From the Guidelines
The immediate management for an arterial bleed is to apply direct pressure to the wound site with a clean cloth, gauze, or your hand if nothing else is available, as recommended by the most recent European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. Maintain firm, continuous pressure for at least 15 minutes without lifting to check the wound, as this can disrupt clot formation. If the bleeding is from a limb, elevate it above the level of the heart to reduce blood flow to the area while continuing to apply pressure. For severe arterial bleeding that cannot be controlled with direct pressure, a tourniquet may be applied 2-3 inches above the bleeding site (but not over joints), tightened until bleeding stops, and the time of application should be noted. Call emergency services immediately, as arterial bleeding is life-threatening due to the rapid blood loss that occurs when arteries, which carry blood under high pressure from the heart, are damaged. Arterial blood is typically bright red and may pulse or spurt with each heartbeat. Do not remove any embedded objects from the wound as they may be tamponading the vessel and removal could worsen bleeding. The goal is to stabilize the patient until definitive medical care can be provided, which may include surgical intervention, arterial repair, or embolization, as suggested by the European guideline 1.
Some key points to consider in the management of arterial bleeding include:
- Immediate bleeding control procedure for patients with an obvious bleeding source or in haemorrhagic shock in extremis 1
- Restricted volume replacement strategy with a target systolic blood pressure of 80-90 mmHg until major bleeding has been stopped 1
- Use of tranexamic acid as soon as possible to reduce the risk of death from bleeding 1
- Consideration of damage-control surgery, pelvic ring closure and stabilisation, and embolisation or packing for severe bleeding 1
From the Research
Immediate Management for Arterial Bleed
To stop an artery bleed, immediate management is crucial. The following steps can be taken:
- Apply direct pressure to the wound, as it remains the most effective "medical" intervention for initial hemorrhage control 2
- Use pressure dressings, wound packing, and hemostatic dressings as adjunctive aids for hemorrhage control 2
- Elevate and splint (immobilize) any bleeding extremity or body part to aid in hemorrhage control, especially when used in conjunction with direct pressure 2
- Consider the use of a tourniquet, although its effectiveness in reducing mortality or blood product use is still debated 3
Use of Tourniquets and Tranexamic Acid
The use of tourniquets and tranexamic acid can be beneficial in certain situations:
- Tourniquets may be used when life-threatening limb bleeding cannot be controlled with direct pressure, but their effectiveness in reducing mortality or blood product use is still uncertain 3
- Tranexamic acid, an antifibrinolytic agent, can be used to reduce blood loss and the need for transfusions, especially when combined with tourniquet use 4
- The combination of tranexamic acid and tourniquet use throughout surgery has been shown to significantly reduce blood loss and the need for transfusion in certain clinical settings, such as total knee arthroplasty 4
Important Considerations
When managing an arterial bleed, it is essential to consider the following:
- Placing a circumferential compressive bandage that is too tight or restrictive around the neck, thorax, or abdomen may occlude the patient's airway, restrict chest expansion, or prevent adequate respiration 2
- Noncircumferential bandages may not generate sufficient pressure to abate arterial hemorrhage, particularly when systolic arterial blood pressure is restored postfluid resuscitation 2
- Definitive hemostasis for massive internal hemorrhage is best achieved through early surgical intervention 2