colon are other commonly encountered causes for major haemorrhage.

Initial management of major haemorrhage Resuscitation An exsanguinating patient should undergo both the initial assessment and resuscitation simultaneously. Resuscitation is best conducted in the operating room in the haemodynamically unstable patient requiring emergency surgery. Recent randomized controlled trials have shown no clear benefit in using colloids over crystalloids and some of the colloid solutions may adversely affect the coagulation pathways. Blood is drawn for full blood count, urea and electrolytes, amylase, clotting and cross-match. Intravenous access is secured through two large bore cannulae and central venous access is reserved until the patient arrives in the operating room.

Clinical examination In the trauma patient, initial assessment is based on the ATLS principles to ensure a patent airway with adequate ventilation and haemorrhage control. Mechanism of injury and corroborating physical signs of bruising, puncture wounds, bony injuries and haematoma are sought. Chest and abdominal wall bruising from seat belts should raise suspicion of significant thoracic and abdominal injuries. Often, however there may be a complex combination of mechanisms involved in the injury. Hence a meticulous secondary survey with adequate exposure by

Baskett’s classification of hypovolaemic shock4

Blood loss % Total blood volume (TBV) Absolute volume (70 kg male) Blood pressure Systolic Diastolic Heart rate (bpm) Capillary refill Respiratory rate Urine output Extremities Colour Mental state

Class I

Class II

Class III

Class IV

<15% TBV

15e30% TBV

30e40% TBV

>40% TBV

750 ml

800e1500 ml

1500e2000 ml

>2000 ml

Unchanged Unchanged Mild tachycardia Normal Normal >30 ml/hour Normal Normal Alert

Normal Raised (narrow pulse pressure) 100e120 Slow (>2 seconds) Normal 20e30 ml/hour Pale Pale Anxious/aggressive

Reduced Reduced >120 (reduced volume) Slow (>2 seconds) Tachypnoea (>20/min) 10e20 ml/hour Pale Pale Anxious, aggressive or drowsy

Very low Very low >120 (very weak) Undetectable Tachypnoea (>20/min) 0e10 ml/hour Pale and cold Ashen Drowsy, confused or unconscious

Table 1

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Control of haemorrhage Direct digital pressure is often very effective in controlling troublesome bleeding from wound sites. Blind use of clamps and haemostats should be avoided. In peripheral vascular trauma, use of extraluminal balloon tamponade may serve as a temporizing measure for haemorrhage control. A Foley catheter inflated within the missile track and secured with circumferential skin sutures is a good example. In combat casualties, there is inconclusive evidence in favour of tourniquets as life saving for bleeding from major limb trauma.5 However it should be reserved for cases where other measures have failed and should not be applied for longer than 90 minutes. Stabilizing fractures prevent further damage to soft tissues and vasculature and this is performed during the initial phase of resuscitation. Often this helps to improve the peripheral circulation in ischaemia.

FFP can be given in a dose of 15e20 ml/kg if PC is unavailable and subsequent doses given peri-operatively as required. The effect of unfractionated heparin (UFH) can be reversed by protamine to facilitate surgery for life-threatening bleeding. Protamine isolated from fish sperm binds to unfractionated heparin and neutralizes its anticoagulant effect. However the binding of protamine to low-molecular-weight heparin is only partial. Protamine 1 mg neutralizes 100 units of heparin and the dose is reduced by 50% for every hour after heparin administration. Aspirin and clopidogrel cause platelet inhibition and an increase in bleeding time. Although this in itself requires no specific treatment, in emergency surgery platelet transfusion should be considered early in major haemorrhage.8 Hypothermia Major haemorrhage renders patients susceptible to hypothermia from exposure to the environmental elements and aggressive resuscitation with cold fluids. Hypothermia causes platelet dysfunction, inactivates coagulation enzymes, disrupts the fibrinolytic balance and prolongs clotting time. In particular, factor IX levels are reduced and there is impairment of the inhibitors of fibrinolysis. Oxygen delivery to the tissues is impaired by hypothermia with shift of the Bohr curve to left. This further impairs oxygen and substrate use by the tissue with anaerobic metabolism leading to metabolic acidosis. This further aggravates the coagulopathy by prolonging activated partial thromboplastin time (APTT) and decreasing factor V activity. Hence it is critical to maintain body temperature by the use of rapid infusion devices, blood-warming equipment and patient-warming blankets.

