Hemorrhage Control

  • Rachel M. Russo
  • Joseph J. DuBose


Blast injury from improvised explosive devices has proven an increasingly encountered mechanism of traumatic injury in military and civilian settings. The emergency surgeon will undoubtedly encounter dramatic and troubling extremity injuries that may occur in conjunction with a multitude of apparent or occult concomitant injuries. Advancements in hemorrhage control and resuscitation have allowed hundreds of patients to survive injuries previously thought to be lethal. This chapter will discuss available strategies for initial hemorrhage control in the patient with multiple traumatic amputations. This will include the identification of the source and severity of hemorrhage, initial prehospital and early in-hospital interventions, and then methods for operative control. The bulk of the chapter focuses on practical advice on the anatomy and techniques for exposure, control, and repair or temporization of the major vascular structures in the thorax, abdomen, and pelvis.


Hemorrhage control Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Vascular trauma Blast injury Mangled extremity Surgical exposures Traumatic amputation 


  1. 1.
    Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–7.CrossRefGoogle Scholar
  2. 2.
    Blackbourne LH, Czarnik J, Mabry R, Eastridge B, Baer D, Butler F, et al. Decreasing killed in action and died of wounds rates in combat wounded. J Trauma. 2010;69(Suppl 1):S1–4.CrossRefGoogle Scholar
  3. 3.
    DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med. 2005;352(13):1335–42.CrossRefGoogle Scholar
  4. 4.
    Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast injuries. Lancet. 2009;374(9687):405–15.CrossRefGoogle Scholar
  5. 5.
    Hull JB, Bowyer GW, Cooper GJ, Crane J. Pattern of injury in those dying from traumatic amputation caused by bomb blast. Br J Surg. 1994;81(8):1132–5.CrossRefGoogle Scholar
  6. 6.
    Hull JB. Traumatic amputation by explosive blast: pattern of injury in survivors. Br J Surg. 1992;79(12):1303–6.CrossRefGoogle Scholar
  7. 7.
    Nessen SC, Lounsbury DE, Hetz SP, editors. War surgery in Afghanistan and Iraq: a series of cases, 2003–2007 (textbooks of military medicine). 1st ed. Washington, DC: Walter Reed Army Medical Center Borden Institute; 2008.Google Scholar
  8. 8.
    Blackbourne LH, Baer DG, Eastridge BJ, Kheirabadi B, Bagley S, Kragh JF Jr, et al. Military medical revolution: prehospital combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S372–7.CrossRefGoogle Scholar
  9. 9.
    Kragh JF Jr. Use of tourniquets and their effects on limb function in the modern combat environment. Foot Ankle Clin. 2010;15(1):23–40.CrossRefGoogle Scholar
  10. 10.
    Singleton JA, Gibb IE, Hunt NC, Bull AM, Clasper JC. Identifying future 'unexpected' survivors: a retrospective cohort study of fatal injury patterns in victims of improvised explosive devices. BMJ Open. 2013;3(8):e003130.CrossRefGoogle Scholar
  11. 11.
    Alarhayem A, Myers J, Dent D, Eastridge B. No Time to bleed: the impact of time from injury to the operating room on survival in patients with hemorrhage from blunt abdominal trauma. AAST; Sept 2015; Las Vegas, NV.Google Scholar
  12. 12.
    Kue RC, Temin ES, Weiner SG, Gates J, Coleman MH, Fisher J, et al. Tourniquet use in a civilian emergency medical services setting: a descriptive analysis of the Boston EMS experience. Prehosp Emerg Care. 2015;19(3):399–404.CrossRefGoogle Scholar
  13. 13.
    King DR, Larentzakis A, Ramly EP, Boston Trauma C. Tourniquet use at the Boston Marathon bombing: lost in translation. J Trauma Acute Care Surg. 2015;78(3):594–9.CrossRefGoogle Scholar
  14. 14.
    Kheirabadi BS, Terrazas IB, Miranda N, Estep JS, Corona BT, Kragh JF Jr, et al. Long-term effects of combat ready clamp application to control junctional hemorrhage in swine. J Trauma Acute Care Surg. 2014;77(3 Suppl 2):S101–8.CrossRefGoogle Scholar
  15. 15.
    Cubano M, editor. Emergency war surgery. 4th ed. Fort Sam Houston: Office of the Surgeon General. Borden Institute. Department of the Army; 2013.Google Scholar
  16. 16.
    Carrick MM, Morrison CA, Pham HQ, Norman MA, Marvin B, Lee J, et al. Modern management of traumatic subclavian artery injuries: a single institution’s experience in the evolution of endovascular repair. Am J Surg. 2010;199(1):28–34.CrossRefGoogle Scholar
  17. 17.
    Kragh JF Jr, Kirby JM, Ficke JR. Chapter 9: Extremity injury. In: Savitsky E, Eastridge B, editors. Combat casualty care: lessons learned from OEF and OIF. Washington, DC: Department of the Army, Office of the Surgeon General, Borden Institute; 2012. p. 777.Google Scholar
  18. 18.
    Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869–72.PubMedGoogle Scholar
  19. 19.
    Smith RS, Chang FC. Traumatic rupture of the aorta: still a lethal injury. Am J Surg. 1986;152(6):660–3.CrossRefGoogle Scholar
  20. 20.
    LF P, TW M, WC M, EJ J. Nonpenetrating traumatic injury of the aorta. Circulation. 1958;17(6):1086–101.CrossRefGoogle Scholar
  21. 21.
    Kaewlai R, Avery LL, Asrani AV, Novelline RA. Multidetector CT of blunt thoracic trauma 1. Radiographics. 2008;28(6):1555–70.CrossRefGoogle Scholar
  22. 22.
