Control of external hemorrhage from an injury is a priority of basic first aid. It begins with first responders before arrival at the hospital and continues with Physicians in the resuscitation suite (Figure 137-1). Bleeding from extremity wounds is common. Most bleeding is a minor inconvenience for the busy Emergency Physician in the crowded Emergency Department, prolonging wound closure and complicating wound healing. Major exsanguinating hemorrhage can be life-threatening. Hemorrhage from extremity injuries was a leading cause of death in the Vietnam War and Operation Desert Storm.1,2 Hemorrhage remained the leading cause of death in Operation Iraqi Freedom and Operation Enduring Freedom, with torso hemorrhage leading the deaths.3 Methods for rapid and effective control of bleeding are essential in managing traumatic injuries and optimizing wound management.
A traumatic amputation with a SWAT-T Tourniquet. (Courtesy of TEMS Solutions LLC, Abingdon, VA.)
ANATOMY AND PATHOPHYSIOLOGY
Hemostasis is the first biological response to injury.4-6 Hemostatic platelet plugs form at the ends of transected vessels within seconds of traumatic disruption of the skin. Fibrin fibers gather about the platelet plug within minutes. This fibrin mesh becomes part of an early matrix that initiates wound healing.4
Hemostasis is the priority in wound management for the Emergency Physician caring for traumatic wounds.7 Control of bleeding is necessary to establish hemodynamic stability and prevent further blood loss (Figure 137-1). Hemostasis is the first step in preparing for wound closure. Inadequate hemostasis with hematoma formation impairs wound healing, increases the risk of wound infection, leads to tissue ischemia, and results in hypertrophic scars.8,9 Large hematomas may cause delayed wound dehiscence.
Bleeding from wounds may be superficial or deep. Superficial wounds (e.g., abrasions, avulsions, or simple lacerations) involve damage to the epidermis, dermis, and subcutaneous tissue. Bleeding from most superficial wounds is predominantly from capillaries, small veins, or arterioles. Wounds deep to the fascia involve larger vessels and are typical of deep punctures, gunshot wounds, major crush injuries, and stab wounds. The approach to the bleeding wound will depend upon the nature of bleeding (e.g., large vessel versus small, discrete source versus diffuse), the site of injury, and its association with other major organ injury (Figure 137-2).
An algorithm for hemorrhage control.
The immediate control of excessive bleeding is always a priority during the first contact with the patient. All bleeding must be controlled (Figure 137-2). Exsanguinating hemorrhage must be immediately controlled. All other bleeding can wait until the ABCs (airway, breathing, and circulation) and life-threatening conditions are addressed. The timing and selection of specific measures to isolate and ...