Permissive hypotension In the context of major uncontrolled haemorrhage, attempts at normalizing blood pressure to pre-trauma levels risk further bleeding by raising intravascular pressure, reducing blood viscosity and dislodgement of haemostatic plug.6 This has an adverse effect on overall patient survival. Permissive hypotension aims at restricting fluid resuscitation until control of bleeding is achieved. It is accepted that the perfusion of vital organs is suboptimal with this strategy and a systolic pressure of 70e90 mmHg is the target. Traumatic brain injury is a contraindication to permissive hypotension as it can result in adverse neurological outcome.7

Investigations

Coagulopathy Fluid resuscitation has a dilutional effect on clotting factors and platelet count resulting in deranged haemostatic function. As a rough guide, 12 units of red cells or 1.5 times blood volume replacement causes a reduction in fibrinogen level to <1 g/litre. A blood loss of 8e12 units of red cells halves the clotting factor concentration with a rise in prothrombin time ratio >1.5. In addition every one blood volume replaced halves the platelet count. In major haemorrhage, the patient can initially be resuscitated with crystalloids although haemodilution and coagulation defects will warrant early use of blood and blood products. Red cell transfusion improves tissue oxygenation by increasing the oxygen-carrying capacity of blood. Full blood count, biochemistry and coagulation profile are tested every 4 hours, when onethird of blood volume is replaced and after giving fresh frozen plasma (FFP). If bleeding is ongoing and prothrombin time >1.5, fresh frozen plasma at an initial dose of 15 ml/kg is recommended. However further doses of FFP may be considered if bleeding continues. A platelet count of 75e100  109/litre is the target and 1.5 times blood volume replacement would necessitate a 1 pool platelet transfusion. Cryoprecipitate replenishes fibrinogen and factor VIII. Administration of 10 single donor units to an adult will raise the fibrinogen level by 1 g/litre. Patients on warfarin requiring emergency surgery for major haemorrhage may require immediate correction of their coagulation profile. Prothrombin complex concentrate (PC) which comprises factor II, VII, IX and X concentrate, is given in a dose of 30e50 units/kg along with vitamin K 1e5 mg intravenously.

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In trauma, the ATLS series of cervical spine, chest and pelvic X-rays are performed whilst resuscitation is in progress. Special investigations are reserved for the adequately resuscitated and haemodynamically stable patient. Indications for emergency surgery are a haemodynamically unstable patient with active bleeding and expanding haematoma. Plain radiography The chest radiograph yields vital information in blunt and penetrating trauma. A widened mediastinum is seen in 90% of thoracic aortic injuries. Other relevant radiographic features are fractures of the sternum, clavicle and ribs, haemothorax and diaphragmatic rupture. In penetrating injuries, markers at the entry and exit points add valuable information on the missile track. Pelvic radiographs identify the extent of bony injury to the pelvis and help gauge pelvic blood loss. Unstable pelvic fractures are more likely to cause arterial and venous injuries and carry a higher risk of bleeding, coagulopathy and mortality. In radiological terms an unstable pelvic fracture has more than 0.5 cm separation of any fracture line.9 Computed tomography (CT) CT has become the most widely used investigation in the haemodynamically stable patient with suspected haemorrhage. Appropriately timed contrast-enhanced images add valuable information on arterial and venous bleeding. In blunt abdominal and pelvic injuries this is critical to decide between conservative non-operative management and surgical intervention.

