Nominal Artery Bleed

[Sublime]

Has anyone ever seen or had to treat one of these? I saw one that was a late stage throat cancer patient, and it was the craziest code I've ever been involved in. This was in the hospital and a nurse and I were the first ones in the room. The patient had blood literally shooting out of his stoma. Seemed like within a minute or two he had bled out in front of us. I had never seen one before so I was clueless on how to control it. I tried deep tracheal suctioning and all I was getting was a steady stream of blood back. After a short attempt at bagging him through his trach. which was not working at all the doc intubated him and we started pressure infusing him with saline till we got some blood to give him.

The ENT team was paged and got to the room pretty quickly and was able to repair the bleed (not sure what they did exactly). We lost a pulse at one point and had to do some CPR and give some epi. He was resuscitated but died a day later in ICU. This was about 4-5 months ago.

Thought I'd never see one again but we had another one come in the ER a couple days ago. I wasn't directly involved in this one's care, but I saw him as EMS brought him through. Another throat cancer pt. with a trach. Apparently he had an esophagotracheal fistula that had formed which caused the nominal artery bleed. They ended up transfusing quite a bit of blood without ever successfully controlling the bleeding. I was told they were able to pinch it off at his throat to stop the blood from coming out his trach. but it just started coming out his mouth instead.

The doc ended up buying pizza for the whole ER the next day to make up for this code. This is a level 1 trauma center, so you know it was a messy code when the doc here buys everyone pizza lol.

Anyways, if anyone has any experience or advice on how to better handle these situations please chime in.

 

[jwk]

It took me a minute to realize what you were talking about. It's the innominate artery. It's the first big artery coming off the aorta after it leaves the left ventricle. The innominate then splits and becomes the right carotid and right subclavian arteries.

The phrase that comes to mind is "you can't get there from here". Some things are just basically a lethal injury, and this is almost always the case with this type of bleed. There's really not much of a repair that is possibe without splitting the sternum - anything less is a bandaid approach.

 

[JPINFV]

The other thing I can think of, given the vignette, is the possibility of alcohol abuse. Alcohol abuse can lead to squamous cell cancer of the upper GI track (mouth, pharynx, larynx, esophagus), as well as cirrhosis of the liver. Liver cirrhosis can lead to an esophageal varicose, which can then rupture and lead to massive bleeding.

 

[Handsome Robb]

The other thing I can think of, given the vignette, is the possibility of alcohol abuse. Alcohol abuse can lead to squamous cell cancer of the upper GI track (mouth, pharynx, larynx, esophagus), as well as cirrhosis of the liver. Liver cirrhosis can lead to an esophageal varicose, which can then rupture and lead to massive bleeding.

Portal hypertension?

Never seen ruptured varicices but I heard it's a catastrophe when it happens.

 

[Merck]

Ruptured varices are nasty with a lot of blood but also venous in nature. The inominate artery, like jwk eluded, is a big-*** artery. A rupture of that likely requires a solid 40 seconds of palliative care followed by housekeeping. Never seen one but I'll keep my eye out on my next CA/stoma pt.

 

[Handsome Robb]

It took me a minute to realize what you were talking about. It's the innominate artery. It's the first big artery coming off the aorta after it leaves the left ventricle. The innominate then splits and becomes the right carotid and right subclavian arteries.

The phrase that comes to mind is "you can't get there from here". Some things are just basically a lethal injury, and this is almost always the case with this type of bleed. There's really not much of a repair that is possibe without splitting the sternum - anything less is a bandaid approach.

So if I'm reading this correctly, even if you were to be able to gain access and hold direct tamponade on the artery you've now effectively reduced cerebral blood flow by a solid amount?

Seems like a lose-lose situation no matter how you look at it.

 

[JPINFV]

So if I'm reading this correctly, even if you were to be able to gain access and hold direct tamponade on the artery you've now effectively reduced cerebral blood flow by a solid amount?

Seems like a lose-lose situation no matter how you look at it.

So a Kavorkian Scarf would work?


Well, the other carotid (the bracheocephalic is only on the right) could compensate to a bit. Of course that was also what is making me thing esophageal varices since those are treated with band ligation.

 

[Handsome Robb]

So a Kavorkian Scarf would work?


Well, the other carotid (the bracheocephalic is only on the right) could compensate to a bit. Of course that was also what is making me thing esophageal varices since those are treated with band ligation.

If a kitten like that ever came after me with one of those I'd run screaming like a little girl.

How much can be compensated for though? It seems like, as jwk said, this is a lethal injury. Even if you do survive it doesn't seem as though you'd have a good quality of life.

 

[JPINFV]

If a kitten like that ever came after me with one of those I'd run screaming like a little girl.

Actually that's a squirrel (Foamy!). If they person who made them focused on the squirrel (especially his rants) instead of the goth owner (who I'd like to stab), I might have continued watching them.

How much can be compensated for though? It seems like, as jwk said, this is a lethal injury. Even if you do survive it doesn't seem as though you'd have a good quality of life.

Depends. The blood loss is a big issue. I know that if a carotid artery closes slowly, the other can basically compensate for all of the blood flow (including 100% stenosis). Albeit there's a higher incidence of stroke and TIAs, but I'm not sure about a rapid loss of a carotid artery, such as clamping it off for someone bleeding off.

Of course I guess it's also an issue of immediate death, vs death a short time later if it can't be repaired and reopened.

 

[Sublime]

It took me a minute to realize what you were talking about. It's the innominate artery. It's the first big artery coming off the aorta after it leaves the left ventricle. The innominate then splits and becomes the right carotid and right subclavian arteries.

The phrase that comes to mind is "you can't get there from here". Some things are just basically a lethal injury, and this is almost always the case with this type of bleed. There's really not much of a repair that is possibe without splitting the sternum - anything less is a bandaid approach.

