Introduction
The primary objective in the resuscitation of traumatic hemorrhage is to achieve effective hemostasis and maintain hemodynamic stability. The severity of bleeding depends on the depth of the wound and the type of injured vessel. The approach to bleeding control should be tailored to the type and size of the bleeding vessel and the specific anatomical regions involved. Delayed or ineffective haemorrhage management can complicate the healing process and, in severe cases, lead to fatality. Extremity haemorrhage has historically contributed significantly to high mortality rates from casualties during wars [1]. Therefore, the prompt implementation of appropriate haemostatic techniques is a crucial aspect of efficient trauma management. This critical task is typically initiated by the prehospital team and followed by more advanced, invasive techniques provided by the trauma team in a controlled hospital setting
Types of Wounds
Wound is an impairment to the structural integrity of biological tissues, including the skin, mucous membranes, and organ tissues. This disruption in tissue integrity may arise from a diverse range of causes, including traumatic injuries, pathological processes, or surgical interventions. Metric parameters such as size (length), depth, shape, and whether they are open or closed are used to describe wounds.
The subsequent descriptors represent the terminology utilized for the classification of wounds:
Contusions
Contusions result from perpendicular blunt force to the skin, usually through a layer of clothes. Rupture of subcutaneous capillaries can occur, resulting in the formation of a hematoma (Figure 1). The recommended management for this type of wound consists of analgesics and following the “RICE” protocol (Rest, Ice, Compression, and Elevation) [2].
Abrasion
Abrasion is the scraping or scratching of the surface layers of skin (epidermis) when subjected to oblique forces (Figure 2). Proper wound care involves cleansing the wound, applying a sterile bandage, administering analgesics, ensuring tetanus protection, and implementing the RICE protocol [2].
Incision
Incision is defined as a cut that features straight edges along the margins of the wound. It can be caused by sharp objects like scalpels, knives, sharp metal pieces, or glass (Figure 3). Tissue loss is uncommon, and the wound margins can be easily aligned for closure with medical glue or sutures [1,2,3].
Lacerations
Characterized irregular or jagged edges, appearing torn rather than neat incisions [1,3]. They can have an irregular or linear direction and may branch out (Figure 4). Objects with broken or serrated edges or blunt impact on tissue overlying bone typically cause lacerations. Treatment approaches for lacerations are similar to those for incision wounds. However, the appropriate subspecialty should manage deep, complex lacerations or those involving sensitive areas like the face, joints, or tendons.
Avulsion
Avulsion involves a full-thickness laceration-type wound, which usually creates a flap of tissue (Figure 5) [1,3]. Mechanical accidents involving fingers (degloving injuries) can cause avulsions. More severe cases may include exposure of internal organs. Avulsions are challenging to repair and should never be considered minor injuries.
Amputation
Amputations differ from avulsions in that they involve the complete loss of a limb, whereas avulsions result in the loss of just a flap of skin (Figure 6). It can occur at any point along an extremity and is usually accompanied by significant arterial bleeding. Despite the seriousness of this injury, a properly cooled and transported amputated limb may sometimes be surgically reattached in a hospital setting.
Puncture and Penetrating Wounds
Puncture and penetrating wounds result from the penetration of a sharp object into the tissue without lateral movement from the point of entry (Figure 7). Puncture wounds can be deceptive, as they may appear small on the surface but extend deeply, potentially damaging the neurovascular structure or internal organs and causing significant internal bleeding or secondary injuries.
Stab wounds from knives or sharp objects, as well as bullet wounds, are examples of penetrating injuries [1,2,3]. Occasionally, the penetrating object may remain logged to the injury and should never be removed without careful assessment by the trauma team, as it might act as mechanical hemostatic and result in further bleeding once removed.
Site of Injury
Injuries can also be classified into three types, depending on the injured site of the body; each entails a different approach to management. Extremity injuries refer to damage inflicted on the blood vessels of the arms or legs. Junctional injuries, on the other hand, involve vascular damage occurring at the junction where the extremities meet the torso, such as the hip, axilla, or base of the neck. Torso injuries often involve non-compressible truncal hemorrhage that occurs anywhere on the torso and involves large blood vessels.