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Angiography Angiography as a diagnostic test should be reserved for the adequately resuscitated and haemodynamically stable patient. Cervical, thoracic and abdominal vascular injuries are well delineated by angiography, although much of this information is now available from a CT scan which is faster and non-invasive. There is a definite role for angiography where therapeutic intervention is planned and this is often performed in the modern combined theatre angiography suite.

Packing helps control bleeding by a tamponade effect. At laparotomy, when major haemorrhage is encountered, the four quadrants of the abdominal cavity are tightly packed. This may help control the bleeding and allow the team to address other critical issues. This is an opportune pause to ensure that the patient is warm, and to secure additional intravenous lines and arterial lines for monitoring blood pressure. When massive haemorrhage is anticipated, as in ruptured aortic aneurysm surgery, cell salvage should be considered. This process of collecting blood aspirated from the operative field and returning to the patient after processing has been found to reduce the need for allogenic blood transfusion. Adequate retraction to optimize access, good illumination and appropriate surgical assistance are essential. Careful removal of packs starts from the lower quadrants and areas of bleeding identified and controlled with artery or mosquito forceps with suture ligation reserved for later. Contamination from bowel contents is minimized by the prompt use of bowel clamps and stapling devices across areas of perforation. Haemorrhage from the left upper quadrant is likely to be from splenic injuries and in a haemodynamically unstable patient a splenectomy is performed. In scenarios where haemorrhage is not controlled by the above techniques of packing or where an expanding retroperitoneal haematoma is encountered, it is imperative to get control of proximal and distal vessels before any attempt at exploration of the haematoma, which could otherwise result in a catastrophic loss of the tamponade effect.10

General principles in the management of major haemorrhage Surgical considerations In life-threatening bleeding, positioning of the patient on the operating table is crucial. In suspected abdominal and chest bleeding, the arms are fully abducted and skin preparation should include the entire chest from the suprasternal notch, abdomen, groin and upper thigh (to harvest the long saphenous or superficial femoral vein) and laterally to the posterior axillary line to accommodate chest and abdominal drains. In pelvic and perineal injuries, positioning the patient on leg holders will improve access. In the haemodynamically unstable and hypotensive patient, skin preparation should be carried before induction of anaesthesia. This ensures immediate access for laparotomy or thoracotomy as there is a possibility of acute haemodynamic deterioration with induction of anaesthesia in the unstable patient. Generous incisions are used to access the abdomen and chest. A midline laparotomy gives good access for abdominal bleeding and may be extended into a midline sternotomy. A left anterior thoracotomy gives access to the thoracic aorta to secure proximal control before laparotomy in the unstable patient with irreversibly low systolic pressure. A chevron incision from the anterior axillary line to upper abdomen provides good exposure of lateral abdominal structures and the retroperitoneum (Figure 1).

Damage control surgery The principles of damage control surgery are to limit the stress imposed by surgery and this applies to the haemodynamically unstable patient with uncontrolled bleeding and coagulopathy. Simple straightforward repairs are best suited for the exsanguinating patient to achieve haemostasis and restore distal vascularity promptly. Complex reconstructions are reserved as secondary procedures after adequate resuscitation and correction of coagulopathy. Primary suture repair of vessel wall is a simple technique to gain haemostasis and suits clean lacerations of the artery and vein. However it is not suited for complete vessel transaction or in the presence of devitalized vessel wall. Ligation of vessel is a simple but effective technique for gaining rapid haemostasis in life-threatening bleeding. This may be the best option in scenarios where the access is difficult and complex repairs are time consuming. The subclavian vein, iliac vein and inferior vena cava can be ligated albeit with the risk of limb oedema although this may be life saving in the context of uncontrolled haemorrhage. The external carotid artery can be ligated with no consequences although internal carotid artery ligation risks neurologic deficits. Ligation of femoral arteries can result in critical limb ischaemia although subclavian artery ligation may be better tolerated. Temporary shunts ensure distal perfusion through a damaged vessel. This is a temporizing measure until the patient is stable enough to return for complex reconstructive repair after correction of coagulopathy. Choice of vascular shunts can range from simple endotracheal suction tubing cut to desired lengths to specifically designed vascular shunts such as the carotid shunts. Insertion of a shunt requires control of the proximal and distal

