As we have considered, the initial stabilization of the emergency patient has much to do with stopping the bleeding, recovering blood lost into different body cavities, and beginning fluid resuscitation. However, there are still many techniques that could be employed in the early part of the emergency period to avoid the use of blood.

Close off the Pipes

A technique that may be employed to stop internal bleeding without surgery is known as arterial embolization. To embolize means to occlude or clog up a blood vessel. During surgery, a blood vessel can be tied up, pinched close with surgical instruments, or cut into and cauterized. But can something be done without performing surgery?

Radiologists have the equipment that allows them to look into the body and watch its function in real time. To augment this picture, the doctors may inject a contrast medium into the blood vessel. This agent makes the circulatory system show up extremely clear on the doctor’s screen. He can see where blood is circulating in organs and where it is leaking out of damaged blood vessels without ever having to perform surgery.

Additionally, an interventional radiologist is able to do something about this damaged vessel. He carefully winds a probe called a catheter into the blood vessel to a place ‘upstream’ of the damage. Then, a substance, a chemical or mechanical embolizing agent, is placed into the artery stopping the blood flow. With this plug in place the bleeding stops and the patient can stabilize. With some of embolizing agents there is the capacity to dissolve after a length of time. This allows the artery to heal during this rest. Once healed, blood flow returns to normal. 1, 2, 3, 4, 5, 6, 7

This technique of embolization has proven effective for many cases. However, it would not be recommended in some areas that do not have good collateral flow or into vital organs such as the brain and heart.

Chemical Hemostatics

The human body has a unique system for controlling bleeding. This arrangement is known as the clotting system. It acts by sensing a break in the ‘pipes’ that carry the blood throughout the body. When a break is sensed, circulating blood proteins are released in the walls of the blood vessels are other sensitive structures. These proteins are part of what is known as the clotting cascade.

A cascade can be defined as a succession of stages, processes, operations, or units. With clotting, a series of specific compounds are triggered one in a row. Each of these compounds are called clotting factors, and they are designated by roman numerals such as VII or IX. The final compound to be activated is fibrinogen, which forms fibrin, a glue-like substance that can plug the leak.

This efficient system works well throughout an individual's life to keep one from bleeding. We rarely ever think about it or become concerned about its presence. However, hemophiliacs, or individuals who are missing one or more of these clotting factors in their body, are reminded daily by easily bleeding and bruising.

The question arises, "Can this system be augmented, or made better? Yes, it can. But how?

Desmopressin

Desmopressin is a synthetic drug with the trade name of DDAVP. It is an analogue, or close relative, to vasopressin, a naturally occurring hormone in the body. Desmopressin was originally developed to control nocturnal enuresis (bed wetting in children). It was noted that the need for clotting factor injections decreased in children with von Willebrand Disease while receiving desmopressin for bed wetting. This disease is one of several types of hemophilia. These types include such ones as "classic," "Christmas Tree," and "von Willebrand's." Some require the replacement with factors such as VII, IX, and in von Willebrand's, vWF:IIV.

Now desmopressin is labeled by the FDA for the treatment for von Willebrand disease. It has also been found that desmopressin is able to increase the activity of platelets, another component of the clotting system. Desmopressin can therefore be used to transiently increase the clotting factors and activity of the circulating platelets. This has been effective especially in the surgical patient or in those that have taken anti-platelet compounds such as aspirin. In the acute bleeding episode, desmopressin can be administered to make the clotting system hyperactive in areas where there are breaks in the walls of the blood vessels. This may allow the bleeding to stop long enough for the clotting system to plug the hole adequately. It has also been effective in decreasing bleeding in individuals who have low platelet counts. Desmopressin is also unique in that it can be given in a nasal spray form which is immediately active in the body, and is very beneficial for those with some forms of hemophilia.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20

Antifibrinolytics: Keeping it Together

As mentioned earlier, the clotting system is a unique cascade of proteins that work in harmony to stop bleeding without causing damage. The final product, fibrinogen, breaks down into fibrin, a product that forms the clot. However, when fibrinogen breaks down, it also releases a product known as a fibrinolytic. Fibrinolytic means to ‘eat fibrin,’ or to break it down.

It might seem peculiar that the body releases a compound to break down a product at the same time it is being made. However, there is balance in this process. If fibrin activated without a regulator, then the whole blood stream might turn into one large clot, in essence, turning the blood in our body into a Jell-O like substance. We could not live if this were so. However, if there is a massive problem with bleeding then there is little need to produce the fibrinolytic agent. This is where a group of drugs known as antifibrinolytic agents become useful.

