a b s t r a c t

Massive hemorrhage from the inguinal space is an indication for the use of the Femostop device in the emergency department. This case report describes a middle-aged male with metastatic and recurrent penile cancer status post inguinal lymph node dissection and chemoradiation with a nonhealing left groin wound with extension to the femoral vessels. The patient experienced Massive bleeding from erosion of an open wound in left groin into femoral vein requiring massive transfusion. Direct pressure and pressure dressings were unable to control the bleeding present in the patient’s left groin. The Femostop device was applied and hemostasis was immediately achieved.

Introduction

Femostop devices have been studied and proven reliable devices in the setting of hemostasis at femoral post cardiac catheterization inguinal sites [3]. However, the literature in demonstrating its usefulness in the emergency department in the setting of acute massive hemorrhage is lacking. Massive inguinal bleeding is known to all emergency physicians and surgeons alike to be one of great difficulty in achieving adequate hemostasis, especially at an emergency department bedside and not an operat- ing room. In this case report we present an option for inguinal hemorrhage hemostasis via the Femostop device (see Fig. 1).

Case description/summary

A 49 year old male presented to our emergency department with a chief complaint of bleeding from his left inguinal space. The patient had a past medical history of penile cancer, diabetes and hypertension. His penile cancer was complicated by metastatic disease present in his left inguinal lymph node system. He subse- quently received radiation therapy and developed an open wound in the left inguinal space. The patient presented to our ED with acute onset bleeding in the area after simply shifting in his recliner and noticing that the wound seemed to have ”broken open” and began bleeding. Patient was noted to be hypotensive in the field by EMS with BP of 70/40.

* Corresponding author.

E-mail address: [email protected] (J. Cambron).

He had a past surgical history positive for penectomy related to Squamous cell carcinoma. Patient was complaining of bleeding from left groin with associated pain but had no other complaints upon presentation. He was noted to be tachycardic with heart rate of 104 and mildly hypotensive with blood pressure of 88/63. His mentation was normal, he was pale and diaphoretic in appearance with a wound within his left inguinal space with minimal bleeding present after direct manual pressure was applied by EMS and nurs- ing with overlying 4 x 4 gauze. The patient and his wife states that ”massive” bleeding took place in their residence before EMS arrived and applied direct pressure.

The patient’s laboratory evaluation revealed a hemoglobin of

7.4 g/dl, an acute kidney injury with BUN/Creatinine level of 46/2.5 and a metabolic acidosis with bicarbonate level of 16. Dur- ing prior visits the patient’s hemoglobin level was measured at

13.1. It should also be noted that his Coagulation studies revealed PT/INR level of 10.7/1.1 during this visit. CT imaging of the pelvis revealed a left inguinal ulceration with extension to the underlying left common femoral vasculature. By this time, complete hemosta- sis of the patients bleeding had been achieved via direct manual pressure and a simple dressing had been applied. Due to tachycar- dia, mild hypotension and acute anemia patient was transfused 1 unit Packed red blood cells. The patient was stable in the emer- gency department awaiting admission to the ICU for approxi- mately 5 h when at 9:45 pm a family member came out of the room stating there was significant bleeding from his left Groin area. He quickly became hypotensive and unresponsive. The patient was intubated for airway protection. The patient had developed brisk bleeding from the inguinal site wound. His blood pressure dropped to 65/30 and massive transfusion protocol was initiated.

https://doi.org/10.1016/j.ajem.2019.10.034 0735-6757/

849.e2 J. Cambron, M.A. Miller / American Journal of Emergency Medicine 38 (2020) 849.e1-849.e2

Fig. 1. Proper Placement of Femostop device

Additional treatments included TXA and a dose of DDAVP due to underlying chronic renal failure and a concern for platelet dysfunc- tion. Despite these interventions as well as heavy direct pressure, the patient continued to bleed heavily. With manual direct pres- sure not adequately slowing down the rate of bleeding, we began troubleshooting an alternative method of Hemorrhage control. Inguinal hemorrhage control devices status post cardiac catheriza- tion procedures were discussed and it was discovered that this device at our facility is called the Femostop. One of these devices was quickly obtained we then applied a femoral Femostop device. After proper placement and inflation, hemostasis was immediately achieved.

The Femostop Device maintained adequate hemostasis for 90 min while the patient was resuscitated with 10 units packed red blood cells, 10 units fresh frozen plasma and two 10 pack pla- telet units. interventional radiology team was organized during this time and patient was transported to IR suite under direction of on call vascular surgeon in attempt to stent the injured vessel. Patient underwent arterial and venous angiogram which demon- strated active extravasation along patient’s left external iliac and common femoral vein. Unfortunately, during an attempt to stent

the venous injury, re-bleeding occurred, and the patient entered cardiac arrest with family declaring the patient DNR shortly after and he died.

Discussion

This case report describes the use of the Femostop device in a novel manner to control inguinal hemorrhage. Complex and unique situations that lead to inguinal bleeding present challenges in acute treatment from the ED setting [1,2]. Direct pressure and the use of products to enhance hemostasis such as TXA may be used but are commonly ineffective. The Femostop device is easy to place, to the point that any provider should be able to read the directions/illustrations provided within the Femostop con- tainer and easily be able to apply it and inflate it in less than one minute. The Femostop or a similar device will be available at any functional cath lab facility and is affordable with list prices as low as $74.50.

When compared to other FDA cleared devices for junctional hemorrhage control such as the Combat Ready Clamp (CRoC) or SAM junctional Tourniquet, the Femostop is more affordable, accessible and easy to apply [1,2]. Emergency department provi- ders will encounter inguinal injuries requiring an attempt at hemostasis, especially if surgical interventional will not be rapidly available then a device such as the Femostop should readily avail- able to attempt hemostasis.

Declaration of Competing Interest

The authors declare no conflict of interest.

References

1. Klotz JK, Leo M, Anderson BL, Nkodo AA, Garcia G, Wichern AM, et al. First case report of SAM? Junctional tourniquet use in Afghanistan to control inguinal hemorrhage on the battlefield. J Spec Oper Med 2014;14(2):1-5.
2. Kotwal RS, Butler FK, Gross KR, et al. Management of junctional hemorrhage in tactical combat casualty care: TCCC guidelines-Proposed change 13-03. J Spec Oper Med 2013;13:85-93.
3. Armstrong J. Mechanical external compression with FemoStop plus Retrieved from. Cath Lab Digest 2003;11(11). https://www.cathlabdigest.com/articles/ Mechanical-External-Compression-FemoStop%C2%AE-plus.