Control of external hemorrhage from an injury is a priority of basic first aid, beginning with the first responder in the prehospital setting and continuing with Emergency and Trauma Physicians in the resuscitation suite. Bleeding from extremity wounds is common. Most extremity bleeding is a minor inconvenience for the busy Emergency Physician in the crowded Emergency Department, prolonging wound closure and complicating wound healing. However, major exsanguinating extremity hemorrhage can be a life threat. 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; however, torso hemorrhage was the leading cause of death.3 Methods for rapid and effective control of bleeding are essential in managing traumatic injuries and optimizing wound management.
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 also the first priority in wound management for the Emergency Physician caring for traumatic wounds. Control of bleeding is necessary to establish hemodynamic stability and prevent further blood loss. 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.7,8 Large hematomas may cause delayed wound dehiscence.
Bleeding from wounds may be superficial or deep. Superficial wounds, such as 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 puncture or stab wounds, gunshot wounds, or major crush injuries. The approach to the bleeding wound will depend upon the nature of bleeding (e.g., large vessel vs. small, discrete source vs. diffuse), the site of injury, and its association with other major organ injury.
The immediate control of excessive bleeding is always a priority and should occur during the first contact with the patient. All bleeding must be controlled. Exsanguinating hemorrhage must be immediately controlled. All other bleeding can wait until the ABC's and life-threats are addressed. The timing and selection of specific measures to isolate and treat the bleeding source will depend upon the management priorities of each patient. A simple compressive dressing or tourniquet may be used as a first-line measure to control bleeding in a multiple trauma patient. Measures that are more definitive may be taken early to identify and treat the specific injury if it is isolated.
There are no absolute contraindications to any particular technique to control bleeding. The Emergency Physician ...