Vascular Injury
Injury to any blood vessel type can result in external bleeding. The specific type of vascular injury can be identified based on the characteristics of bleeding observed [1,2,4].
The following are the distinct types of vascular injuries and their corresponding patterns of bleeding:
Arterial Bleeding
Arterial bleeding typically occurs as a consequence of deep penetrating injuries or amputations. It is distinguished by the forceful ejection of bright red blood from the wound synchronized with each heartbeat [2]. Complete laceration of the artery may trigger spontaneous constriction, which helps to control bleeding. However, if only the artery wall is damaged without complete dissection, it can lead to persistent bleeding.
Indicators of arterial injury are classified into hard signs and soft signs [2]. Identifying hard signs indicates an immediate need for arterial exploration and surgical intervention. To aid in the recollection of these hard signs, the mnemonic “The Broken PIPE” can be employed (Box 1). Conversely, soft signs indicate the necessity for additional investigations such as ankle-brachial index measurement, Duplex Doppler ultrasound, or CT angiography, as determined by clinical assessment. The soft signs can be represented by the mnemonic “NON-Deadly HemorrHage” (Box 2).
Venous Bleeding
Venous Bleeding is characterized by a slower flow of dark red blood out of the wound [2]. However, caution is still recommended in venous bleeding, as it can contribute to significant and rapid bleeding if left untreated [4].
Capillary Bleeding
Capillary Bleeding usually results from damage to subcutaneous capillaries. It is characterized by slow, intermittent bleeding in the form of dots or small oozing [2,4].
Indications of Bleeding Control Techniques
Achieving hemodynamic stability necessitates the effective control of all life- or limb-threatening bleeding. While in most cases of traumatic and non-traumatic resuscitation, emphasis is placed on managing the airway and ensuring proper breathing, in situations of exsanguinating bleeding, prioritizing massive hemorrhage control surpasses the immediate focus on airway and breathing management [1]. The choice of hemostatic technique should be based on the depth and specific location of the injury, as outlined in detail in the “Bleeding Control Techniques” section below.
Contraindications of Bleeding Control Techniques
There are no absolute contraindications to any specific hemostatic method [1]. However, bleeding injuries should not distract the physician from managing concurrent immediate life-threatening conditions. Additionally, immediate wound closure is not recommended in wounds older than 8 hours. Instead, these types of wounds should be cleaned thoroughly, covered with sterile dressing, and closed after 3-5 days if there are no signs of infection. This is referred to as “delayed primary closure” [2,3].
Preparation
Similar to all medical procedures, thorough preparation is essential to ensure efficient hemostasis. This preparation encompasses the healthcare team, equipment, medications, the patient, and the wound.
Team Preparation
The healthcare providers involved in the procedure should possess comprehensive knowledge of indications, contraindications, techniques, and potential complications. The team should wear appropriate personal protective equipment, including face masks, face shields, surgical gowns, gloves, and shoe covers as necessary [3]. This protective gear is crucial to safeguard against blood splashes and potential contact with body fluids, particularly in trauma settings where the patient’s health status may be unknown.
Equipment Preparation
The equipment and medications used for hemostasis must be meticulously prepared and checked for the expiry date and functionality. The required equipment is listed under the corresponding techniques in the “Bleeding Control Techniques” section below.
Patient Preparation
A detailed explanation of the procedure should be provided to the patient, and informed consent should be obtained if applicable. Additionally, securing intravenous access and collecting a blood sample for type and cross-matching and coagulation profile are imperative. Administering analgesics and local anesthetics before procedural maneuvers helps to effectively minimize patient discomfort and disruptive movements.
Wound Preparation
A thorough assessment of the wound should be conducted. Distal movement and neurovascular function should be assessed prior to any manipulation. Contaminated wounds require proper irrigation to remove foreign bodies, followed by sterilization of the surrounding skin using antiseptic solution such as povidone iodine or chlorhexidine. However, wound preparation should not delay definitive hemostatic measures [1,3].
