EMERGENCY MANAGEMENT OF LIFE-THREATENING PROBLEMS
The “ABCs” of resuscitation must be addressed before wounds are evaluated. Open wounds are dramatic and often draw the attention of the emergency physician or resuscitation team away from more life-threatening injuries. It is rare that bleeding from even large tissue defects will immediately impact the patient’s survival. Secure the airway, ensure adequate ventilation, and stabilize blood pressure prior to assessing wounds.
Should the wound have significant bleeding, the simplest and most common method used to achieve hemostasis is direct pressure. A gauze 4X4 is wrapped firmly with an elastic bandage will usually stop venous, capillary, and arteriolar hemorrhage. Smaller arterial bleeding can be temporarily stopped with this method and larger bleeding vessels may be controlled with digital pressure. Digital pressure can be applied over large vessels that supply the area. Remember that pressure is pounds per square inch. One single gauze 4X4 with pressure applied by a thumb will provide more pressure than several gauze dressings applied with a palm. Large arteries may ultimately require vascular repair or suture ligation.
The decision to ligate an artery should be made cautiously; any uncertainty as to the impact on distal tissue perfusion should prompt consultation of the appropriate surgical specialist. Proximal extremity arterial injuries require emergency vascular surgery consultation.
Simple tying or suture ligation is indicated for most vessels more than 2 mm (1/16 in) in external diameter. To avoid excessive tissue trauma, one must precisely identify and clamp the vessel end prior to ligation. Severed arteries usually require only simple tying. Veins, however, do not hold ligatures well, and suture ligation is preferable. Suture ligation may be performed by passing the suture needle through a portion of the vessel wall and then circumferentially tying the vessel. This method prevents slippage of the ligature. Caution: Do not ligate arteries and veins en masse, because this may predispose to arteriovenous fistula formation. Absorbable sutures are preferred for tying and suture ligation in the acute wound. Synthetic absorbable sutures (polyglycolic acid [Dexon] and polyglactin [Vicryl]) are advantageous because of their low reactivity and high friction coefficients. Chromic catgut is also satisfactory.
Inflatable cuff tourniquets can be used for temporary hemostasis during wound exploration and repair but are not recommended for periods over 20–40 minutes. Inflate the pressure cuff on the extremity proximal to the wound until hemostasis is achieved. Take particular care to remove tourniquets after 15–20 minutes and before the procedure is completed to check for residual bleeding. A tourniquet inadvertently left in place may cause permanent ischemic damage to the limb.
Epinephrine-containing local anesthetic agents such as lidocaine or bupivacaine are commonly used to control bleeding prior to wound repair. This ...