Chapter 31

### IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS

Hemorrhaging wounds can easily divert attention from more important considerations in the trauma patient. It is unlikely that a bleeding wound will alter the immediate outcome of a trauma patient; however, unverified and compromised airway, breathing, and systemic circulation (ABCs of trauma) most certainly will. Although major wounds require prompt attention of the resuscitation team in evaluation of the patient, the ABCs must be addressed first. Only after the primary survey has been conducted should proper hemostasis be applied and wounds managed appropriately. Primary methods for hemostasis by the emergency physician include direct pressure, tourniquets, epinephrine-containing anesthetics, and suture ligation.

#### DIRECT PRESSURE

A simple approach is often best. Direct pressure on a bleeding wound is easy, effective, and cost-efficient. Although large-vessel bleeding requires more advanced methods of hemostasis, bleeding from small vessels can often be contained with a pressure dressing made of a bulky dressing held by hand or with an elastic or self-adherent bandage. Direct pressure in the wound compartment often helps contain bleeding after a wound has been firmly closed with suture material.

#### TOURNIQUETS

Application of tourniquets to extremity sites can be fraught with complications, but proper use can provide adequate hemorrhage control in patients where direct pressure is ineffective. Commercial products are available; however, a simple well-placed blood pressure cuff can provide similar results. Gauze should be placed underneath the cuff to protect intact skin, and the cuff should be inflated initially to 20 mm Hg above patient’s blood pressure. Higher pressure may be required. It is advised that a tourniquet be in place for no longer than 60 minutes total, and no longer than 20-30 minutes before releasing for 5 minutes for temporary restoration of blood flow to prevent distal tissue ischemia.

Finger tourniquets require a different approach in a difficult-to-control situation. Three primary methods are typically employed: (1) a commercially available finger tourniquet (Tourni-cot, T-Ring Digital Tourniquet); (2) a Penrose drain is placed under the base of the finger can be effective; and (3) a sterile glove is placed over the injured hand. After cutting the tip of the glove of the affected finger, the finger of the glove is rolled toward the base of the finger providing a hemostatic and sterile field.

#### EPINEPHRINE-CONTAINING ANESTHETICS

Lidocaine mixed with a standard concentration of epinephrine to provide hemostasis is effective for many bleeding wounds. Historically, physicians avoided this practice for concern of ischemia in the digits, ears, nose, and genitals, although no evidence of harm may have been found. Studies demonstrate the absence of complications, improved hemostasis, increased duration of anesthesia, and decreased anesthesia requirements. In addition, surgical subspecialists conclude that benefits of epinephrine-containing anesthetics outweigh perceived harm and advocate their use to obtain a hemostatic field in otherwise difficult-to-control areas. Despite more modern approaches, many physicians continue to avoid the ...

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