Bleeding Control Techniques
Direct Pressure
The initial step in controlling bleeding involves applying direct pressure to the bleeding wound. This facilitates the formation of a platelet plug and the initiation of the physiologic coagulation cascade, which is typically achievable within 10 to 15 minutes of proper pressure application [1].
Equipment
- Sterile gauze pad size 4×4
- Compression bandage
- Splint\brace
Technique
Ensuring the proper replacement of skin flaps is essential, followed by placing multiple 4×4 sterile gauzes, ideally low adherent type, with equal pressure applied. The wound can be wrapped with a compression bandage if it is in the head or extremities. Following the application of a compression bandage to the extremities, distal mobility, sensation, and perfusion should be checked. Limbs should be placed in a brace to minimize movement and keep it elevated. In body junctions, the wound can alternatively be packed with gauze or hemostatic agents along with topical pressure application [1,2,4].
Precautions
It is important to avoid removing soaked gauze, as this can function as a foreign clot; instead, a new gauze should be applied on top of the existing ones [4]. Compression bandages should be avoided in thoracic wounds, as they can constrict breathing.
Pressure on Arteries
When the source of bleeding cannot be identified, applying proximal pressure can help control the bleeding by reducing blood flow to the injured artery [1]. This is only feasible with extremity wounds and should not be applied to the carotid artery, as this can precipitate ischemic brain insult or vagal stimulation, resulting in bradycardia [4].
Precautions
The time of application is limited to 10 minutes due to the risk of tissue necrosis distal to the pressure point.
Tourniquet
The indication to use tourniquets is severe extremity bleeding that is not controlled by direct pressure application. The concept is constricting arterial flow to the injured area. It is an extremely painful procedure, and proper analgesia should be ensured before applying a tourniquet if time allows.
Equipment
- Proper size tourniquet
- Alternative: Blood pressure cuff
Technique
Remove any clothing obstructing the tourniquet application site, ensuring it is directly applied to the skin and remains visible. Position the tourniquet approximately 2-3 inches above the wound, avoiding joints (Figure 8). Tighten the tourniquet until the bleeding stops and the pulse distal to the tourniquet is no longer palpable. Note the time of placement on the tourniquet tag or consider using an indelible marker to write it on patient’s skin. [4,5].
If bleeding is not controlled and the distal pulse is still present after applying the first tourniquet, apply a second one just above its location [4]. Increasing the width of the second tourniquet is more effective in controlling bleeding and reducing complications than excessively tightening the initial one. Administer analgesia as needed after the tourniquet is applied.
An alternative to the tourniquet is applying a blood pressure cuff proximal to the wound. The cuff is then inflated 20-30 mm Hg above systolic blood pressure or over 250 mm Hg, and the tubing is clamped with a hemostat [2]. There are many ways to improvise a tourniquet using non-stretchable clothing and a windlass rod like a pen; however, a commercially designed tourniquet is preferable and not likely to loosen easily with patient movement.
To safely remove the tourniquet, apply a pressure dressing directly onto the wound. Then, gradually release the tourniquet while carefully monitoring for any signs of bleeding. If bleeding is successfully controlled, keep the tourniquet loosely secured in case of potential re-bleeding. If bleeding recurs, reapply firm pressure by tightening the tourniquet [5].
Precautions
The maximum duration for tourniquet application is 120 minutes [2]. Prolonged tourniquet application can lead to complications such as nerve injury, tissue necrosis, compartment syndrome, and rhabdomyolysis. However, if the extremity is amputated or if the tourniquet has been applied for more than 6 hours, it should not be loosened as permanent muscle damage occurs after 6 hours and might require amputation.1 Moreover, potential reperfusion injury may occur after 60 minutes of tourniquet use, leading to inflammation-induced damage in local areas and systemic effects on vital organs caused by inflammatory mediators [5].
