Emergency Medicine

Answer 2 Apply direct pressure to the wound. The priority in the treatment of injuries that threaten circulation is to arrest external hemorrhage. Blood that spills on the floor is forever lost to the patient. Consequently, bleeding wounds should be managed even before venous access is obtained. Active hemorrhage is best controlled by direct digital pressure. Tourniquets should not be used except in the unusual circumstance of an amputated extremity because they crush tissue, may provoke venous thrombosis, and cause distal ischemia.3 Use of hemostats is not only time-consuming, but the blind clamping of vessels risks damage to adjacent nerves and unaffected vessels. The approach of delaying fluid resuscitation (hypotensive resuscitation) has been suggested.4 A tenuous clot forms in injured arteries, preventing further blood loss. Factors that would tend to prevent clot formation and permit renewed bleeding include increased volume, increased blood pressure, vasodilation, and decreased blood viscosity secondary to hemodilution‹all factors associated with fluid resuscitation. Wound exploration can exacerbate blood loss. Additionally, satisfactory hemostasis is critical prior to wound repair, because hematoma formation is associated with wound dehiscence and infection. REFERENCES 3. Arrillaga A, Bynoe R, Frykberg ER, Nagy K. Practice management guidelines for penetrating trauma to the lower extremity. Eastern Association for the Surgery of Trauma (EAST). Available at http://www.east.org/tpg/lepene.pdf. Accessed 3 Oct 2002. 4. Capone AC, Safar P, Stezoski W, et al. Improved outcome with fluid restriction in treatment of uncontrolled hemorrhagic shock. J Am Coll Surg 1995;180:49-56. Click here to return to the questions

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