Incisions for access A – Midline laparotomy B – Chevron incision C – Midline sternotomy D – Left anterior thoracotomy C D

D

C

B

B

A Figure 1

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injured vessel and subsequently the shunt is easily introduced and secured with vascular loops held by ligaclips (Figure 2). Primary amputation may be the only option to secure expeditious haemostasis in a mangled extremity. This decision is often made by a multidisciplinary team where patient’s haemodynamic instability precludes complex reconstructive repair. Here, after dividing bone and muscle, major vessels are ligated and pressure pack applied to the open stump with a view to revision and closure as a secondary procedure when the patient is stable.11

thoracic and proximal abdominal aorta and the internal and external iliac arteries. This allows time for open surgical exposure for a definitive repair. Angiographic embolization using coils, plugs and Gelfoam helps arrest of haemorrhage. Embolization has a key role in the non-surgical management of blunt trauma to liver, spleen and kidney (Figure 3). In addition, bleeding from the gastrointestinal tract can be dealt with by selective embolization and thus avoiding the morbidity associated with laparotomy and bowel resection. Injury to major vessels is amenable to endovascular repair by use of stent grafts. Injuries to the thoracic aorta, thoracic outlet vessel and carotid vessels can be considered for such repair.12 In addition, stent grafts are increasingly being used in the repair of ruptured abdominal aortic aneurysms.

Other adjuncts Tranexamic acid or epsilon-aminocaproic acid inhibits fibrinolysis by blocking active binding sites on plasmin and promotes haemostasis. It has been proven to be beneficial in cardiac and orthopaedic surgery. Aprotinin is a bovine protein with similar function on plasmin as tranexamic acid. It has been shown to reduce allogenic blood transfusion requirements in cardiac surgery. DDAVP (desmopressin) affects haemostasis by releasing stores of factor VIII and von Willebrand factor from endothelial cells. However its effect may be limited after major blood loss due to depletion of stores. Topical haemostatic agents are a useful adjunct to secure adequate control of troublesome local bleeding despite all efforts at systemic correction of coagulation defects and also the use sutures. It provides a local coagulum which promotes haemostasis. The commonly used agents are fibrin (TissealÒ), albumin/ glutaraldehyde (BioglueÒ) and thrombin (FloSealÒ).

Specific measures Neck injuries The majority of neck injuries are caused by penetrating trauma and vascular injuries to the neck are associated with a high incidence of morbidity and mortality. The neck is divided into three anatomical zones to aid in management strategies:  Zone 1 extends from the clavicle to the cricoid membrane.  Zone 2 from the cricoid membrane to the angle of the mandible.  Zone 3 from the angle of mandible to base of the skull. The large vessels of the neck are best accessed through an incision sited along the anterior border of the sternocleidomastoid muscle, which can be extended the full length between the mastoid process and the sternal notch if required. Following incision of skin and platysma, the anterior border of sternocleidomastoid should be freed and retracted to allow access to the internal jugular vein. Ligation of the facial vein and retraction of the internal jugular will then expose the carotid. Indications for immediate exploration are active bleeding and airway compromise. The haemodynamically stable patient warrants further investigations. Zones 1 and 3 are investigated by arch angiography whilst ultrasound duplex imaging is vital for Zone 2 injuries. Carotid artery injuries are best managed by primary surgical repair and active bleeding from vertebral artery injury is amenable to angiographic embolization.12 The internal jugular vein may either be repaired, or ligated with impunity if necessary.

