Notes – Extremity Trauma/External Hemorrhage Management

Extremity Trauma/External Hemorrhage Management

Patient Safety Considerations

  1. If tourniquet use:
    1. Ensure that it is sufficiently tight to occlude the distal pulse, in order to avoid compartment syndrome
    2. Ensure that it is well marked and visible and that all subsequent providers are aware of the presence of the tourniquet
    3. Do not cover with clothing or dressings
  2. Mark time of tourniquet placement prominently on the patient
  3. If pressure dressing or tourniquet used, frequently re-check to determine if bleeding has restarted. Check for blood soaking through the dressing or continued bleeding distal to the tourniquet. Do not remove tourniquet or dressing in order to assess bleeding

Notes/Educational Pearls

Key Considerations

  1. Tourniquet may be placed initially to stop obvious severe hemorrhage, then replaced later with pressure dressing after stabilization of ABCs and packaging of patient. Tourniquet should not be removed if:
    1. Transport time short (less than 30 minutes)
    2. Amputation or near-amputation
    3. Unstable or complex multiple-trauma patient
    4. Unstable clinical or tactical situation
  2. If tourniquet is replaced with pressure dressing, leave loose tourniquet in place so it may be retightened if bleeding resumes
  3. Survival is markedly improved when a tourniquet is placed before shock ensues
  4. Commercial/properly tested tourniquets are preferred over improvised tourniquets
  5. If hemostatic gauze is not available, plain gauze tightly packed into a wound has been shown to be effective
  6. Arterial pressure points are not effective in controlling hemorrhage
  7. Amputated body parts should be transported with patient for possible re-implantation
    1. It should remain cool but dry
    2. Place the amputated part in a plastic bag
    3. Place the bag with the amputated part on ice in a second bag
    4. Do not let the amputated part come into direct contact with the ice

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914097 – Injury-Extremity
  • 9914083 – Injury-Bleeding/Hemorrhage Control

Key Documentation Elements

  • Vital signs and vascular status of extremity after placement of tourniquet, pressure dressing, or splint
  • Documentation of elimination of distal pulse after tourniquet placement
  • Time of tourniquet placement

Performance Measures

  • Proper placement of tourniquet (location, elimination of distal pulse)
  • Proper marking and timing of tourniquet placement and notification of subsequent providers of tourniquet placement
  • Appropriate splinting of fractures
  • EMS Compass® Measures (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
    • Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
    • Trauma-02: Pain re-assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
    • Trauma-04: Trauma patients transported to trauma center. Trauma patients meeting Step 1 or 2* or 3** of the CDC Guidelines for Field Triage of Injured Patients are transported to a trauma center
      • *Any value documented in NEMSIS eInjury.03 – Trauma Center Criteria
      • **8 of 14 values under eInjury.04 – Vehicular, Pedestrian, or Other Injury Risk Factor match Step 3, the remaining 6 value options match Step 4.

Source: Bulger et al. 2014

*Use of tourniquet for extremity hemorrhage is strongly recommended if sustained direct pressure is ineffective or impractical; Use a commercially-produced, windlass, pneumatic, or ratcheting device, which has been demonstrated to occlude arterial flow and avoid narrow, elastic, or bungee-type devices; Utilize improvised tourniquets only if no commercial device is available; Do not release a properly-applied tourniquet until the patient reaches definitive care

#Apply a topical hemostatic agent, in combination with direct pressure, for wounds in anatomic areas where tourniquets cannot be applied and sustained direct pressure alone is ineffective or impractical; Only apply topical hemostatic agents in a gauze format that support wound packing; Only utilize topical hemostatic agents which have been determined to be effective and safe in a standardized laboratory injury model

References

  1. Bulger E et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163-73.
  2. Doyle G, Taillac P. Tourniquets: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care. 2008;12(2):241-56.
  3. Kragh J, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med. 2011;41(6):590-7.
  4. Leonard J, Aietlow J, Morris D, et al. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma. J Trauma Acute Care Surg. 2016;81(3):441-4.
  5. Mawhinney A and Kirk S. A systematic review of the use of tourniquets and topical haemostatic agents in conflicts in Afghantistan and Iraq. J R Nav Med Serv. 2015;101(2):147-54.
  6. Meusnier J, Dewar C, Mavrovi E, et al. Evaluation of two junctional tourniquets used on the battlefield: Combat Ready Clamp® versus SAM® Junctional Tourniquet. J Spec Oper Med. 2016;16:41-6.
  7. Prehospital Trauma Life Support, 8th Edition. Burlington, MA: Jones & Bartlett; 2016.
  8. Van Oostendorp S, Tan E, Geeraedts L. Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care: a review of treatment options and their applicability in the civilian trauma setting. Scand J Trauma Resusc Emerg Med. 2016;24(1):110.
  9. Watters J, Van P, Hamilton G, et al. Advanced hemostatic dressings are not superior to gauze for care under fire scenarios. J Trauma. 2011;70(6):1413-9.