Control of life-threatening haemorrhage from the neck: a new indication for balloon tamponade

Case report: Zone 3 gunshot wound to the left neck treated with combined Foley catheter balloon tamponade and interventional radiology stent placement

In the trauma and military setting, catheter balloon tamponade has been successfully used as an effective tool for the management of exsanguination secondary to penetrating injuries. This maneuver may improve outcomes in patients with uncontrolled bleeding, particularly in penetrating neck injuries (PNI), thorax, axillae, and groin. We describe a case of a stab wound to the left neck that led to surgical left neck exploration utilizing Foley catheter balloon tamponade (FCBT) for initial control of massive hemorrhage and a subsequent interventional radiology (IR) endovascular stent placement for a zone 3 internal carotid artery injury.

Trauma Bay Evaluation and Resuscitative Decision-Making

The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.

The effectiveness of Foley catheter balloon tamponade versus expanding sponges and hemostatic granules for catastrophic penetrating groin hemorrhage with small skin defect: A comparative study in a live tissue porcine model with evaluation of a concise training program

BACKGROUND

Prompt bleeding control in the prehospital phase is essential to improve survival from catastrophic junctional hemorrhage. This study aimed to compare the effectiveness and practicality of Foley catheter balloon tamponade (FCBT), Celox-A, and XSTAT for the treatment of catastrophic hemorrhage from penetrating groin injuries with a small skin defect in a live-tissue porcine model. In addition, this study aimed to determine whether a training program could train military personnel in application of these advanced bleeding control adjuncts.

METHODS

A standardized wound was created in 18 groins from 9 anesthetized swine. Eighteen military medics participated in the training program and performed a bleeding control procedure after randomization over the swine and test products and after transection of the femoral neurovascular bundle. Primary endpoints were bleeding control, time to bleeding control, rebleeding, blood loss, medic performance, and user product rating.

RESULTS

No significant differences were found in vital signs and laboratory values between the groups. In the Celox-A group, 3/6 groins achieved hemorrhage control. This was 6/6 in the XSTAT and FCBT groups. XSTAT scored best on application time, time to obtain hemorrhage control, hemorrhage control score, and practicality. No significant differences were found between groups for rebleeding, amount of blood loss, and medic performance. Military medics had a significant higher preference for XSTAT over Celox-A. This was not significant for FCBT.

CONCLUSION

All tested products proved effective in obtaining hemorrhage control. XSTAT has the highest effectivity and shortest application time for the treatment of catastrophic bleeding from nonpackable, penetrating junctional groin injuries with a small skin defect, compared with Celox-A and FCBT. XSTAT scored best on practicality. This study shows that our training curriculum can be used to train military medics with limited prior experience in the use of advanced bleeding control techniques for penetrating junctional groin injuries with small skin defect.

Foley Catheter Balloon Tamponade for Actively Bleeding Wounds Following Penetrating Neck Injury is an Effective Technique for Controlling Non-Compressible Junctional External Haemorrhage

BACKGROUND

The foley catheter balloon tamponade (FCBT) has been widely employed in the management of trauma. This study reviews our cumulative experience with the use of FCBT in the management of patients presenting with a penetrating neck injury (PNI).

METHODS

A retrospective study was conducted at a major trauma centre in South Africa over a 9-year period from January 2012 to December 2020. All patients who presented with a PNI who had FCBT were included.

RESULTS

A total of 1581 patients with a PNI were managed by our trauma centre, and 44 (3%) patients had an FCBT. Of the 44 cases of FCBT, stab wounds accounted for 93% (41/44) and the remaining 7% were for gunshot wounds. Seventy-five per cent of all FCBT (33/44) were inserted at a rural hospital prior to transfer to our trauma centre; the remaining 25% (11/44) were inserted in our resuscitation room. The success rate of FCBT was 80% (35/44), allowing further CT with angiography (CTA) to be performed. CTA findings were: 10/35 (29%) positive, 18/35 (51%) negative, and 7/35 (20%) equivocal. Fifteen patients required additional intervention (open surgery or endovascular intervention). The overall morbidity was 14% (6/44). Eighteen per cent required intensive care unit admission. The median length of stay was 1 day. The overall mortality rate was 11% (5/44).

CONCLUSION

FCBT is a simple and effective technique as an adjunct in the management of major haemorrhage from a PNI. In highly selective patients, it may also be used as definitive management.

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

An Update on Foley Catheter Balloon Tamponade for Penetrating Neck Injuries

BACKGROUND

Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT.

METHODS

Adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes.

RESULTS

During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9 years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48-72 h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound.

CONCLUSION

This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.

