Case #5: A Pain in the Neck
The Patient*
A twenty-year-old male presented with a single stab wound to the left lateral neck. He was haemodynamically stable, and initially had no hard or soft signs of vascular injury.
As you can see, this Zone II wound clearly breaches platysma, but what's less obvious is that, posterolaterally, the wound also extends more deeply through the body of sternocleidomastoid.
Given that the patient had no hard signs mandating immediate surgical exploration, he was booked for CT angiography. Because the wound had a small amount of ooze from the defect in sternocleidomastoid, external pressure was applied.
After a while, the medical student applying pressure mentioned he needed more gauze. It was only after fetching this for him that I realised quite how much gauze he had already soaked through.
I re-examined the wound, and could see a tiny muscular arteriole pulsing from the muscle belly itself - so I tied this off with a superficial figure-of-8 suture. Unfortunately, my fiddling disrupted some haematoma from within the wound, turning what was just a little squirter into darker venous bleeding.
Management
I re-applied external pressure, but this time the gauze was soaking through much more aggressively than it had been before. While suctioning the wound so I could more easily see the wound tract, I inserted a Foley catheter, and inflated the balloon with 20mL of saline. This didn't stem the ooze welling up from the wound, so I inserted another Foley catheter, again inflating it with 20mL of saline, before suturing both of these in place.
The colleague who had dutifully been suctioning my field of view then told me the suction canister had a litre of blood in it. I looked at the patient and saw he was now incredibly diaphoretic, much more so than he'd been ten minutes earlier. At this point, we called the on-call consultant - thinking we had reached the limits of what we could achieve in Resus, and that surgical exploration was now inevitable.
Upon her arrival, the consultant made several changes that immediately halted any further blood loss. Firstly, she inflated each Foley catheter with 40mL, instead of my 20. Secondly, she sutured the skin closed, rather than just suturing the Foleys to the skin individually. Finally, she removed the Mosquitos that I had used to clamp each catheter, and instead occluded each Foley's lumen using plungers that she had individually removed from 2mL syringes.
The bleeding stopped, and the haematoma did not expand any further. The patient proceeded to his CT angiogram, which revealed a transected left internal jugular vein, as well as the haematoma you can see surrounding the two Foley balloons:
Given that this was a venous injury, the patient was managed conservatively. He remained on the ward for 48 hours before the balloons were deflated. No re-bleeding occurred, and he was discharged uneventfully.
Discussion
Foley catheter balloon tamponade (FCBT) is a tried and tested technique in trauma, but needs to be utilised correctly in order to work. It was first described by Gilroy et al. right here at Bara in 1992 [1], and has been employed ever since with great success [2,3]. There are some nuances, however, that until this case I hadn't fully appreciated.
Firstly, the tamponading pressure generated by the balloon is (obviously) proportional to the volume it's inflated with, and standard latex balloons don't tend to burst until filled with 80-110mL of water (this depends on what size the catheter is - and note that silicone balloons burst at much lower volumes than latex ones). Insert the uninflated Foley into the wound, then inflate until you get resistance. This consultant told me she routinely inflates these with as much as 60mL.
Suturing the skin closed feels cosmetic, rather than haemostatic, but it's necessary to allow the catheter's balloon to do its job. Closing the potential space means tamponade can actually occur - the same way a pelvic binder closes an open-book pelvis.
Finally, a 2mL syringe plunger can be used to occlude the Foley lumen - this avoids needing to use a heavier instrument like artery forceps that may cause the Foley to become dislodged under traction.
Take Home Points
Don't fiddle - if it ain't broke, don't fix it. Clots are easy to disrupt.
Don't flail - if it ain't working, try something new.
Suction can be your friend and your foe - what it let me see, it made me not see.
Foley tamponade requires larger balloon volumes than you would normally use.
Close the skin - pressure will only be applied if there is closure of the potential cavity - just as you can bind a pelvis to close an open book, so can you suture the wound to close an open neck.
*Note that patient details have been changed for the purposes of de-identification.
Dr Nick Chapman is an emergency doctor with a strong sub-specialty interest in trauma and retrieval. He completed his Postgraduate Diploma in Aeromedical Retrieval in 2021 and the last of his fellowship exams for the Australasian College for Emergency Medicine in 2026. He currently works for the Royal Flying Doctor Service and prior to that worked at The Alfred Hospital's Emergency & Trauma Centre.
References
[1] Gilroy D, Lakhoo M, Charalambides D, Demetriades D. Control of life-threatening haemorrhage from the neck: a new indication for balloon tamponade. Injury. 1992;23(8):557-9.
[2] Tan LTP, Lim CYJ, Li CX, Kong V, Lee D, Ahn J, Wineberg D, Crawford R, Laher N, Oosthuizen G, Clarke D. Foley catheter balloon tamponade for actively bleeding wounds following penetrating neck injury: a systematic review and meta-analysis. Ann R Coll Surg Engl. 2026;108(4):249-58.
[3] Kong V, Ko J, Cheung C, Lee B, Leow P, Thirayan V, Bruce J, Laing G, Khashram M, Clarke D. Foley catheter balloon tamponade for actively bleeding wounds following penetrating neck injury is an effective technique for controlling non-compressible junctional external haemorrhage. World J Surg. 2022;46(5):1067-75.
