Category Archives: General

Best Of: Off-Label Use of the Foley Catheter

Foley catheters are a mainstay of medical care in patients who need control or measurement of urine output. Leave it to trauma surgeons to find warped, new ways to use them!

Use of these catheters to tamponade penetrating cardiac injuries has been recognized for decades (see picture, 2 holes!). Less well appreciated is their use to stop bleeding from other penetrating wounds.

Foley catheter in heart

Foley catheters can be inserted into just about any small penetrating wound with bleeding that does not respond to direct pressure. (Remember, direct pressure is applied by one or two fingers only, with no flat dressings underneath to diffuse the pressure). Arterial bleeding, venous bleeding or both can be controlled with this technique. 

In general, the largest catheter with the largest possible balloon should be selected. It is then inserted directly into the wound until the entire balloon is inside the body. Inflate the balloon using saline until firm resistance is encounted, and the bleeding hopefully stops. Important: be sure to clamp the end of the catheter so the bleeding doesn’t find the easy way out!

Use of catheter tamponade buys some time, but these patients need to be in the OR. In general, once other life threatening issues are dealt with in the resuscitation room, the patient should be moved directly to the operating room. In rare cases, an angiogram may be needed to help determine the type of repair. However, in the vast majority of cases, the surgeon will know exactly where the injury is and further study is not needed. The catheter is then prepped along with most of the patient so that the operative repair can be completed.

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Interesting Concept: The Abdominal Aortic & Junctional Tourniquet

Tourniquets for extremity bleeding are definitely back in vogue. Our military experience over the past 20 years has shown us what a life saver this simple tool can be. It’s now carried by many prehospital trauma professionals for use in the civilian population. But what about bleeding from the nether regions? You know what I’m talking about, the so-called junctional zones. Those are the areas that are too proximal (or too dangerous) to put on a tourniquet, like the groin, perineum, axilla, and neck.

Traditionally, junctional zone injury could only be treated in the field with direct pressure, clamps, or in some cases a balloon (think 30Fr Foley catheter inserted and blown up as large as possible, see link below). In the old days, we could try blowing up the MAST trousers to try to get a little control, but those are getting hard to find. 

An Alabama company (Compression Works) developed a very novel concept to try to help, the Abdominal Aortic and Junctional Tourniquet (AAJT). Think of it as a pelvic compression device that you purposely apply too high.

Note the cool warning sticker at the bottom of the device!

The developers performed a small trial on 16 volunteer soldiers after doing a preliminary test on themselves (!). The device was placed around the abdomen, above the pelvis, and inflated to a maximum of 250 torr. Here are the factoids:

  • All subjects tolerated the device, and no complications occurred
  • Flow through the common femoral artery stopped in 15 of the 16 subjects
  • The subject in whom it did not work exceeded the BMI and abdominal girth parameters of the device
  • Average pain score after application was 6-7 (i.e. hurts like hell!)

Here’s a list of the criteria that preclude use of this device:

Bottom line: This would seem to be a very useful device for controlling hemorrhage from pesky areas below the waist.

BUT! Realistically, it will enjoy only limited use in the civilian population for now. Take a closer look at the exclusion criteria above. Half of the population is ineligible right off the bat (women). And among civilians, more than a third are obese in the US. Toss in a smattering of the other criteria, and the unlikelihood of penetrating trauma to that area in civilians, it won’t make financial sense for your average prehospital agency to carry it. Maybe in high violence urban areas, but not anywhere else.

The company has received approval for use in pelvic and axillary hemorrhage control, so we’ll see how it works when more and larger studies are released (on more and larger people). 

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Reference: The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower abdominal hemorrhage. Military Med 178(11):1196-1201, 2013.

Thanks to David Beversluis for bringing this product to my attention. I have no financial interest in Compression Works.

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Warfarin Reversal For Emergent Surgery Using PCC

Yesterday I published a protocol that Regions Hospital uses for rapid reversal of warfarin in patients with life-threatening bleeding. This is very useful in trauma patients, but a number of other specialties use it as well (GI, etc). But what about that patient who doesn’t have a major bleeding problem, but needs emergency surgery or some invasive procedure? If something isn’t done prior to the case, the surgeon or interventionalist may inflict life-threatening bleeding!

We use a variant of the protocol I posted yesterday. The differences arise from the fact that, in this case, there is a little bit of time to find out some of the patient’s medical history. Certain things may modify the protocol, or contraindicate it entirely, such as:

  • Is the patient in DIC?
  • Do they have heparin induced thrombocytopenia (HIT)?
  • Do they have a history of significant peripheral vascular disease or thrombotic tendencies?
  • Will they need to be re-anticoagulated afterwards?

Again, feel free to download this protocol and modify it as you wish. Comments and questions are welcome!

Download the warfarin reversal for emergent surgery protocol here

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Warfarin Reversal With Prothrombin Complex Concentrate

Everybody is looking for good algorithms. They’re very helpful in standardizing care and they are a great teaching tool to show one good way to do something. All trauma centers have at least a few, like the Massive Transfusion Protocol.

Well, as the population ages and more of our elders are placed on drugs like warfarin, they run the risk of life-threatening bleeding if an accident occurs. Why reinvent the wheel? Don’t spend the time combing through the literature and designing your own protocol if someone else has already done the leg work!

Here’s a copy of our protocol for rapid reversal of warfarin with prothrombin complex concentrate (PCC) when life-threatening bleeding is present (e.g. blood in the head). Please note that the INR must be 2 or above to use this protocol, or the risks of giving the drug begin to outweigh the benefits.

Once the patient is found to be eligible, a single dose of PCC based on INR is given, as well as 10mg of vitamin K. The INR usually returns to near normal within about 30-45 minutes. If it’s still elevated, then begin administering plasma.

Feel free to copy and share. Also, any and all comments are welcome!

Download the protocol by clicking here

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Formalizing The Prehospital to In-Hospital Handoff

I’ve written quite a bit about the benefits and pitfalls of the handoff process. Handoffs involving critical trauma patients is particularly important, because the receiving team needs to know a lot of information about what happened before patient arrival. All too often, the patient gets moved to the bed, and the medics are pushed to the side as the team descends upon him.

A number of hospitals around the US and the world have come up with solutions to strengthen this process. The regional trauma advisory committee here in the Twin Cities codified and implemented a formal handoff process to be used by emergency medical services providers any time they deliver a trauma activation patient to one of the area trauma centers.

I’d like to share our solution with you. This 4 minute video describes and demonstrates the process. Our expectation is that once things really get going, EMS will want to do this with just about every patient they deliver to the hospital.

Have a look, and feel free to comment or describe what you do!

Here’s a link to a Word document with the contents of the poster that can be placed in your trauma bay. Feel free to add your logos or change it in any way you wish. Download the poster here.

I first started writing about this project over a year ago. See these related posts on how it progressed:

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