Endovascular management The advances in radiological imaging and interventional techniques have had a major impact on the management of the patient with major haemorrhage. The minimally invasive nature of the procedure, access distant to the site of injury and choice of devices that enable arrest of haemorrhage make this a vital treatment modality without further compromise to the physiological reserve. In trauma to the great vessels, endovascular management with stent grafts avoids the high morbidity and mortality associated with thoracotomy and aortic cross clamping in the polytrauma patient. Vascular control by placement of an intraluminal balloon offers proximal control for bleeding and this is particularly relevant for inaccessible vessels such as the subclavian artery,

Thoracic injuries Most thoracic vascular injuries are due to penetrating trauma and these patients are haemodynamically unstable due to ongoing bleed into the thoracic cavity. CT scan remains the investigation of choice in the stable patient. Immediate surgery is indicated in the unstable patient or when there is an initial haemorrhage of >1500 ml in the chest drain or ongoing bleeding of 200e300 ml/hour. For emergency thoracotomy when the underlying injury has not been defined, an anterolateral thoracotomy through the 4th intercostal space on the side of the injury is the best approach. This incision can be extended across the sternum or into the abdomen as required. When an injury to the central organs of the chest is expected, a midline sternotomy will provide the best access to the heart, the great vessels of the mediastinum and the hila of both lungs. Dealing with a complex thoracic injury through a sub-

Fixation of temporary vascular shunt Vascular loops

Ligaclips Damaged vessel

Shunt Figure 2

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Selective angiography of the splenic artery showing active bleeding a and coil embolization for control of bleeding b. (Images provided courtesy of Dr Greg Vanschie, Perth, Western Australia). Figure 3

Abdominal injuries Vascular injuries: penetrating trauma is the most likely cause for injury to the major vessels of the abdomen although blunt injury by crushing or shear mechanisms from seat belts is also implicated. These patients present in a state of shock with

optimally placed incision will carry a greater risk of morbidity and mortality than a second alternatively placed incision, that is performed following initial exploration and haemorrhage control. Endovascular repair is the treatment of choice in traumatic aortic injury in the haemodynamically stable patient (Figure 4).

Blunt injury to chest from road traffic accident resulting in a thoracic aneurysm a successfully repaired by stent graft b. (Images provided courtesy of Dr Brendan Stanley, Perth, Western Australia.) Figure 4

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abdominal pain and distension and are often unstable for any investigations. Exposure of the midline vascular structures requires reflection of the abdominal viscera to the midline from the left or right. Large, right sided retroperitoneal haematoma or dark blood gushing and not spurting are suggestive of vena caval injury. The exposure of the vena cava and right iliac vessels is achieved by incising the peritoneum lateral to the duodenum and right colon, and medial reflection of the colon and small bowel mesentery. Surgical exposure of these large veins has to be done with extreme care as these vessels are thin walled and liable to tear or result in avulsion of side branches. Venous bleed rapidly wells up obscuring the surgical field and control of haemorrhage is often best achieved by compression using swab sticks or simple pinching of the tear to allow for exposure and suturing of the defect. Bright red blood bleeding briskly from the epigastrium or a large haematoma in this region should raise the suspicion of injury to the aorta or its major vessels. Control of the aortic inflow can be temporarily achieved by compressing the aorta against the vertebral body at the aortic hiatus of the diaphragm. Aortic exposure is accomplished by displacing the spleen and colon medially after incising the lateral peritoneal attachments. The proximal aorta is exposed by dividing the left crus of the diaphragm. Exposure of anterior aorta and proximal trunk requires the kidney to remain posterior during this exposure and medial displacement of the kidney exposes the posterior aorta. The pelvic vessels are best exposed by a lateral approach and displacing the sigmoid colon or caecum medially. Access to the iliac veins is difficult due to the overlying arteries and occasionally may warrant initial division of the iliac artery and retract them to repair the vein, followed by arterial anastamosis to reestablish distal circulation.

