Can we pack the wound when bleeding is not controlled?

Wound Packing for Uncontrolled Bleeding

Yes, wound packing is strongly recommended when bleeding is not controlled by direct pressure alone, as it is an essential component of early bleeding control that can significantly reduce mortality in hemorrhagic shock.1

Initial Approach to Bleeding Control

1. First-line intervention:

   • Direct manual pressure should be applied as the initial method to control external bleeding 1
   • Apply firm, continuous pressure directly on the bleeding site

2. When direct pressure fails:

   • Proceed to wound packing as part of damage control approach 1
   • Packing aims to compress bleeding sources and exert direct pressure on bleeding vessels 1

3. Packing technique:

   • Pack the wound firmly with appropriate material (gauze or hemostatic dressing if available)
   • Apply enough pressure to compress bleeding vessels but not cause additional tissue damage
   • Maintain pressure for at least 5 minutes before checking if bleeding has stopped

Evidence for Wound Packing

Wound packing is supported by strong evidence in trauma management guidelines:

• The European guideline on management of bleeding following major trauma specifically recommends: "early bleeding control of the abdomen be achieved using packing, direct surgical bleeding control and the use of local haemostatic procedures" (Grade 1C) 1

• Packing is particularly effective for:

  • Venous bleeding 1
  • Liver ruptures 1
  • Pelvic fractures with retroperitoneal bleeding 1
  • When surgical measures are unsuccessful 1
  • When the patient is cold, acidotic and coagulopathic 1

Damage Control Approach

Wound packing is a key component of damage control surgery, which should be employed when:

• Patient presents with deep hemorrhagic shock
• There are signs of ongoing bleeding
• Coagulopathy is present
• Patient has hypothermia or acidosis
• Major anatomical injury is present 1

The damage control approach includes:

1. Initial control of bleeding (including packing)
2. Intensive care treatment
3. Definitive surgical repair once the patient is stabilized 1

Adjunctive Measures

• Hemostatic dressings: Can be used alongside packing to improve effectiveness of direct pressure 1
• Pressure dressings: May be applied after bleeding is controlled to maintain hemostasis 1
• Tourniquets: For life-threatening extremity bleeding that cannot be controlled by direct pressure and packing 1

Important Considerations and Pitfalls

• Timing of pack removal: Packs should preferably be removed only after 48 hours to lower the risk of rebleeding 1

• Avoid non-therapeutic interventions: In cases of pelvic trauma with packing, non-therapeutic laparotomy should be avoided 1

• Monitor for complications: Potential complications of wound packing include:

  • Infection
  • Tissue necrosis
  • Compartment syndrome
  • Pressure damage to adjacent structures

• Definitive care: Packing is a temporary measure - definitive surgical control of bleeding is still required 1

• Avoid delays: In exsanguinating patients, do not delay packing while attempting other interventions 2

Wound packing is a critical life-saving intervention in the management of uncontrolled bleeding and should be implemented promptly when direct pressure alone is insufficient to achieve hemostasis.