The term antifibrinolytic agent means literally ‘against fibrin eaters.’ These antifibrinolytic drugs are a family of compounds that inhibit the activity of the fibrinolytic agents, and thereby make clots, formed with fibrin, more stable. The two main ones are aminocaproic acid (Amicar) and tranexamic acid (Cyklokapron). These injectable medications can be given in an emergency situation, during surgery, or even for low platelet counts. 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37

Topical Agents: Closing the Lid

If all of the above measures have failed to stop the bleeding, the last option may be to perform surgery to close up any bleeding. Though mechanical closure of a blood vessel or two may work well, at times the area of damage is to a solid organ. Such organs as the spleen and liver are highly vascularized and hold blood in their structure somewhat like a sponge. If such an organ becomes torn or lacerated, it may become quite difficult to stop the bleeding. This is an instance where a topical agent may prove effective.

Topical agents may include some common agents used in surgery such as surgicel. Newer agents now include topical fibrin glue [For some with religious objections this may be a concern] and autologous platelet gel [For some with religious objections this may be a concern]. These agents are placed over large areas of bleeding from solid organs like glue. The substance then bonds to the surface to stop the bleeding. Over time the body reabsorbs the compound only after the organ has healed. 38, 39, 40

Conclusion

The immediate control of bleeding will help to avoid the use of blood and save lives. These specialized techniques may be new to some but have proven themselves effective in the clinical realm. The use of one or more of these techniques may prove to be just what the doctor ordered.

1. Gomes AS, "Angiographic Treatment of Gastrointestinal Hemorrhage: Comparison of Vasopressin
   Infusion and Embolization," AJR, 1986, May, Vol. 146, No. 5


2. Lemme-Plaghos LA, "Combination of Embolization and Radiosurgery in the
   Treatment of Arteriovenous Malformations," Radiosurgery: Baseline
   Trends, 1992


3. Machida H, "Transcatheter Arterial Embolization for Massive Abdominal
   Bleeding in Post-Pancreaticoduodenectomy—First Report," J of
   Japanese Surgical Society, 1990, June, Vol. 91, No. 6


4. Pearl ML, "Percutaneous Transcatheter Embolization for Control of Life-Threatening
   Pelvic Hemorrhage From Gestational Trophoblastic Disease," OBSTET-GYNECOL,
   1992, September, Vol. 80, No. 3


5. Qureshi S, "Use of Interlocking Detachable Coils in Embolization of Coronary
   Arteriovenous Fistulas," AM-J-CARDIOL, 1996, July, Vol. 78


6. Sclafani SJA, "Nonoperative Salvage of Computed Tomography-Diagnosed Splenic
   Injuries: Utilization of Angiography for Triage and Embolization for Hemostasis," J-TRAUMA,
   1995, November, Vol. 39, No. 5


7. Yamashita Y, "Transcatheter Arterial Embolization in the Management of
   Postpartum Hemorrhage Due to Genital Tract Injury," OBSTET-GYNECOL,
   1991, January, Vol. 77, No. 1


8. Castaman G, "Clinical Usefulness of Desmopressin for Prevention of Surgical
   Bleeding in Patients With Symptomatic Heterozygous Factor XI Deficiency," British
   Journal of Haematology, 1996, July, Vol. 94, No. 1


9. Cattaneo M, "The Effect of Desmopressin on Reducing Blood Loss in Cardiac
   Surgery - a Meta-Analysis of Double-Blind, Placebo-Controlled Trials," Thrombosis
   and Haemostasis, 1995, October, Vol. 74, No. 4


10. Chard RB, "Use of Desmopressin in the Management of Aspirin-Related and
    Intractable Haemorrhage After Cardiopulmonary Bypass," Australian
    New Zealand J Surg, 1990, February, Vol. 60, No. 2


11. Czer LSC, "Treatment of Severe Platelet Dysfunction and Hemorrhage After
    Cardiopulmonary Bypass: Reduction in Blood Product Usage With Desmopressin," J
    American College Cardiology, 1987, May, Vol. 9, No. 5


12. Jacquot Ch, "Addition of Desmopressin to Recombinant Human Erythropoietin
    in Treatment of Haemostatic Defect of Uraemia," LANCET, 1988, February
    20, Vol. 1, No. 8582


13. Kobrinsky NL, "Synergistic Shortening of the Bleeding Time by Desmopressin
    and Ethamsylate in Patients with Various Constitutional Bleeding Disorders," Am
    J Ped Hematology/Oncology, 1991, Winter, Vol. 13, No. 4


14. Kobrinsky NL, "Treatment of Refractory Thrombocytopenic Bleeding With
    1-Desamino-8-D-Arginine Vasopressin (Desmopressin)," J-PEDIATR, 1988,
    June, Vol. 112, No. 6


15. Lethagen S, "Blood Loss and Safety With Desmopressin or Placebo During
    Aorto-Iliac Graft Surgery," European J Vascular Surgery, 1991, April,
    Vol. 5, No. 2


16. Letts M, "Desmopressin (DDAVP): An Adjunct to Hemostasis?," Spine:
    State of Art Reviews, 1991, January, Vol. 5, No. 1


17. Mannucci PM, "Desmopressin: A Nontransfusional Form of Treatment for Congenital
    and Acquired Bleeding Disorders," Blood, J Am Soc of Hematology, 1988,
    November, Vol. 72, No. 5


