What are the management and treatment options for arterial injuries (arterial wounds)?

From the Guidelines

Arterial wounds require immediate medical attention, and the first step is to apply direct pressure to the wound using a clean cloth or bandage while elevating the injured area above the heart level, as stated in the guidelines for acute care of severe limb trauma patients 1. When dealing with arterial wounds, it is crucial to prioritize immediate medical attention to prevent severe blood loss and potential death. The application of direct pressure to the wound is the initial step in managing arterial bleeding.

• Apply a clean cloth or bandage to the wound and elevate the injured area above the heart level to reduce blood flow to the affected area.
• Call emergency services immediately, as arterial bleeding can lead to rapid blood loss and hypovolemic shock.
• Avoid applying a tourniquet unless you have proper training, as improper use can cause additional damage.
• While waiting for medical help, maintain firm pressure on the wound without removing the initial bandage; instead, add more layers if blood soaks through.
• Avoid removing embedded objects as they may be preventing further bleeding. The Ankle-Brachial Index (ABI) is a useful diagnostic tool in assessing arterial injuries, with a sensitivity of 87% and specificity of 97% for diagnosing vascular injury, as demonstrated by Lynch and Johansen 1.
• The ABI is calculated by dividing the systolic blood pressure measured at the ankle by the systolic blood pressure measured at the arm.
• A meta-analysis by deSouza et al. concluded that in the absence of clinical signs suggesting a vascular injury and in the presence of a normal ABI, the probability of vascular injury is virtually zero 1. Medical professionals will typically treat arterial wounds with direct pressure, specialized hemostatic agents, surgical exploration, vessel repair or ligation, and possibly blood transfusions depending on the severity, as recommended by the guidelines for management of bleeding following major trauma 1.
• Endovascular revascularization is a recommended treatment option for patients with critical limb ischemia (CLI) and nonhealing wounds or gangrene, as stated in the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease 1.
• The goal of endovascular therapy is to establish direct in-line blood flow to the affected limb, and the use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and nonhealing wounds or gangrene 1.

From the Research

Arterial Wounds Overview

• Arterial wounds can lead to significant blood loss and are a major cause of preventable death 2
• Common sources of trauma-induced massive hemorrhage include injury to a major artery or other large vessel, such as the external jugular, femoral, or carotid artery 2
• Blood loss from a major arterial source can rapidly lead to exsanguination and death in as little as 3-5 minutes 2

Hemorrhage Control Methods

• Direct pressure remains the most effective "medical" intervention for initial hemorrhage control 2
• Other methods for controlling arterial hemorrhage include wound packing, hemostatic dressings, pressure bandages, and tourniquet application 2, 3, 4, 5
• Tourniquet use has been shown to be effective in controlling extremity hemorrhage, but its use in civilian settings is less uniform than in military settings 3, 5
• Noncircumferential bandages may not generate sufficient pressure to abate arterial hemorrhage, particularly when systolic arterial blood pressure is restored post-fluid resuscitation 2

Tourniquet Use

• Tourniquet application is a lifesaving intervention in people experiencing extremity hemorrhage, but its use is associated with a risk of complications, such as limb loss 3, 5
• The use of tourniquets in civilian settings is associated with a low rate of complications, and aggressive use of this potentially lifesaving intervention is justified 5
• Improvised tourniquets, such as a leather belt or an improvised windlass, may be effective in emergency settings where commercial devices are not available 4

Management of Acute Wounds

• The management of acute wounds requires timely and evidence-driven intervention to achieve optimal clinical outcomes 6
• Recent advances in the management of acute wounds have centered on stabilization and treatment in the military and combat environment, including advancements in hemostasis, resuscitation, and infection risk mitigation 6
• Critical issues in the management of acute wounds include infection control, pain management, and unique considerations for pediatric patients 6