Management of Life-Threatening Hemorrhage from Maxillofacial Firearm Injuries Using Foley Catheter Balloon Tamponade

The aim of this study is to evaluate the efficacy of Foley catheter in the management of hemorrhage from penetrating maxillofacial injuries in austere environment. This retrospective cohort study evaluated all penetrating head and neck trauma caused by firearm injuries reported to a military hospital at a forward aid location during 2015-2017. Foley catheter was used in the emergency management of bleeding in 11 cases. The effectiveness of this technique in controlling hemorrhage, its indication, contraindications, and complications has been explained. Out of 26 penetrating injuries received during the time period, 11 patients underwent Foley catheter balloon tamponade for the control of hemorrhage. Ten out of 11 patients responded adequately to balloon tamponade. One patient with a bullet lodged inside the neck underwent immediate surgical exploration for its removal and repair of internal jugular vein. No neurological deficits or complications were noted in any of the patients. Foley catheter balloon tamponade is very effective in managing hemorrhage from head and neck penetrating injuries. It significantly reduces the mortality by controlling bleeding from the major vessels especially in a combat environment.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage in a Perfused Human Cadaver Model

BACKGROUND

Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate.

OBJECTIVES

We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT).

METHODS

Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded.

RESULTS

There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000).

CONCLUSIONS

The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Penetrating neck injury: a review

Penetrating injury to the neck has inspired considerable controversy with regard to its management, owing to the large number of important, susceptible structures contained in this area. Mandatory exploration of all wounds has generally given way to selective operative management. Clinical assessment has, once again, become the prime diagnostic tool. This review describes the evolution of management and the value of various diagnostic modalities. It concludes with a summary of appropriate operative techniques.

Safety in selective surgical exploration in penetrating neck trauma

BACKGROUND

Selective management of penetrating neck injuries has been considered the standard of care with minimal risks to patient safety. In a previous non-randomized prospective study conducted at our center, selective management proved to be safe and reduced unnecessary exploratory cervicotomies. In the present study, the role of clinical examination and selective diagnostic tests were assessed by reviewing demographic and clinical data. A comparison of results between two groups (mandatory surgical exploration versus selective surgical exploration) was made to check the safety of selective management in terms of the rates of morbidity and mortality.

METHODS

A retrospective analysis at the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo was performed by a chart review of our trauma registry, identifying 161 penetrating neck trauma victims.

RESULTS

Of the 161 patients, 81.6 % were stabbed and 18.4 % had gunshot injuries. Stratifying the wound entry points by neck zones, we observed that zone I was penetrated in 32.8 %, zone II in 44.1 % and zone III in 23.1 % of all the cases. Thirty one patients (19.2 %) had immediate surgical exploration, which had a mean length of stay of 6 days, a complication rate of 12.9 % and a mortality rate of 9.4 %. Of the 130 who underwent selective surgical exploration 34 (26.1 %) required operative procedures after careful physical examination and diagnostic testing based on clinical indications. The mean length of stay for the selective surgical exploration group was 2 days with a complication rate of 17.6 % with no mortality, and virtually all of them were related to associated injuries in distant body segment. No statistical significance was found comparing mortality and complication rates between the two groups. Selective approach avoided 59 % of unnecessary exploratory cervicotomies.

CONCLUSION

Careful evaluation of asymptomatic and stable patients with minor signs of injury can safely avoid unnecessary neck explorations with low rates of morbidity. This should be the standard management of such patients.

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study

BACKGROUND

The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice.

METHODS

Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient.

RESULTS

The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11).

CONCLUSION

This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

Trap-door incision for penetrating thoracic trauma: an obsolete approach?

Penetrating injuries to the subclavian vessels are uncommon and very severe lesions. They are difficult to expose and carry a high mortality. "Trap-door" incisions have lately been dismissed as too mutilating for the occasional victim of a penetrating thoracic trauma with massive bleeding difficult that is to expose. We present a case of severe bleeding from a stab wound in the left subclavicular area in a heavy-built patient where a "trap-door" incision proved inevitable to expose and repair the injury, and most probably saved his life.

Management of penetrating neck injuries

BACKGROUND

Routine surgical exploration after penetrating neck injury (PNI) leads to a large number of negative neck explorations and potential iatrogenic injury. Selective non-operative management (SNOM) of PNI is gaining favour. The present study assessed the feasibility of SNOM in PNI.

METHODS

Seventy-seven consecutive patients with PNI presenting to a tertiary trauma centre were included in this prospective study from September 2009 to December 2009. All patients were managed according to Advanced Trauma Life Support guidelines, and either underwent emergency surgery or were managed without surgery, based on clinical presentation and/or outcome of special investigations.

