INTERESTING DISCUSSIONS ON “BLEEDING MANAGEMENT”



Dr. Lim Ju Boo in Beijing 2010

The blogger’s note:  It was recently reported that a 14-year-old boy was washing his hands in the bathroom when the sink broke and was said to have hit him.  He finally died of excessive bleeding due to vascular injury to the left thigh. (See: http://www.thestar.com.my/News/Nation/2014/02/17/Hotel-operator-giving-family-the-runaround/).  This sparked off some interesting discussions among the blogger’s e-buddies culminating in their most-learned Dr. JB Lim delivering an informative and educational lecture on ‘Bleeding Management”.  These are reproduced for the benefit of the readers of this blog as follows:

On Mon, Feb 17, 2014 at 12:15 PM, Tan Seng Khoon wrote:

CHM,

I don’t understand this news.

How can the sink he was washing his hands in, break and cut his hand and he bled to death?

How can he bleed to death by a cut from a sink?

Does it make sense to you?

Rgds

Khoon

On Mon, Feb 17, 2014 at 3:36 PM, Zou Hanming wrote:

Khoon,

The sink could be an old/defective one that broke up when he leaned against it and it fell and gashed the teenager's thigh. Panicky and in pain he may have bled to death. Hey! Wait. Please delete. I shouldn't be answering this question. Please refer to Dr. JB Lim as he is the best qualified and a doctor with 3 Phds. Aiyoh, malu lah!!!!

CHM

From: Lim Juboo

Sent: Tuesday, February 18, 2014 3:59 AM

I really cannot comment how the sink broke by washing his hands. It could be anything.

The only closest thing I may be able to comment is from this sentence in the report:

“Ming Shen died of excessive bleeding due to vascular injury to the left thigh”

There is a very major artery in the thigh called the femoral artery. It fact this is the only main and major artery supplying blood to the entire leg even though it has a few smaller branches. It is an offshoot of the external iliac artery which is higher up through the inguinal canal.

The blood through this artery in the thigh is so huge that a pulse can be palpated (felt) at in that area. Hence the blood pressure at that point is very high.

If this artery is cut, blood will just shoot out unless a pressure point is applied at once.

Most people who do not know first-aid would not know what to do in such medical emergency.

A child would normally have a faster heart rate, a much smaller blood volume, and if this arterial bleeding is not arrested at once, the child will bleed to death within  5 -10 minutes depending on his cardiac output (stroke volume X cardiac rate).

This is possible in this child’s case.

Lim juboo MD PhD ACLS

(Advanced Cardiac Life Support)

Formerly Regional Training Officer for

St John Ambulance Malaysia

On Tue, Feb 18, 2014 at 11:55 AM, Tan Seng Khoon wrote:

I think we should learn a lesson from here.

Because if it can happen to Ming Shen, it can also happen to ANYONE, including you and me.

The issue is clear.  Ming Shen was cut by the broken sink and he bled to death.

For that to happen, as our consultant Dr.Lim rightly informed,  his femoral artery was probably completely CUT.

By the time he was sent to the hospital, he has lost all his blood and died.

Therefore, what can one do in such a case?

Does one lose his leg if the femoral artery is cut?

Can the leg survive if the main artery is severed and oxygen cannot reach the muscle down the rest of the leg?

Can the blood find another route?  Is there a secondary or minor femoral artery?

In the diagram below, there appear to be another smaller bypass.

What to do in a case like this?

Hope our dear Dr. Lim can give us his valuable guidance on this, 

SO THAT WE KNOW HOW TO TAKE CARE OF OURSELVES WHEN SUCH SIMILAR DISASTER STRIKES.

rGDS

kHOON

From: Lim Juboo

Sent: Tuesday, February 18, 2014 11:44 PM

Dear those who asked me,

Thanks for your questions.

Actually I tried to make my previous explanation as short and brief as possible so as to make it simple for others to read.

But now it looks like some readers are asking me more information than I expect.

For educational purpose let me expand what I wrote earlier to make it clearer. Do take time to read for my trouble to write. Do not delete as this is very useful medical education. You may need it in an emergency.

First, to answer the question how come car accident victims whose limbs are severed in car accidents survived when an ambulance comes late.

It is not necessary to assume that all of them survive. Most cases if the haemorrhage is very severe, they don’t - they just do not.

Blood volume:

The total volume of blood in an average human body is just about 5 litres.

We are talking about circulating blood (extracellular fluid) volume, We are not talking about fluid inside the cells, tissues and organs (intracellular biological fluid).

The blood volume depends on the size and body weight of an individual, much less in a child than in adults.

The amount of blood pumped out by the heart each minute is called the cardiac output which is measured by the stroke volume and cardiac ejection percentage of the ventricles x the pumping rate of the heart per minute.

In a male adult who is resting, this volume would be about 5.5 litres, and nearly 5 litres in a female, and in a child, depending on his weight and size, it is about half or less for the entire body.

 

You can imagine if a main artery is severed, all the blood would be drained out within a minute in an adult, and faster in a child based on this cardiac output. But this is not so. Let me explain.