Topical Hemostatic Agents
Another alternative or adjunct to tourniquet use is topical hemostatic agents. These agents create a platform for platelet deposition and facilitate hemostasis [6]. Examples include [1] oxidized cellulose (e.g., Surgicel), dry gelatin (e.g., Gelfoam, Surgifoam), or cyanoacrylate.
Equipment
- Hemostatic agent (e.g., Combat Gauze, Celox Gauze, or ChitoGauze)
- Pressure dressing
Technique
The hemostatic gauze is applied with direct pressure for at least 3 minutes. After the field dries, the wound can be sutured, or pressure dressing can be applied. It is important to note that a dry field is required to apply the cyanoacrylate type. Pressure or tourniquet should be used before its application. An alternative to hemostatic gauze is topical thrombin. It can be used directly or diluted with saline and sprayed onto the wound. A concentration of 100 units/mL is effective. In severe bleeding, a concentration of 1000 to 2000 units/mL can be used [1].
Precautions
Potential complications associated with hemostatic agents include excessive granulation tissue and fibrosis with absorbable gelatin agents or foreign body reaction with cellulose [1,7].
Balloon Catheter
Balloon catheters can be used as an improvised tamponade technique to temporarily control severe bleeding from deep injuries, when other conventional methods fail [1,8].
Equipment
- Fogarty catheters, Foley catheters, or Sengstaken-Blakemore tubes.
- 10 cc syringe
Technique
The tube is blindly inserted into the wound, then the ballon is inflated to halt bleeding from deep vascular injuries [1].
Suture Ligation
Suture ligation is used for controlling large bleeding vessels. An effective ligation technique requires careful examination and knowledge of the vascular anatomy to trace and identify the sources of bleeding. A retracted artery can be a potential source of delayed bleeding. Therefore, once an injured vessel is identified, the opposite end should also be traced and ligated [1].
Equipment
- Blood pressure cuff
- Absorbable suture (e.g., Vicryl, Monocryl, and PDS).
- Haemostat
- Needle holder
- Scissors
Technique
A blood pressure cuff is placed proximally and inflated until the bleeding stops to create a clear field. With gradual deflation of the cuff, large bleeding vessels will start to be visible. Ligation is then completed with suturing in the following steps: [1]
- Using a haemostat pinch the free end of the bleeding vessel.
- Wrap a proper-sized suture around the vessel.
- Tie the suture at the base of the vessel.
- Release the haemostat carefully (Figure 9).
if the vessel can not be seen, a figure 8 suture can be applied (Figure 10) [1,3].
Cauterization
Cauterization is cost effective and simple haemostatic technique for small vessels measuring less than 2 mm in diameter. Electrical cauterization involves using electrical current to heat an electrode, which then is used to thermally burn the vessel wall and seal it with charred tissue [1,10].
Chemical cauterization can be achieved using silver nitrate (AgNO3). This involves applying the agent to the vessel wall using an applicator, typically a long and small wooden stick tipped with the silver nitrate. Silver nitrate reacts with proteins in the tissue, forming an insoluble deposit that blocks the blood flow. It is only effective when applied to a dry tissue or minimal oozing [1].
Equipment
- Blood pressure cuff
- Silver nitrate or electric cautery
Technique
Position a blood pressure cuff proximally and gradually inflate it until bleeding stops, to achieve a clear field. Then gently release the pressure, until the smaller bleeding vessels become visible. Use the electrocautery to burn the end of the bleeding vessel or rub the silver nitrate against it to achieve an artificial clot [1].
Vasoconstrictors
In normal conditions, small vessels spontaneously stop bleeding. However, if bleeding persists, local vasoconstrictors mixed with local anaesthetics can be applied. Local anesthetic solutions containing epinephrine, such as lidocaine and bupivacaine, are readily available in the Emergency Department.
