What is the management for an arm laceration with an arterial bleed?

Management of Arm Laceration with Arterial Bleed

For an arm laceration with arterial bleeding, a tourniquet should be employed as an adjunct to stop this life-threatening bleeding from the open extremity injury. 1

Immediate Management

1. Direct pressure application:

   • Apply firm, continuous direct pressure to the bleeding site using clean gauze or cloth
   • Maintain pressure for at least 15 minutes without removing the gauze
   • If blood soaks through, add additional gauze on top without removing initial gauze 2

2. Tourniquet application:

   • When direct pressure fails to control pulsatile arterial bleeding
   • Apply tourniquet proximal to the wound site
   • Ensure proper tightness to stop arterial flow but not excessive 1
   • Document time of application clearly

3. Wound management:

   • Elevate the injured extremity above heart level to reduce hydrostatic pressure 2
   • Apply local cold therapy (ice pack) after initial pressure control 2
   • Avoid exploring the wound in pre-hospital setting

Hospital-Based Management

1. Initial assessment:

   • Assess extent of traumatic hemorrhage using combination of:
     • Patient physiology (vital signs, perfusion)
     • Anatomical injury pattern
     • Mechanism of injury
     • Response to initial resuscitation 1

2. Hemostasis priorities:

   • Patients with hemorrhagic shock and identified bleeding source should undergo immediate bleeding control procedure 1
   • The time elapsed between injury and definitive bleeding control should be minimized 1

3. Surgical management options:

   • Direct surgical bleeding control
   • Local hemostatic procedures
   • Packing if needed
   • In exsanguinating patients, aortic cross-clamping may be considered as last resort 1

4. Damage control approach:

   • Consider damage control surgery for patients with:
     • Deep hemorrhagic shock
     • Signs of ongoing bleeding
     • Coagulopathy
     • Hypothermia or acidosis 1

Special Considerations for Forearm Arterial Lacerations

• In a well-perfused hand with intact palmar arch circulation, one intact artery (radial or ulnar) is adequate to sustain viability 3
• Critical ischemia requires expeditious surgical restoration of arterial perfusion 3
• Early consultation with a hand specialist should be pursued for complex injuries 3

Monitoring and Follow-up

• Monitor for complications including:
  • Compartment syndrome
  • Neurovascular compromise
  • Infection 2
• Tourniquets should be left in place until surgical control of bleeding is achieved 1
• Keep tourniquet application time as short as possible to prevent complications like nerve paralysis and limb ischemia 1

Important Cautions

• Pressure point control alone is ineffective due to rapid development of collateral circulation 1
• Improper or prolonged tourniquet placement can lead to nerve damage and tissue ischemia 1
• Military reports indicate tourniquets have remained in place for up to six hours with limb survival, but civilian guidelines suggest a maximum of two hours when possible 1
• Subclinical injuries are common in forearm lacerations - 49% of full-thickness lacerations have underlying structural damage not detected on initial examination 4

By following this evidence-based approach to arterial bleeding control, you can effectively manage this potentially life-threatening condition while minimizing complications and preserving limb function.