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 hemodilutiončall 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.
- Apply direct pressure to the wound.
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.
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