Control of Traumatic Extremity Hemorrhage

Abstract

Although most extremity hemorrhage from trauma can be controlled with direct pressure and/or pressure dressings, the occasional uncontrolled hemorrhage can be life threatening. Tools that may be able to control such life-threatening extremity hemorrhage include hemostatic dressings, tourniquets, and several new devices that have recently become available. Hemostatic dressings, a relatively new concept, incorporate materials that increase coagulation into a dressing that is applied directly to the wound. Although the use of tourniquets has a long history, recent military conflicts have provided numerous studies that supported and refined their use. The novel extremity hemorrhage control devices effectively control bleeding in one of several ways: direct compression, arterial compression above the level of injury, and sealing the wounds’ edges, creating a hematoma.

Hemorrhage control, a fundamental skill: A review of direct pressure, dressings, wound packing and bandages for life-saving

“…Neither Advanced Trauma Life Support nor Trauma Nursing Core Course curricula specify an ideal or minimum time to maintain pressure (Assid et al, 2014;Rotondo et al, 2012). Empirical recommendations for how long to hold pressure are scarce: nursing literature suggests a minimum five to 10 minutes (Day, 2016), and European consensus for physicians recommends moving to more aggressive measures if hemorrhage control is not achieved in one minute (Forrest, Lax & van der Velde, 2014), but neither offer evidence or rational for the recommendations. A meta-analysis of angiography hemostat devices may offer the best evidence for minimum pressure time, concluding that hemostatic devices have the best time to hemostasis, but range widely, with an average around 20 minutes (Dahal et al, 2017).…”

“…Tourniquets can be improvised or commercially manufactured, but commercial tourniquets have been shown to be superior to improvised devices (Bulger et al, 2014). Improvised, or incorrectly used tourniquets have been shown to worsen bleeding if the pressure used is insufficient to occlude arterial flow (Day, 2016). Venous-only tourniquets, like a tourniquet to start an IV or blood draw, will result in increased venous pressure and dilation and will hasten bleeding.…”

“…Venous-only tourniquets, like a tourniquet to start an IV or blood draw, will result in increased venous pressure and dilation and will hasten bleeding. For this reason, use a commercial tourniquet, if available, tighten the tourniquet until active bleeding stops and pulses are no longer palpable, mark the time of application, and leave the tourniquet in place until definitive management of the bleeding can be achieved (Day, 2016). If hemorrhage control is not achieved with one tourniquet, an additional tourniquet should be placed in the same manner, proximally.…”

Contrôle de l’hémorragie, une compétence fondamentale : Un examen de la pression directe, des pansements, de l’insertion de pansement dans une blessure et des bandages pour sauver des vies

“…Cependant, les garrots commerciaux sont considérés comme étant de meilleure qualité que les dispositifs improvisés (Bulger et al, 2014). Improvisés ou mal utilisés, les garrots peuvent aggraver le saignement si la pression est insuffisante pour bloquer le flux artériel (Day, 2016). Les garrots uniquement veineux, comme un garrot pour commencer une IV ou prise de sang, entraîneront une augmentation de la pression veineuse, une dilatation et une accélération du saignement.…”

“…Les recommandations empiriques sur la durée du maintien de la pression sont assez vagues. Les documents en soins infirmiers suggèrent un minimum de cinq à dix minutes (Day, 2016), et le consensus européen des médecins recommande de passer à des mesures plus agressives si le contrôle de l'hémorragie n'est pas réussi en une minute (Forrest, Lax & van der Velde, 2014). Cependant, aucun n'offre de preuves ou de raison claire à ces recommandations.…”