There are many protective mechanisms the body will instantly mobilize to shut down rapid and excessive loss of blood. Briefly, without going into highly complex technical physiological explanations, among the main ones, are:

Clinical events:

1.   The blood pressure will drop to reduce pressure and volume.

2.   Complex clotting mechanisms becomes operative.

3.   Hormones like adrenalin will be released to constrict the blood vessels.

However, these protective mechanisms apply to bleeding in smaller blood vessels which may shut down, but are less effective in major vessels which are more opened like huge pipes. The pressure and volume of the blood does not allow the open ends of a major vessel to constrict. There is also no valve in arteries, only in veins.

Furthermore, even if there are valves, blood can only flow forward, not backwards. The valves (only in veins) block retrograde flow. So blood will still shoot out (in arteries) whether in veins (only flows, not shoot out) or from arteries.

Scenario in bleeding:

In a car accident or in a trauma there may be a possibility these mechanisms become operative by the body’s attempt to reduce excessive haemorrhage, but not in all cases. It all depends on the extent of the trauma. Many car accidents do die on the spot from excessive bleeding even if their limbs are not severed.

 

Internal bleeding:

We have also to consider internal bleeding as well, not just bleeding on the outside. Internal bleeding is very hard to check by compression. In fact it is almost impossible unless it is ‘compartmentalized’ bleeding due to increasing pressure exerted by the accumulated blood in a confined compartment itself - example in pelvic bleeding, resulting in ‘compartment syndrome’.

In such cases, the internal bleeding may stop by itself, compressed by its own accumulated pressures within a confined space.

In most cases in external bleeding, if the bleeding cannot be effectively managed, then what actually happens is that the body will try very hard to compensate blood loss by inducing other mechanisms. Some of them are:

Intense thirst:

This is to force the victim to ask for water drink water or any fluid to drink to compensate for the loss of blood volume. He feels very thirsty, and if he / she is conscious, he will ask for water.  This is a very natural physiological response we observed in the practice of natural medicine.

Increase in heart rate:

An increase in the heart rate (tachycardia) becomes operative to force the heart to work harder to supply whatever blood that  remains to all the vital organs, especially to the brain first,  as the brain cannot tolerate without blood supply and oxygen (low or hypo-perfusion). It will die, especially resulting in brain stem death without blood or oxygen supply within just 3 minutes.

.

Vascular spasms:

All smaller blood vessels to less important parts of the body, example skin, ears, lips, eyes, muscles, nerves will shut down and vital blood diverted to the deeper more vital organs such as the brain, heart (coronary vessels), lungs and kidneys.

This it does by secreting hormones (example adrenaline) to cause all unimportant blood vessels especially to the skin to go into a spasm (vasoconstriction) so that blood can be diverted to all the important organs preferentially.

That is why a person with severe bleeding will feel clammy and cold when the blood supply to the periphery (outer part: skin) of the body is shut down automatically in a neuro-response. He then becomes very pale (pallor) in the face, lips, hands, legs, etc. This is the clinical presentation in serious acute haemorrhages. 

Left open and bare:

In an emergency ward of a hospital, normally the patient in shock is not kept warm with blankets, but left open in an air cond. or under fans in an so that the cold can encourage the peripheral blood to the skin can further shut down, and warmer blood diverted to the vital internal organs.

This, I am sure will surprise most of you as you expect  patients  going into shock and shivering due to hypovolaemia (low blood volume) should  be kept warm with blankets. I don’t blame you if you think that way if you are not medically trained to understand the compensatory mechanisms of shock. 

Shocks:

However, if all these natural responses (as in natural medicine) of the body still fails to check further blood loss,  then what happens is, the body goes into a shock (mainly hypovolemic shock and / or  cardiogenic shock) due serve  blood and fluid loss (hypovolemia). He will be severely dehydrated,  and this will further compromise his already weakening heart.

His blood pressure will continue to drop further, affecting all the organs. His initial tachycardia (increased heart rate) will now go into reverse – slowing down (bradycardia), and ultimately stopped completely (cardiac arrest). Normally a number of drugs are used to counteract a drop in blood pressure, example the use of a catecholamine such as norepinephrine or a vasopressin (Trelipressin, just an example) to bring up the pressure.

This is just a very brief summary of the clinical scenario or clinical events featured in a person with severe haemorrhage if left untreated.

It is very hard for me to explain with further details using such a short explanations as it took me years to learn even basic trauma and emergency medicine in various structured courses I did at Hospital Kuala Lumpur, Selayang Hospital and at University Hospital Kebangsaan Malaysia (HUKM) during my training with St John Ambulance Malaysia.

So back to your question, a trauma victim in a car accident does often die on the spot due to severe injuries whether or not his limbs were severed.

.