18. Martens PR, "Desmopressin and Jehovah's Witness," LANCET, 1989,
    June 10, Vol. 1, No. 8650


19. Rose EH, "Nasal Spray Desmopressin (DDAVP) for Mild Hemophilia A and von
    Willebrand Disease," ANN-INTERN-MED, 1991, April 1, Vol. 114, No.
    7


20. Sheridan DP, "Use of Desmopressin Acetate to Reduce Blood Transfusion
    Requirements During Cardiac Surgery in Patients With Acetylsalicylic-Acid-Induced
    Platelet Dysfunction," Canadian Journal of Surgery, 1994, February,
    Vol. 37, No. 1


21. Bartholomew JR, "Control of Bleeding in Patients With Immune and Nonimmune
    Thrombocytopenia With Aminocaproic Acid," ARCH-INTERN-MED, 1989, September,
    Vol. 149, No. 9


22. Ben-Bassat I, "Tranexamic Acid Therapy in Acute Myeloid Leukemia: Possible
    Reduction of Platelet Transfusions," European J of Haematology, 1990,
    August, Vol. 45, No. 2


23. Chen RH, "Antifibrinolytic Therapy in Cardiac Surgery," Texas
    Heart Institute Journal, 1995, Vol. 22, No. 3


24. Daily PO, "Effect of Prophylactic Epsilon-Aminocaproic Acid on Blood Loss
    and Transfusion Requirements in Patients Undergoing First-Time Coronary Artery
    Bypass Grafting," J-THORAC-CARDIOVASC-SURG, 1994, July, Vol. 108,
    No. 1


25. Garewal HS, "Anti-Fibrinolytic Therapy With Aminocaproic Acid for the
    Control of Bleeding in Thrombocytopenic Patients," Scandinavian J
    of Haematology, 1985, November, Vol. 35, No. 5


26. Hardy J, "Natural and Synthetic Antifibrinolytics in Adult Cardiac Surgery:
    Efficacy, Effectiveness and Efficiency," Canadian J of Anaesthesia,
    1994, November, Vol. 41, No. 11


27. Hiippala S, "Tranexamic Acid (Cyklokapron) Reduces Perioperative Blood
    Loss Associated With Total Knee Arthroplasty," British Journal of
    Anaesthesia, 1995, May, Vol. 74, No. 5


28. Horrow JC, "Prophylactic Tranexamic Acid Decreases Bleeding After Cardiac
    Operations," J-THORAC-CARDIOVASC-SURG, 1990, January, Vol. 99, No.
    1


29. Isacson S, "Tranexamic Acid in Acute Upper Gastrointestinal Bleeding," Scand
    Journal Gastroenterology, 1987, Vol. 137


30. Jordan D, "Prophylactic Aminocaproic Acid (EACA) Administration Minimizes
    Blood Replacement Therapy During Cardiac Surgery," ANESTH-ANALG, 1995,
    April, Vol. 80, No. 4


31. Karski JM, "Prevention of Bleeding After Cardiopulmonary Bypass With High-Dose
    Tranexamic Acid," J-THORAC-CARDIOVASC-SURG, 1995, September, Vol.
    110, No. 3


32. Rousou JA, "Tranexamic Acid Significantly Reduces Blood Loss Associated
    With Coronary Revascularization," ANN-THORAC-SURG, 1995, March, Vol.
    59, No. 3


33. Saba HI, "Brief Report: Treatment of Bleeding in Hereditary Hemorrhagic
    Telangiectasia With Aminocaproic Acid," N-ENGL-J-MED, 1994, June 23,
    Vol. 330, No. 25


34. Schwartz BS, "Epsilon-Aminocaproic Acid in the Treatment of Patients With
    Acute Promyelocytic Leukemia and Acquired Alpha-2-Plasmin Inhibitor Deficiency," ANN-INTERN-MED,
    1986, December, Vol. 105, No. 6


35. Shore-Lesserson L, "Tranexamic Acid Reduces Transfusions and Mediastinal
    Drainage in Repeat Cardiac Surgery," ANESTH-ANALG, 1996, July, Vol.
    83, No. 1


36. Stefanini M, "Safe and Effective, Prolonged Administration of Epsilon
    Aminocaproic Acid in Bleeding From the Urinary Tract," J-UROL, 1990,
    March, Vol. 143, No. 3


37. Takada A, "Prevention of Severe Bleeding by Tranexamic Acid in a Patient
    With Disseminated Intravascular Coagulation," Thrombosis Research,
    1990, April 15, Vol. 58, No. 2


38. Gibble JW, "Fibrin Glue: The Perfect Operative Sealant?," Transfusion,
    1990, Vol. 30, No. 8


39. Kram HB, "Techniques of Hepatic Hemostasis Using Fibrin Glue," Contemporary
    Surgery, 1990, September, Vol. 37, No. 3


40. Tawes RL, Jr, "Autologous Fibrin Glue: The Last Step in Operative Hemostasis," AM-J-SURG,
    1994, August, Vol. 168, No. 2