\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[polish,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Occlusion of femoral artery using foley catheter: a REBOA inspired tale
to save a life}



\author[1]{Amir  Papan}%
\author[1]{Mofid Husseinzade}%
\author[2]{Kamran Heydari}%
\author[1]{Hossein Hamidi}%
\affil[1]{Ahvaz Jondishapour University of Medical Sciences}%
\affil[2]{Shahid Beheshti University of Medical Sciences}%


\vspace{-1em}



  
  \date{June 17, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
we report a case of lower extremity hemorrhage refractory to usual
methods of bleeding control, which was controlled using a Folley
catheter which was placed in to external iliac artery.%
\end{abstract}%



\sloppy


\textbf{Occlusion of femoral artery using foley catheter: a REBOA
inspired tale to save a life}

Amir Mohammad Papan\textsuperscript{1}, Mofid
Husseinzade\textsuperscript{1}, Kamran Heydari\textsuperscript{2},
Hossein Hamidi\textsuperscript{1}

1.Departement of Emergency Medicine Ahvaz Jundishapur University of
Medical Sciences, Ahvaz, Iran

2. Department of Emergency Medicine Shahid Beheshti university, Tehran,
Iran

Corresponding author: Amir Mohammad Papan

Amirmohammadpapan@gmail.com

\textbf{Abstract} :

in this case report, we emphasize the need to control the bleeding by
any measures in the Emergency department as this is the first step in a
good resuscitation effort to save a patient life who is actively
bleeding.

Key words:

Emergency Medicine, General Surgery, Vascular Surgery

``Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy''

\textbf{Introduction} :

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a
procedure that involves placement of an endovascular balloon in the
aorta to obtain proximal control of hemorrhage . In recent years, REBOA
has become increasingly popular amongst trauma surgeons for the
management of traumatic non-compressible torso hemorrhage (NCTH) .

The concept of using a balloon to occlude an artery has been around for
decades, a recent example of that using ROEBA in traumatic patients
requiring emergent control of bleeding, but has not been widely
available in third-world countries. The standard method of bleeding
control is placing a tourniquet proximal to site of injury in the
Emergency room followed by a definitive measure in the operating room.
This sequence of interventions is successful in majority of cases.

In this case report we represent, a ROBEA inspired method to control
extremity hemorrhage in rural hospital, which was a last-ditch effort to
save patients life by an emergency physician.

This case emphasizes the need to control hemorrhage in any way to save
patient's life in the absence of expertise and tools in rural settings.

\textbf{Case Report}

A 52-year-old man who had a gunshot wound to both legs and knees brought
to the emergency room by ambulance. He was in a state of hemorrhagic
shock with vitals of respiratory rate of 24, blood pressure of 100/60
mmHg and a heart rate of 156 and a maximum Glasgow coma scale of 13. A
make shift torniquet was placed on his lower thigh by bystanders but he
was still bleeding profusely from the injury site(figure 1). We urgently
began the resuscitation process by inserting 2 large bore IVs and a
large dialysis catheter was placed in his right subclavian vein and 2
units of O positive and one liter of normal saline was given as fast as
possible. Two torniquets were placed on his thigh and the extremity was
put in an emergency splint and pressure was applied to the injured site.
Despite these efforts the patients bleeding did not stop and his
mentation and perfusion were deteriorating by the minute with minimum BP
of 60 over pulse and heart rate of 175. We decided to block the blood
flow the from a more proximal site, femoral artery 5cm distal to
inguinal ligament was chosen due to its accessibility. A dialysis
Catheter kit was used initially to insert a needle into the femoral
artery, then a guide wire was threaded through the needle, the route was
dilated, using a standard dilator, then small skin incision was made,
then using a small Hemostat, a 6 fr foley catheter was placed over the
guide wire in to the femoral artery and was guided to distal external
iliac artery, subsequently balloon was inflated by injecting 5ml of
Saline 0.9 \%. Standard foley catheters have a side hole at their end in
order to better thread the catheter, end of the catheter was cut to make
end hole catheter(figure 2). Hemorrhage was controlled, and within
minutes patient's vitals were improved drastically. The patient was then
transferred to a Level one Trauma Center, capable of handling vascular
injuries. Thereafter in the operating room, due to extensive crush of
the injury site, the leg had to be amputated. The patient survived the
operation and was moved to the ICU. He was discharged on day 15.

\textbf{Discussion}

The challenge in this case was the need to control the hemorrhage in a
rapidly deteriorating patient in a rural setting without onsite help
from any other specialties. Although it was evident that bleeding should
be controlled, this act proved to be quite challenging. This case
emphasizes the role of emergency physician to be resourceful and quick
thinking. REBOA Is a procedure to control bleeding usually used in
non-compressible torso bleeding but this device is expensive and not
readily available in our country. extremities arterial bleedings are
usually controlled either by direct compression or application of
tourniquet. Nonetheless, despite conventional efforts to control
bleeding, we were unable to occlude the bleeding site, hence the need of
a technique similar to REBOA to control bleeding. Also due to patients'
obesity no suitable pneumatic torniquets were available in the hospital
which could fit him.

There are surgical techniques to ligate the artery from a more proximal
site like ligating the artery proximally, but we did not have the
experience to achieve this in time sensitive manner. Indeed, the patient
was deteriorating at an extremely alarming pace. Using a familiar
technique(seldinger) which is remarkably similar to placing a central
venous line (something that we are quite experienced with), allowed us
to rapidly place a sheath and guide wire into the femoral artery and
occlude the mentioned artery by a small foley catheter. This technique
is also similar to the usage of Fogarty Balloon in vascular surgery.
Also, the need for adequate resuscitation cannot be stressed enough.

Conclusion

Placing a foley catheter into at the femoral artery in a profusely
bleeding patient allowed us to rapidly achieve hemostasis and adequately
resuscitate the patient enough to transfer him to a higher-level center
for definitive care. We believe due to its simplicity this technique can
be a good addition to the skillset of emergency physicians.

References:

\begin{enumerate}
\tightlist
\item
  Marciniuk P, Pawlaczyk R, Rogowski J, Wojciechowski J, Znaniecki \selectlanguage{polish}Ł.
  \selectlanguage{english}REBOA--new era of bleeding control, literature review. Polish Journal
  of Surgery. 2020;92:54-9.
\item
  Manzano Nunez R, Naranjo MP, Foianini E, Ferrada P, Rincon E,
  Garc\selectlanguage{ngerman}ía-Perdomo HA, Burbano P, Herrera JP, García AF, Ordoñez CA. A
  meta-analysis of resuscitative endovascular balloon occlusion of the
  aorta (REBOA) or open aortic cross-clamping by resuscitative
  thoracotomy in non-compressible torso hemorrhage patients. World
  Journal of Emergency Surgery. 2017 Dec;12(1):1-9.
\item
  BenÍtez CY, Ottolino P, Pereira BM, Lima DS, Guemes A, Khan M, JUNIOR
  R, FONTENELLE MA. Tourniquet use for civilian extremity hemorrhage:
  systematic review of the literature. Revista do Colégio Brasileiro de
  Cirurgiões. 2021 Jan 13;48.
\item
  Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al.
  Practical use of emergency tourniquets to stop bleeding in major limb
  trauma. J Trauma. 2008;64(2 Suppl):S38-49; discussion S49-50.
\item
  Butler FK. Military history of increasing survival: the U.S. military
  experience with tourniquets and hemostatic dressings in the
  Afghanistan and Iraq conflicts. Bull Am Coll Surg. 2015;100(Suppl
  1):60
\end{enumerate}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/20210725-141414/20210725-141414}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/20210725-141336/20210725-141336}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

