What is the management for persistent bleeding in extremities?

Management of Persistent Bleeding in Extremities

Direct manual pressure is the immediate first-line intervention for all extremity bleeding, and if this fails to control life-threatening hemorrhage, a commercial tourniquet should be applied and tightened until bleeding stops. 1

Initial Hemorrhage Control

Direct Manual Pressure (First-Line)

• Apply firm, continuous direct manual pressure over the bleeding site using gauze or clean cloth—this is the most effective initial intervention for hemorrhage control 1, 2
• Maintain pressure for sufficient duration; the amount of pressure and duration are the most critical factors for successful bleeding cessation 2, 3
• If bleeding continues, add more gauze on top without removing the initial layer 2
• Do not waste time with pressure points (brachial/femoral artery compression)—these are ineffective and delay proper treatment 1, 2
• Do not rely on limb elevation alone as a hemorrhage control method 2

Hemostatic Dressings (Adjunctive Therapy)

• If direct pressure alone is insufficient, add a hemostatic dressing to improve effectiveness 1, 2
• Hemostatic dressings (containing materials that promote clotting) result in higher rates of bleeding cessation within 5 minutes (51.2%) compared to direct pressure alone (32.5%) 1
• These dressings shorten time to hemostasis compared to standard gauze 2, 4
• Apply the hemostatic dressing directly to the wound with continued direct pressure for 3 minutes 5

Pressure Dressings (Maintenance)

• Once bleeding has stopped with direct pressure, apply a pressure dressing to maintain hemorrhage control 1, 2
• Wrap an elastic bandage firmly over gauze to hold it in place with sustained pressure if continuous manual pressure cannot be maintained 2
• Commercial pressure dressings and elastic adhesive dressings are effective when applied by trained personnel 1

Tourniquet Application for Life-Threatening Bleeding

When to Apply a Tourniquet

Apply a tourniquet only when direct pressure (with or without hemostatic dressings) fails to control life-threatening extremity bleeding 1, 2

Life-threatening bleeding is recognized by:

• Pooling of blood on the ground 1
• Continued arterial spurting despite direct pressure 1
• Mangled extremity injuries, penetrating wounds, blast injuries, or traumatic amputations 1

Proper Tourniquet Technique

• Use a commercial tourniquet—these are superior to improvised tourniquets 1, 2
• If an improvised tourniquet must be used, ensure it is at least 2 inches wide to minimize tissue damage and pain 1
• Narrow tourniquets cause more pain, tissue damage, and are less effective than wider tourniquets 1
• Apply the tourniquet proximal to the wound and tighten until bleeding completely stops 1
• Document the exact time of tourniquet application and communicate this to all healthcare providers 6, 2

Tourniquet Duration and Removal

• Leave the tourniquet in place until surgical control of bleeding is achieved, but minimize this time as much as possible 1, 6
• Some guidelines suggest a maximum application time of 2 hours, though military data shows extremity survival with up to 6 hours of tourniquet time 1, 6
• Prolonged or improper tourniquet placement can cause nerve paralysis and limb ischemia 1, 6
• Consider removing the tourniquet after applying a hemostatic dressing with direct pressure if hemorrhage control is maintained 5

Adjunctive Measures

Local Cold Therapy

• Apply ice packs to the wound area to help control bleeding 2
• This is useful as an adjunctive measure alongside direct pressure 2

Mechanical Pressure Devices

• Consider mechanical pressure devices (pressure bandages) when direct manual pressure is not feasible, such as in mass casualty events 1
• These devices may be useful when there are insufficient resources to provide continuous direct pressure to all victims 1

Critical Pitfalls to Avoid

• Do not delay tourniquet application if direct pressure fails—blood loss from major arterial injury can cause exsanguination and death in 3-5 minutes 3
• Do not apply tourniquets to the neck, thorax, or abdomen—circumferential compression in these areas can occlude the airway, restrict chest expansion, or prevent adequate respiration 3
• Do not remove initial gauze layers when adding more—this disrupts clot formation 2
• Do not use narrow improvised tourniquets—they require higher pressure, cause more pain, and increase risk of nerve injury 1
• Minimize time from injury to definitive hemorrhage control (surgery or embolization)—every minute of delay increases mortality 1

Special Considerations

Hemostatic Dressings with Tourniquets

• Hemostatic dressings can reduce tourniquet time while maintaining hemorrhage control 5
• After tourniquet application achieves hemostasis, apply a hemostatic dressing with direct pressure for 3 minutes, then attempt tourniquet removal 5
• If bleeding recurs after tourniquet removal, immediately reapply the tourniquet 5

Transport Considerations

• Elastic adhesive dressing compression is effective during ambulance or helicopter transport 7
• This method provides immediate, effective, and lasting hemorrhage control without compromising distal blood flow 7