What are the trauma guidelines for managing severe hemorrhage (severe bleeding) from a stab wound to the upper limb?

From the Guidelines

Management of severe bleeding from an upper limb stab wound requires immediate direct pressure to the wound using gauze or clean cloth while elevating the limb above heart level, with the addition of a hemostatic dressing if available, as it has been shown to increase the proportion of patients with cessation of bleeding in less than 5 minutes 1. The use of direct pressure is the mainstay of treatment, and applying a hemostatic dressing can augment the effectiveness of direct manual pressure 1.

Key Interventions

• Apply direct pressure to the wound using gauze or clean cloth
• Elevate the limb above heart level
• Use a hemostatic dressing if available
• Apply a pressure dressing once bleeding slows
• Avoid tourniquets unless bleeding is life-threatening and uncontrollable by other means
• If a tourniquet is necessary, place it 2-3 inches above the wound, tighten until bleeding stops, and note the application time 1

Additional Considerations

• For hemodynamically unstable patients, establish two large-bore IV lines and administer crystalloid fluids like normal saline or Ringer's lactate at 1-2 L initially, followed by blood products if needed
• Tranexamic acid should be given at 1g IV over 10 minutes within 3 hours of injury, followed by 1g over 8 hours
• Assess for neurovascular compromise by checking distal pulses, capillary refill, sensation, and motor function
• Pain management with IV morphine 0.1 mg/kg or fentanyl 1-2 mcg/kg is appropriate
• Prophylactic antibiotics such as cefazolin 2g IV (or clindamycin 600mg IV for penicillin-allergic patients) should be administered These interventions work by controlling hemorrhage through direct pressure, maintaining tissue perfusion via fluid resuscitation, stabilizing clot formation with tranexamic acid, and preventing infection in the traumatized tissue.

From the Research

Management of Upper Limb Severe Bleeding from Stab Wound

• The assessment and management of patients with stab wounds, including those to the upper limb, is crucial in the emergency department 2.
• Tourniquet placement is a common intervention for acute trauma resuscitation, particularly in cases of severe bleeding from extremities 3.
• The use of tourniquets has been shown to be effective in controlling hemorrhage, but its application and efficacy can vary depending on several factors, including the type of injury, location, and personnel applying the tourniquet 3, 4.

Tourniquet Application and Efficacy

• Studies have demonstrated that prehospital tourniquet application can limit ongoing hemorrhage and reduce the need for blood products in patients with extremity arterial trauma 4.
• However, tourniquet application has also been associated with increased frequency of transfusion and initial amputation in some cases, particularly in upper extremity injuries 4.
• The application of tourniquets can also have a causal relationship with increases in blood pressure, which may provide additional therapeutic potential in states of low cardiac output 5.

Resuscitation Strategies

• Hypotensive resuscitation, or permissive hypotension, is a resuscitation strategy that involves maintaining a lower-than-normal blood pressure until operative control of the bleeding can occur 6.
• This approach has been shown to reduce complications compared to aggressive fluid resuscitation, but its survival benefit is still being studied and debated 6.
• The optimal fluid resuscitation strategy for trauma patients with severe bleeding from stab wounds, including those to the upper limb, requires further research and consideration of individual patient factors.