RESULTS

Eight patients (10 per cent) were haemodynamically unstable at presentation. Foley catheter balloon tamponade (FCBT) was successful in stopping active bleeding in six of these patients, and diagnostic angiography revealed an arterial injury in five. The remaining 69 patients were managed using SNOM. Angiography or computed tomography was done in 41 patients (53 per cent), and showed arterial injury in 15. These injuries were treated surgically (7 patients), radiologically (stenting in 3) or conservatively. Contrast swallow and/or endoscopy were performed in 37 patients (48 per cent) for suspected oesophageal injury, but yielded no positive results. During follow-up no missed injuries were detected.

CONCLUSION

FCBT was useful in patients with PNI and active bleeding. Stable patients should undergo additional investigation based on clinical findings only.

An evidence based review of the assessment and management of penetrating neck trauma

BACKGROUND

Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. OBJECTIVES OF REVIEW: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format.

TYPE OF REVIEW

Structured, non-systematic review of recent medical literature.

SEARCH STRATEGY

An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms 'neck injuries' and 'wounds, penetrating' in conjunction with the terms 'assessment' or 'management'. Embase was searched with the terms 'penetrating trauma' and 'neck injury', also in conjunction with the terms 'assessment' and 'management'. Results were limited to articles published in English from 1990 to the present day.

EVALUATION METHOD

Abstracts were reviewed by the first three authors to select full-text articles for further critical appraisal. The references and citation links of these articles were hand-searched to identify further articles of relevance.

RESULTS

147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation.

CONCLUSIONS

Although controversy continues to surround the management of penetrating neck trauma, the role of selective non-operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.

[Operative management of penetrating injuries to the subclavian artery. Technical tutorial]

Penetrating injury to the subclavian arteries is one of the most taxing arterial injuries a trauma surgeon can encounter. Operative access for repair is difficult, crossing two separate anatomical areas-superior mediastinum and base of the neck. The artery runs well protected behind sternum and clavicle and tears easily if clamped. Physiologically unstable patients must be rushed to theatre in an attempt to control exanguinating haemorrhage and to repair the injury. In the rare circumastance of being confronted with it, it is imperative for the occasional trauma surgeon to have a practical operative concept for dealing with this type of injury. This tutorial describes a practical approach for penetrating subclavian injuries, and it discusses alternative surgical strategies when supraclavicular expanding hematomas deny straightforward access.

Use of Foley catheter as a flap retainer

Keeping skin graft or a flap adherent to the underlying surface can sometimes be a difficult job, particularly inside a cavity. Different methods have been used for this function with varying success but the search is still on for an ideal pressure dressing.

Ballistic Arterial Trauma to the Lower Extremity: Recent South African Experience

The aim of this study was to determine the current outcome of gunshots to the arteries of the lower extremity. The authors conducted a retrospective analysis of 104 patients with gunshots to the femoral (n = 71) and popliteal (n = 33) artery. One hundred four patients presented over the 60-month period. Ninety-six (92%) were male and eight of 104 female. Ninety-nine were gunshot injuries, five from shotguns. Nine patients had injury to the common femoral artery, 62 patients had injury to the superficial femoral artery, and 33 had popliteal artery injury. One patient died in the emergency room and another died in the postoperative period, giving an overall in-hospital mortality of two of 104 (1.9%). Forty-three of 70 femoral reconstructions had completion angiograms compared with 20 of 32 popliteal artery reconstructions ( P = 1). Nineteen of 63 (30%) of the completion angiograms prompted revision of the reconstruction. Of the 63 patients who had completion angiograms, two of 63 (3%) required amputation. Seven of 39 (18%) patients who did not have completion angiograms required amputation ( P = 0.025). Including the primary amputation, there were 10 amputations in the 103 patients (9.7%) who survived to undergo operation. Ballistic arterial trauma of the lower limb leads to significant disability. Completion arteriography leads to revision of the reconstruction in nearly one-third of instances and significantly reduces amputation rate.

[What to do if incompressible bleeding from a stab wound occurs in EMS and ER? Temporary control with a Foley catheter]

Exsanguination plays a key role in avoidable prehospital deaths. As some bleedings from deep stab wounds cannot be stopped with direct compression, the insertion of a Foley catheter can prevent ongoing bleedings. A case report of bleeding from a stab wound in the supraclavicular region is given. The simple measure of careful insertion and blocking of a Foley catheter proved to be a key resuscitative procedure which can be done under any suitable circumstances.

Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma

BACKGROUND

Foley catheter (FC) balloon tamponade is a well-recognized technique employed to arrest hemorrhage from penetrating wounds. The aim of this study was to review our experience with this technique in penetrating neck wounds and to propose a management algorithm for patients with successful FC tamponade.

