Dr Kenji Inaba is a trauma surgeon at the University of Southern California. He is also the director of their surgical ICU, one of the most widely published trauma researchers with over 400 publications, and a reserve officer with the Los Angeles police department. You’d think with that kind of background, he would be macho, arrogant, and in your face about how awesome he is but, in fact, he’s just the opposite. Humble, kind, thoughtful and just about the greatest guy you’ll ever meet. In today’s episode, we discuss junctional bleeding: Bleeding from an area that is a junction of an extremity and the torso (and neck) that is not amenable to hemorrhage control by tourniquet.
A patient arrives with a gunshot wound to the groin. The paramedic is holding pressure with a stack of gauze but it’s obvious that bleeding isn’t controlled. Here are the next steps
- Remove the gauze
- Assess the injury
- Where is the hole and what kind of bleeding is coming up?
- If there is sustained bleeding, apply pressure to the specific point of bleeding – ideal if you can compress proximal to the hemorrhage site. Using diffuse pressure with the palm of your hand in the general vicinity of bleeding may be less effective.
- If bleeding continues or you need to free up your hands, consider placing a Foley catheter in the wound.
- The best kind of wound for a foley catheter is one that’s just big enough to allow entry of the catheter (so it balloon stays in the cavity once it’s inflated)
Placement of a Foley catheter to control junctional bleeding as described by Kenji Inaba
- Use the largest Foley catheter that you have. It’s not the size of the catheter that’s so important, it’s that larger catheters will have more balloon volume
- Ask for mulipies catheters because one might not provide hemostasis
- Place the Foley in the hole (bullet or stab wound) and go all the way into the bleeding cavity. Slip the catheter in as deep as it will go
- Inflate the balloon with saline (or some sort of fluid). If the bleeding hasn’t stopped after 20-30 cc of fluid in the balloon, you may need to place a second catheter
- Clamp across the Foley tube (so blood doesn’t come back through the catheter)
- May need to stitch the skin so the balloon doesn’t pop out
- Another option that Kenji uses are the XSTAT pellets
Kenji’s opinion on junctional tourniquets (examples Combat ready clamp, SAM junctional tourniquet )
- They work
- Some are quite bulky, a lot of material in your way during a resuscitation
- If you work in a place were you need to apply pressure and get your hands free and have the capacity to store them, not a bad idea.
- In Kenji’s ED, OR, and ICU, he doesn’t see much return on investment