    Crawford ES, Svensson LG, Hess KR, Shenaq SS, Coselli JS, Safi HJ, et al. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg. 1991;13(1):36–46.CrossRefGoogle Scholar
  23. 23.
    Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg. 2015;78(5):1054–8.CrossRefGoogle Scholar
  24. 24.
    Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery. 1954;36(1):65–8.PubMedGoogle Scholar
  25. 25.
    DuBose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409–19. Publish Ahead of Print.CrossRefGoogle Scholar
  26. 26.
    Russo R, Neff LP, Johnson MA, Williams TK. Emerging endovascular therapies for non-compressible torso hemorrhage. Shock. 2016;46(3S):12–9.CrossRefGoogle Scholar
  27. 27.
    Scott DJ, Eliason JL, Villamaria C, Morrison JJ, Rt H, Spencer JR, et al. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma Acute Care Surg. 2013;75(1):122–8.CrossRefGoogle Scholar
  28. 28.
    Guliani S, Amendola M, Strife B, Morano G, Elbich J, Albuquerque F, et al. Central aortic wire confirmation for emergent endovascular procedures: as fast as surgeon-performed ultrasound. J Trauma Acute Care Surg. 2015;79(4):549–54.CrossRefGoogle Scholar
  29. 29.
    Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado RP, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013;75(3):506–11.CrossRefGoogle Scholar
  30. 30.
    Holcomb JB, Fox EE, Scalea TM, Napolitano LM, Albarado R, Gill B, et al. Current opinion on catheter-based hemorrhage control in trauma patients. J Trauma Acute Care Surg. 2014;76(3):888–93.CrossRefGoogle Scholar
  31. 31.
    Andres J, Scott J, Giannoudis PV. Resuscitative endovascular balloon occlusion of the aorta (REBOA): what have we learned? Injury. 2016;47(12):2603–5.CrossRefGoogle Scholar
  32. 32.
    Ogura T, Lefor AT, Nakano M, Izawa Y, Morita H. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(1):132–5.CrossRefGoogle Scholar
  33. 33.
    Saito N, Matsumoto H, Yagi T, Hara Y, Hayashida K, Motomura T, et al. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(5):897–903. discussion 4.CrossRefGoogle Scholar
  34. 34.
    Tsurukiri J, Akamine I, Sato T, Sakurai M, Okumura E, Moriya M, et al. Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting. Scand J Trauma Resusc Emerg Med. 2016;24(1):13.CrossRefGoogle Scholar
  35. 35.
    Norii T, Crandall C, Terasaka Y. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015;78(4):721–8.CrossRefGoogle Scholar
  36. 36.
    Davidson AJ, Russo RM, DuBose JJ, Roberts J, Jurkovich GJ, Galante JM. Potential benefit of early operative utilization of low profile, partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA) in major traumatic hemorrhage. Trauma Surg Amp Acute Care Open. 2016;1(1):e000028.CrossRefGoogle Scholar
  37. 37.
    Morrison JJ, Ross JD, Rt H, Watson JD, Sokol KK, Rasmussen TE. Use of resuscitative endovascular balloon occlusion of the aorta in a highly lethal model of noncompressible torso hemorrhage. Shock. 2014;41(2):130–7.CrossRefGoogle Scholar
  38. 38.
    Ho rer TM, Cajander P, Jans A, Nilsson KF. A case of partial aortic balloon occlusion in an unstable multi-trauma patient. Trauma. 2016;18(2):150–4.CrossRefGoogle Scholar
  39. 39.
    Okumura E, Tsurukiri J, Oomura T, Tanaka Y, Oomura R. Partial resuscitative endovascular balloon occlusion of the aorta as a hemorrhagic shock adjunct for ectopic pregnancy. Am J Emerg Med. 2016;34(9):1917.e1–2.CrossRefGoogle Scholar
  40. 40.
    Russo RM, Neff LP, Lamb CM, Cannon JW, Galante JM, Clement NF, et al. Partial resuscitative endovascular balloon occlusion of the aorta in swine model of hemorrhagic shock. J Am Coll Surg. 2016;223(2):359–68.CrossRefGoogle Scholar
  41. 41.
    Johnson MA, Neff LP, Williams TK, JJ DB, Group ES. Partial Resuscitative Balloon Occlusion of the AORTA (P-REBOA): clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5):S133–7.CrossRefGoogle Scholar
  42. 42.
    Russo RM, Williams TK, Grayson JK, Lamb CM, Cannon JW, Clement NF, et al. Extending the golden hour: partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg. 2016;80(3):372–80.CrossRefGoogle Scholar
  43. 43.
    Dubose JJ. Chapter 7: Thoracic vascular and great vessel hemorrhage: big red and big blue. In: Ball C, editor. Treatment of ongoing hemorrhage: the art and craft of stopping severe bleeding. Cham: Springer; 2018.Google Scholar
  44. 44.
    Muscat JO, Rogers W, Cruz AB, RCJ S. Arterial injuries in Orthopaedics: the posteromedial approach for vascular control about the knee. J Orthop Trauma. 1996;10(7):476–80.CrossRefGoogle Scholar
  45. 45.
    Blazick E, Conrad MF. Chapter 22: Advanced aneurysm management techniques: open surgical anatomy and repair. In: Mulholland MW, editor. Operative techniques in surgery. Volume 2. Part 6. Section 7. Philadelphia: Wolters Kluwer Health – Lippincott Williams & Wilkins; 2015.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Rachel M. Russo
    • 1
  • Joseph J. DuBose
    • 2
  1. 1.Department of General SurgeryUniversity of California Davis Medical CenterSacramentoUSA
  2. 2.Department of Vascular and Endovascular SurgeryDavid Grant USAF Medical Center, Travis Air Force Base, CaliforniaFairfieldUSA

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