Equipment
- 10 cc syringe
- Epinephrine 1:1000
- Saline-soaked gauze
Technique
Prepare the diluted epinephrine in a 10 cc syringe. Aspirate prior to injection to ensure that the solution is not injected into a blood vessel. Inject 1 to 2 mL of the solution around the bleeding vessel. Apply direct pressure with saline soaked gauze over the wound. Alternatively, spray the wound with the diluted solution. [1,3]
Precautions
It’s important to avoid using epinephrine or other vasoconstrictors in end-arterial areas like fingers, toes, ears, nose, or penis, to avoid organ ischemia.
Complications
Complications arise when the above-listed techniques are either overused or applied inappropriately. For detailed information regarding the particular complications associated with each technique, please refer to the corresponding technique’s “Precautions” section.
Special Patient Groups
Obtaining hemostasis might be challenging in patients with coagulopathy. Therefore, it is important to remain vigilant and promptly assess the platelet count and plasma coagulation profile (PT/PTT/INR) in patients experiencing external bleeding. The early administration of tranexamic acid, blood products, and cryoprecipitate can aid in achieving hemostasis.
Authors
Tasnim Ahmed
Emergency Medicine Residency graduate from Zayed Military Hospital, Abu Dhabi, UAE. Deputy Editor-in-Chief of the Emirates Society of Emergency Medicine (ESEM) newsletter. Senior Board Member and Website Manager of the Emirates Collaboration of Residents in Emergency Medicine (ECREM). Awarded Resident of the Year twice, at ESEM23 and Menatox23. Passionate about medical education, with a focus on blending art and technology into innovative teaching strategies.
Abdulla Alhmoudi
Dr Abdulla Alhmoudi is a Consultant Emergency Medicine, serving at Zayed Military Hospital and Sheikh Shakhbout Medical City - Abu Dhabi. He pursued his residency training in Emergency Medicine at George Washington University in Washington DC and further enhanced his expertise with a Fellowship in Extreme Environmental Medicine. Dr Alhmoudi's passion for medical education is evident in his professional pursuits. He currently holds the position of Associate Program Director at ZMH EM program and is a lecturer at Khalifa University College of Medicine and Health Sciences. Beyond medical education, he maintains a keen interest in military medicine and wilderness medicine.
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References
- Chapter 112. Hemorrhage Control. In: Reichman EF. eds. Emergency Medicine Procedures, 2e. McGraw Hill; 2013. Accessed May 22, 2023. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683§ionid=45343754
- Spehonja A, Prosen G. Basics of Bleeding Control. In: Cevik AA, ed. International Emergency Medicine Education Project. iEM Education Project; 2018:598-601.
- Lammers RL, Smith ZE. Principles of wound management. In: Roberts JR, Hedges JR, eds. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014:611-634.
- Department of the Navy. Bleeding. Brooksidepress.org. 2001. Accessed May 22, 2023. https://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Manuals/Standard1stAid/chapter3.html.
- Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emergency Medicine Journal. 2007;24(8):584-587. doi:10.1136/emj.2007.046359
- Sileshi B, Achneck HE, Lawson JH. Management of surgical hemostasis: topical agents [published correction appears in Vascular. 2009 May-Jun;17(3):181]. Vascular. 2008;16 Suppl 1:S22-S28.
- Levy JH. Hemostatic agents and their safety. J Cardiothorac Vasc Anesth. 1999;13(4 Suppl 1):6-37.
- Feliciano DV, Burch JM, Mattox KL, Bitondo CG, Fields G. Balloon catheter tamponade in cardiovascular wounds. Am J Surg. 1990;160(6):583-587. doi:10.1016/s0002-9610(05)80750-0
- Rudge WB, Rudge BC, Rudge CJ. A useful technique for the control of bleeding following peripheral vascular injury. Ann R Coll Surg Engl. 2010;92(1):77-78. doi:10.1308/rcsann.2010.92.1.77
- Kamat AA, Kramer P, Soisson AP. Superiority of electrocautery over the suture method for achieving cervical cone bed hemostasis. Obstet Gynecol. 2003;102(4):726-730. doi:10.1016/s0029-7844(03)00622-7
Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