Yup thats what I meant. Wrote this right before I went to sleep, not sure where I got the term "nominal".

I was told if you remove the trach. and can see the bleed then you can tamponade it off with your fingers. But then you have to hold it till a surgical intervention is possible.

Next time I see the doc that was involved in the first scenario, I will ask him what the ENT team did to fix it. Once those guys got in there I stepped out of the way, and never got to see what they did.

 

[Jon]

I had a ruptured varices code once.

I've seen horror films with less blood. We had to have FD come out and hose down the parking lot... and it was an all-day affair returning to service.

Needless to say, the patient was dead before we got there.

 

[Milla3P]

These are also very common in people with significant ETOH histories.

Don't just think that every CA pt you encounter is going to start spewing blood everywhere. Some of these ruptured varices won't even present with blood coming out the top end. Could just be nausea, coffee ground poopies and lethargy eventually moving onto shock S/S.

I've seen a few Docs give the temp Tx of spraying a little Epi 1:10,000 through a fibroscope before they clamp it up. Very cool stuff.

 

[Veneficus]

I think for the most part you will find that people who try to resuscitate surgical emergencies by normalizing vital sign numbers are not going to be successful.

Whether from a gunshot, ruptured varices, aneurysms, insufficent aortic valves, etc, these patients will survive based on 2 things.

1. immediate surgical intervention and control.

There has been this theory going around prior to damage control surgery techniques, which are still not widely adopted outside the military, that after resuscitation, you can then perform surgery in order to correct the underlying problem in a definitive way.

It just doesn't work. While certainly convenient for providers, the idea from the perspective of actually helpng people totally sucks.

2. Agrressive resuscitation aimed at both the oxygen delivery deficit and subsequent inflammatory processes.

(which probly means you are not going to definitively repair or close any surgical pathology requiring subsequent operations)

It is a scheduling nightmare and an expensive undertaking.

Most emergency medicine specialists I know are not willing to attempt an emergent surgical procedure that has a low chance of success.

I would wager most surgeons that operate outside of the emergency environments wouldn't either.

On top of that you still need anesthesia for their contributions in both the OR and ICU. Especially ones willing and enthusiastic to work with ASA 5 score patients.

Such individuals are rather rare and teams of them are usually concentrated in certain centers. (which further attracts the new ones to said centers)

There is also the questions of capability and affordability.

Not every center can afford to provide the resources needed for such a high level of medicine without significant reimbursement rates. You could bill anyone for millions, but it doesn't mean you will get it.

If you cannot afford the upfront and ongoing fees for said people and equipment, then you cannot have it.

It has been my experience in 5 countries that if you are really about to die, in order for there to be any hope, you need an academic medical facility.

Otherwise, about the best you can do is make people comfortable as they die, practice your rarely used skills, and make yourself feel better by following a resuscitation guidline that I can sit here and type for hours if not days explaining why it won't work before you even start.

Attempting to "stabilize" numbers of a bleeding person with a still open circuit is just stupid unless the numbers you want to see are all zeros.

 

[VFlutter]

It has been my experience in 5 countries that if you are really about to die, in order for there to be any hope, you need an academic medical facility.

I am very lucky to do my clinicals at a large academic hospital which allows me to see some amazing things however I feel like a lot of times they take things too far just for the sake of doing procedures. I guess it is both good and bad depending on the situation.

 

[Veneficus]

I am very lucky to do my clinicals at a large academic hospital which allows me to see some amazing things however I feel like a lot of times they take things too far just for the sake of doing procedures. I guess it is both good and bad depending on the situation.

That is not only done at academic facilities.

Some people use the recently dead or about to die for procedure practice.

I have mixed feelings on the matter so I really can't offer much judgement to it.

One of my major reasons in favor of it is that emergency surgical techniques are not practicable on standard patients. If you are not comfortable doing a procedure, you will probably not do it.

Another issue along the same lines is that with the proliferation of laparoscopic and robotic surgery, there are less and less chances to become proficent enough in open surgery to be effective in emergent situations.

On the flip side, I think if you are going to do a procedure, you should do it as a Herculean effort for a save, not for the next time.

But as for "too far" in what is acceptable, that is a personal decision.

 

[VFlutter]

On a side note I saw a da Vinci surgery a few weeks ago, absolutely amazing.

 

[Merck]

The comparison that seems to have arisen between the initial topic and varices might be a little too simplistic. The original topic sounds, as I have never seen that particular circumstance, FUBAR - and good luck treating it. Ruptured varices, on the other hand, can be handled perhaps with more success. The pt with ruptured varices may retain a good LOC and be able to maintain an airway while evacuating the blood. If airway control is needed and you are reasonably sure that varices are the culprit then proceed as normal to take the airway emergently (with beaucoup de suction).

Ligation with bands is possible in a stable patient but for bleeding options of surgery and/or Blakemore tube may be tried.

Calls like this are why paramedics get paid so much. (Insert wry, sarcastic laughter here).

 

[Dwindlin]

On a side note I saw a da Vinci surgery a few weeks ago, absolutely amazing.

I hate that machine. . .

I gag every time I think about it. . .

 

[Veneficus]

I hate that machine. . .

I gag every time I think about it. . .

Me too.

Particularly in prostate surgery, look at the rate of complications of robotic surgery vs. non...

(effectiveness of prostate surgery aside)

 

[Dwindlin]

Me too.

Particularly in prostate surgery, look at the rate of complications of robotic surgery vs. non...

(effectiveness of prostate surgery aside)

My reasons aren't even medical...watching DaVinci surgeries (before I finally just started hanging with anesthesia) is painful. Pretty sure I developed PTSD during GYN.