Extremity Trauma/External Hemorrhage Management

Table of Contents

Aliases

None noted

Patient Care Goals

1. Minimize blood loss from extremity hemorrhage
2. Avoid hemorrhagic shock as a result of extremity hemorrhage
3. Minimize pain and further injury as a result of potential fractures or dislocations

Patient Presentation

Inclusion Criteria

1. Traumatic extremity hemorrhage (external hemorrhage)
2. Potential extremity fractures or dislocations

Exclusion Criteria

No recommendations

Patient Management

Assessment

1. Evaluate for obvious deformity, shortening, rotation, or instability
2. Neurologic status of extremity
   1. Sensation to light touch
   2. Distal movement of extremity
3. Vascular status of extremity
   1. Pallor
   2. Pulse
   3. Capillary refill
   4. Degree of bleeding/blood loss with assessment of the color of the blood (venous or arterial) and whether it is pulsatile or not

Treatments and Interventions  (also, see protocol diagram below)

1. Manage bleeding
   1. Apply direct pressure to bleeding site followed by pressure dressing.
   2. If direct pressure/pressure dressing is ineffective or impractical:
      1. If the bleeding site is amenable to tourniquet placement, apply tourniquet to extremity
         1. Apply tourniquet to extremity as high up the limb as possible and tighten until bleeding stops and distal pulse is eliminated
            1. If distal pulse remains after tourniquet placement, reapply but pull strap tighter.
         2. If bleeding continues, place a second tourniquet proximal to the first
         3. For thigh wounds, consider placement of two tourniquets, side-by-side, and tighten sequentially to eliminate distal pulse
      2. If the bleeding site is not amenable to tourniquet placement (i.e. junctional injury), pack wound tightly with gauze and apply direct pressure
         1. Hemostatic gauze is preferable
   3. Groin/axillary injury
      1. Apply direct pressure to wound
      2. If still bleeding, pack wound tightly with gauze and apply direct pressure
         1. Hemostatic gauze is preferable
      3. Consider using a junctional hemostatic device if available
2. Manage pain [see Pain Management guideline]
   1. Pain management should be strongly considered for patients with suspected fractures
   2. If tourniquet placed, an alert patient will likely require pain medication to manage tourniquet pain
3. Stabilize suspected fractures/dislocations
   1. Strongly consider pain management before attempting to move a suspected fracture
   2. If distal vascular function is compromised, gently attempt to restore normal anatomic position
   3. Use splints as appropriate to limit movement of suspected fracture
   4. Elevate extremity fractures above heart level whenever possible to limit swelling
   5. Apply ice/cool packs to limit swelling in suspected fractures or soft tissue injury – do not apply ice directly to skin
   6. Reassess distal neurovascular status after any manipulation or splinting of fractures/dislocations

Notes – Extremity Trauma/External Hemorrhage Management