vascular surgery. This haemorrhage poses great challenges to the surgeon due to difficulties of access. The mortality associated with pelvic haemorrhage from fractures is high and hence haemorrhage control is critical to improve patient survival. A pelvic sling or belt for fracture stabilization is very effective in controlling haemorrhage in the emergency setting. External fixator devices provide robust stabilization of the pelvis and these can be easily applied in the trauma room. Angiographic embolization of bleeding vessels is the treatment of choice for haemodynamically unstable patients with pelvic fractures.13 In surgical bleeding from the pelvis, there are various techniques available to control major haemorrhage. A combination of digital pressure and simple suture ligation is often a very effective technique. However, occasionally haemorrhage control may necessitate ligation of major feeding vessels such as the hypogastric artery and even the internal iliac artery. Haemorrhage from the pre-sacral space and sacral foramina can be controlled by the use of thumbtack. There are ingenious instruments with long handles that can hold the thumbtack and also permit adequate vision of the bleeding vessel in the pelvis. The thumbtack is placed directly into the cortex of the sacral bone using a gentle tap with a mallet or digital pressure and thus occludes the venous bleeding from the sacral venous plexus. There are various methods devised to control pelvic haemorrhage by tamponade. Expandable breast implants and tissue expanders placed in the pelvis and inflated are often very effective. A

REFERENCES 1 Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg Mar 1991; 78: 355e60. 2 Richens D, Field M, Neale M, Oakley C. The mechanism of injury in blunt traumatic rupture of the aorta. Eur J Cardiothorac Surg Feb 2002; 21: 288e93. 3 Marietta M, Facchini L, Pedrazzi P, Busani S, Torelli G. Pathophysiology of bleeding in surgery. Transplant Proc Apr 2006; 38: 812e4. 4 Baskett PJ. ABC of major trauma. Management of hypovolaemic shock. BMJ Jun 2, 1990; 300: 1453e7. 5 Kragh Jr JF, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med; Aug 28, 2009 [Epub ahead of print]. 6 Bickell WH, Wall Jr MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med Oct 27, 1994; 331: 1105e9. 7 Kreimeier U, Prueckner S, Peter K. Permissive hypotension. Schweiz Med Wochenschr Oct 21, 2000; 130: 1516e24. 8 The Stationery Office, ed. Handbook of transfusion medicine. 4th edn; 2007. 9 Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury Jul 2006; 37: 602e13. 10 Mullins RJ, Huckfeldt R, Trunkey DD. Abdominal vascular injuries. Surg Clin North Am Aug 1996; 76: 813e32. 11 Aucar JA, Hirshberg A. Damage control for vascular injuries. Surg Clin North Am Aug 1997; 77: 853e62. 12 Vascular and endovascular surgery. 3rd edn. Elsevier Saunders, 2005. 13 Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury Jul 2004; 35: 671e7.

Abdominal solid organ injury Modern radiological imaging and interventional techniques have significantly modified the management of hepatic and splenic injuries. Although the haemodynamically stable patient with liver or splenic injury is managed conservatively, laparotomy is indicated in the unstable patient. Packing can control most haemorrhages related to hepatic injury. Pringle’s manoeuvre of clamping the porta hepatis via the gastrohepatic ligament is a very effective temporizing measure in the control of hepatic arterial or portal vein injury.13 Where local facilities exist, radiological embolization is the treatment of choice for solid abdominal organ haemorrhage unless haemodynamic instability precludes this. Liver haemorrhage can usually be initially treated by selective embolization of a branch of the hepatic artery within the liver substance, though the delayed complications of infected collections and bile leaks must be subsequently excluded prior to discharge. The majority of splenic lacerations can be treated by conservative management or by embolization and the main splenic artery can be embolized if necessary with subsequent splenic perfusion and function preserved via a blood supply from the short-gastric vessels. The unstable patient with major haemorrhage from splenic injury is an indication for splenectomy. Pelvic haemorrhage Major pelvic haemorrhage is encountered in pelvic fractures and during pelvic dissection in gynaecology, urology, colorectal and

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