Surgical amputation:

In amputation due to diabetes or other causes, bleeding is surgically controlled with surgical clamps and haemostatic drugs in a hospital environment. Moreover he will be invested for bleeding and clotting profiles before surgery can be done. So this is not a major problem

But in accidents even if the limbs are severed, if his bleeding can be arrested, he can be salvaged, and his limbs packed in protective bag of ice, and the casualty with his limbs rushed to a centre (not to any “nearest hospital” – this is a very gross misinformation given in some sub-standard first-aid books, newspapers and health magazine) where micro-vascular and trauma surgeries are available.

Remember, to a centre with trauma facilities, not to “any nearest hospital” such as to an eye hospital, or a hospital dealing with skin diseases or one that delivers babies. This information is wrong and out-dated. What have these “nearest hospitals” got to do with trauma medicine? Do not be mistaken.

Call an ambulance:

In a fully-equipped class-one ambulance where trained and qualified paramedics are available, the ambulance crew inside can do the job much better than an ordinary doctor in a small “nearest hospital”.

I have in my experience with St John Ambulance was told of doctors doing the wrong thing in an emergency, example they said their  patient was “sleeping” when actually his patients hearts have already stopped from some cardiac events such as myocardial infraction (heart attacks) or from some cardiac dysrhythmia.

They finally have to ask the paramedics to take over with CPR, ventricular defibrillation with a defibrillato, or use other logarithms and resuscitation protocols while the doctors just watch how this should be done.

Already stabilized:

All a doctor in a “small nearest hospital” can do is to try to stabilize the patient who is actually already expertly stabilized by qualified ambulance crew and paramedics in a Class One ambulance. 

Paramedics is a medical care  professional  who  received a certified 3-4 years training in a university hospital, and they are trained to use emergency drugs, establish infusion lines, do endotracheal intubation, ventilation of the airways, apply supplemental oxygen, use of defibrillators, and perform EGG readings, etc, etc. They can do a very good professional job, better than an ordinary doctor during an emergency. A doctor may not even be exposed to emergency medicine if he has never been posted in an Emergency Room.

In the “nearest inappropriate hospital” all the doctor can do is to ask the patient to be sent in the same ambulance to a big tertiary hospital where there are facilities and trauma specialists to manage the case. There is nothing more to stabilize in an inappropriate hospital if an ambulance crew has already done that at the site of the accident itself or inside a first class ambulance.

What can a small nearest hospital do when qualified paramedics in a first class ambulance with all the emergency equipment and drugs inside can do the job far better than an ordinary doctor who treats coughs, cold, chills, vomiting and fever and cold cases in small hospital?

Normally the patients are already stabilized by these paramedics, and their job is to send the patient to a specialized medical centre that can further manage the case by a vascular surgeon or by trauma physicians.

The femoral artery:

In fact the femoral artery is so big that even a pulse (femoral pulse) can be palpated (to feel) in the inner upper tight near the groin region.

Clinically I (I do not know about other doctors), normally use the femoral pulse to detect for “femoral delay” and compare this with the radial pulse (they should be felt simultaneously with same volume and rate) to diagnose for stenosis (narrowing of a blood vessel) in the lower limbs.

First aid saves lives:

First aid by qualified first responders are exceeding important in a medical emergency. It saves lives.

I think that boy have died needlessly. All that was needed was someone with trained knowledge in first-aid even at basic level to apply pressure on the femoral artery to stop the bleeding. Do not apply tourniquet.

Pressure points and Trendelenburg Position:

After pressure points are applied, and gauze, cloth or handkerchiefs pressed firmly onto the wounds (do not remove the dressings, but add on to them and press firmly), raise the legs above heart levels, and put the boy feet above the head (Trendelenburg position).  That’s was all that was needed. That boy would have lived today if they have done just that.

That boy need not die if only his parents and the hotel staff knew what to do.

I hope my short explanation will add some knowledge in first aid and basic medicine to others.

lim juboo  ACLS BSc (Med Physiol.) PG Dip Nutr MSc MD PhD (Med) FRSPH FRSM

Formerly Regional Training Officer

St John Ambulance Malaysia

Currently Special Medical and Science Adviser

The Dynapharm Pharmaceutical Group

From: Tan Seng Khoon

Date:20/02/2014 9:05 AM (GMT+08:00)

Dear Dr. Lim,

Thank you for your splendid explanation.

It is sad that nobody did the right thing and so the boy bled to a needless death.

We learnt that what need to be done are.

1.  Do not apply tourniquet.

2. Apply point pressure to the femoral artery to prevent bleeding, by pressing hard  with the thumb.

3. Apply cloth or handkerchief, bandages pressed firmly onto the wounds to prevent bleeding.

4. Lift up the injured leg to be as high as is possible over the heart to reduce aortic pressure to the wound.

5.  Swiftly, ship the patient to a hospital with trauma facility.

RGds

Khoon

From: david chen

Date:  Feb 20 at 9:57 AM

Rev. Koon

People should learn from this unpleasant experience. 

Dr.lim's report on this subject matter

Was par _excellence and timely and 

Appropriately contributed. 

DUE recognition. .will be recorded in our Heart for this.

STILL it was a panic crisis. 

Just unlucky not one wise person 

Was around to handle this reasonably

At least to save the life. 

Regards

David