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Lack of efficacy in life threatening inguinal bleeding: case report A 49-year-old man exhibited lack of efficacy during treatment with desmopressin and tranexamic-acid for management of lifethreatening inguinal bleeding. The man who had a remarkable medical history of hypertension, diabetes and penile cancer presented to the emergency department with a massive bleeding from his left inguinal space. He had metastatic disease in his left inguinal lymph node system. He received radiation therapy. Following this, he developed an open wound in the left inguinal space, which seemed as ’broken open’ wound. He developed hypotension. Due to squamous cell carcinoma i.e. penile cancer, he underwent penectomy. Upon presentation, he was noted to have tachycardia and hypotension. The EMS technician applied direct manual pressure with a gauze, which made his bleeding minimal. His laboratory investigations revealed acute kidney injury and a metabolic acidosis. CT imaging of the pelvis showed a left inguinal ulceration with extension to the underlying left common femoral vasculature. By this time, a complete hemostasis had been achieved via direct manual pressure. Because of tachycardia, mild hypotension and acute anaemia, he was transfused with one unit packed RBCs. Approximately 5 hours later, he again developed significant bleeding from his left groin area. Immediate after this, he was hypotensive and unresponsive. He was then intubated for airway protection. Due to brisk bleeding, massive transfusion protocol was initiated. To enhance the haemostasis, he received tranexamic-acid and a dose of desmopressin [DDAVP; routes and dosages not stated]. Despite these aggressive measures, his bleeding continued. Following a discussion, a device called Femostop was applied for bleeding control. Thereafter, haemostasis was achieved. Meanwhile, he was resuscitated with packed RBCs, [plasma] fresh frozen plasma and platelets. He was then transferred to stent the injured vessel. However, during the stent placement, re-bleeding occurred and he developed cardiac arrest. His family declared do-not-resuscitate (DNR) order. Shortly after this, he died. Cambron J, et al. Use of Femostop device in the setting of life threatening inguinal bleeding. American Journal of Emergency Medicine 38: 849.e1-849.e2, No. 4, Apr 2020. 803498356 Available from: URL: http://doi.org/10.1016/j.ajem.2019.10.034

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Reactions 29 Aug 2020 No. 1819