Faffing or fixing? (Part1)

Recent mixed reviews “I’m stuck in x-ray, fiddling around with a bleeder” “X-ray is not a safe environment for anaesthetics” “Have you done something?, the blood pressure has recovered”

Background 30-40% of early trauma deaths due to haemorrhage 62% of all in hospital deaths within 4hrs – Haemorrhage either primary cause or contributing factor “Majority of preventable deaths after injury occur from unrecognised and hence untreated haemorrhage, particularly within the abdominal cavity making it perhaps the single most important reversible cause of death in the trauma population”. Trauma: Who cares? A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

Haemorrhage control concepts Aims – Stop the bleeding (with surgery or IR) – Restore circulating volume Damage control surgery – Staged approach in exsanguinating patients Permissive hypotension – Maintenance of vital functions without increasing risk of further haemorrhage

1)Contrast extravasation Imaging signs of active bleeding

2False aneurysm

3Missing vessel

4Big hole in vessel

1)Contrast extravasation No treatment Patient died in A&E IR treatment of active bleeding

Treatments 2False aneurysm False aneurysm Filled with glue

Treatments 3Missing vessel Selective angiogram Vessel coiled

Treatments 4Big hole in vessel Gelfoam slurry No improvement Vessel glued

Shock – Inadequate tissue perfusion – Haemorrhage leading cause Coagulopathy Acidosis Hypothermia – All independently predict poor outcome

Treatment Recognition Stop bleeding Restore circulatory volume Improved oxygenation Better outcome ? Prompt intervention, not last resort

Outcomes 72 hour mortality – Patients who had surgery22.7% (25/110) – No surgery 13.7% (92/670). Patients who had timely intervention to control bleeding the 72 hour mortality was – 23.8% (15/63) – 33.3% (8/24) where intervention was considered delayed. Trauma: Who cares? A report of the National Confidential Enquiry into Patient Outcome and Death (2007)