METHODS

A retrospective chart review (July 2004-June 2005 inclusive) was performed of patients identified from a prospectively collected penetrating neck injury computer database in whom FC balloon tamponade was used. The units' policy for penetrating neck injuries is one of selective nonoperative management. All patients with successful FC tamponade underwent angiography. A venous injury was diagnosed if angiography was normal. Ancillary tests were performed as indicated. Removal of the FC was performed in the OR.

RESULTS

During the study period, 220 patients with penetrating neck injuries were admitted to our unit. Foley catheter balloon tamponade was used in 18 patients and was successful in 17 patients. Angiography was positive in 3 patients, all of whom underwent surgery. The FC was successfully removed in 13 patients at a mean of 72 (range 48-96) hours. One patient bled after removal of the catheter, mandating emergency surgery.

CONCLUSION

Foley catheter balloon tamponade remains a useful adjunct in the management of selective patients with penetrating, bleeding neck wounds.

Damage control surgery for thoracic injuries

Damage control of thoracic injuries begins frequently with an emergency department thoracotomy via an anterolateral incision. Bleeding and air leaks are quickly temporised. As opposed to abdominal damage control where most injuries can be temporised, most thoracic injuries require initial definitive repair. Thus, the goal of thoracic damage control is to perform the least definitive repair using the fastest and easiest techniques to shorten the operative time as much as possible. There are some injuries that can be temporised and require re-operation once physiologic normality has been achieved.

Resuscitation and anaesthesia for penetrating trauma

PURPOSE OF REVIEW

The worldwide burden of trauma is increasing, but is unequal between nations. Trauma targets the young and productive in society and imposes a major burden on the health infrastructure. This review provides a distillation of practice in a busy urban trauma centre dealing with large volumes of penetrating trauma.

RECENT FINDINGS

The anaesthetist holds a pivotal role in the management of penetrating injury; the requirements of prompt airway control, early delivery to theatre and control of a physiologically brittle patient can be challenging. Recognition that attempts at definitive surgery in exsanguinating patients may do more harm than good has made surgery a tool of resuscitation rather than an end in itself.

SUMMARY

Depending on where they practice, clinicians are more or less likely to encounter patients with gunshot wounds. However, adherence to basic principles and attention to the details of temperature control, invasive haemodynamic monitoring, blood product therapy and effective communication should translate to improved outcomes for patients after penetrating trauma.

Aide memoire for the management of gunshot wounds

The hospitals in Johannesburg deal with about 4,000 gunshot wounds a year. Although most are from hand guns, a number are from high velocity, military-type weapons. Extensive experience has been built up and many lessons learned. Attention is directed to the actual damage inflicted rather than on theoretical predictions based on presumed velocity of the bullets involved, as this can often be misleading. Some patients are delayed in their presentation to emergency departments, in other cases several gunshot wound patients arrive at the same time, requiring appropriate triage and urgent management.

Subclavian and axillary vascular injuries

Injuries to the subclavian or axillary vessels are associated with a high mortality rate and only patients with short prehospital periods or contained bleeding survive long enough to be treated. The surgical exposure of these vessels can be difficult and excellent knowledge of the local anatomy is critical. This article describes the anatomy, epidemiology, diagnosis, and surgical exposure of these injuries. Newer diagnostic and therapeutic modalities are discussed also.

Penetrating injuries to the subclavian and axillary vessels

BACKGROUND

Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels.

STUDY DESIGN

Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period.

RESULTS

Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location.

CONCLUSIONS

Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.

Balloon catheter tamponade of exsanguinating facial hemorrhage: a case report

A 42-year-old man sustained a gunshot wound to the frontal process of the left maxilla just lateral to the nasal bone medial to the maxilla that caused profuse hemorrhage. Anterior and posterior nasal packing along with packing of the gunshot wound with Vaseline gauze did not control the hemorrhage. A 28 French (30-cc balloon) Foley catheter was placed directly into the wound, and bleeding stopped immediately upon inflation of the balloon with 30 cc of sterile water. Arteriography identified bleeding from an anterior branch of the maxillary artery that was successfully embolized.

Penetrating injuries of the subclavian vessels

A study was made of 76 patients with subclavian vessel injury. The mechanism of trauma was stabbing in 40 patients (53 per cent) and gunshot in 36 (47 per cent). There were marked differences between the two groups in clinical presentation, operative management and outcome. The group with gunshot injury was characterized by a more immediate threat to life, and a greater need for a median sternotomy and use of interposition grafts. The mortality rate in patients with gunshot wounds was more than twice that in the group with stab injury.