Can Emergency Medicine (EM) physicians suture an arterial bleed?

Emergency Management of Arterial Bleeding: Direct Suturing is Not the Primary Approach

Emergency Medicine physicians should not routinely suture arterial bleeds as the primary intervention; instead, they must prioritize immediate direct manual pressure, followed by definitive hemorrhage control through angiographic embolization, surgical vascular repair, or damage control surgery depending on the bleeding source and hemodynamic stability. 1

Immediate Hemorrhage Control: The Critical First Steps

The most effective initial intervention for any arterial bleeding is sustained direct manual pressure applied firmly over gauze or cloth directly on the bleeding source until bleeding stops or definitive care arrives. 1, 2 This remains the gold standard first-line intervention regardless of the bleeding source.

• Manual pressure must be firm and maintained for prolonged periods - the amount of pressure and duration are the most critical factors for successful hemorrhage control 1
• If bleeding continues despite direct pressure, add additional gauze on top without removing the original layer and apply more pressure 1
• Direct pressure is more effective than suturing for initial arterial hemorrhage control in the emergency setting 2

Why Suturing Arterial Bleeds is Problematic in Emergency Settings

Attempting to suture an actively bleeding artery in the emergency department is technically challenging, time-consuming, and often ineffective for several critical reasons:

• Arterial bleeding creates a surgical field obscured by blood, making precise vessel identification and suture placement extremely difficult 1, 3
• Time-consuming procedures should trigger damage control approaches rather than definitive repair in exsanguinating patients 1
• Arterial injuries require proper surgical exposure, proximal and distal control, and vascular repair techniques that are beyond the scope of emergency wound closure 1

Definitive Management Based on Bleeding Source

For Accessible Superficial Arterial Bleeding

• If the bleeding vessel is readily accessible (e.g., during surgery or with direct visualization), repair by simple suturing may be appropriate - but this requires surgical expertise and proper exposure 1
• For most emergency department presentations, the bleeding source is not adequately exposed for safe vascular repair 1

For Deep or Inaccessible Arterial Bleeding

Angiography and embolization are the accepted standard for controlling arterial bleeding that cannot be controlled by direct pressure or fracture stabilization (in the case of pelvic or orthopedic trauma). 1

• Angiographic embolization is highly effective for arterial hemorrhage control and should be pursued when direct pressure fails 1
• Post-operative angio-embolization is a viable option after surgical exploration, allowing hemorrhage control while reducing complications 1

For Life-Threatening Hemorrhage Requiring Surgery

Damage control surgery should be employed in severely injured patients presenting with deep hemorrhagic shock, signs of ongoing bleeding, and coagulopathy. 1

The surgical priorities are:

• Surgical control of bleeding through packing, ligation, or temporary shunting - not definitive vascular reconstruction 1, 3
• Drainage of any associated abscess or hematoma 1
• Hemodynamic stabilization takes priority over anatomical repair in the exsanguinating patient 3

Critical Pitfalls to Avoid

Never attempt time-consuming definitive vascular repair procedures in hemodynamically unstable patients - this violates damage control principles and increases mortality. 1, 3

• Avoid removing direct pressure prematurely to "explore" the wound - this can precipitate uncontrolled hemorrhage 1, 2
• Do not apply tourniquets to non-extremity bleeding (neck, thorax, abdomen) as circumferential compression can occlude airways or restrict respiration 2
• Permissive hypotension strategies apply only to trauma with extracranial bleeding, not to all bleeding scenarios 4

When Emergency Physicians Should Involve Vascular Surgery

Timely referral to a surgeon knowledgeable in vascular complications is essential for arterial bleeding that does not respond to direct pressure. 1

Immediate surgical consultation is required for:

• Any arterial bleeding with hemodynamic instability (hypotension, tachycardia, ongoing blood loss) 1, 5
• Arterial bleeding that persists despite adequate direct pressure for 10-15 minutes 6, 7
• Suspected major vessel injury (femoral, carotid, brachial arteries) where exsanguination can occur within 3-5 minutes 2
• Arterial bleeding in patients with prior vascular surgery or grafts, as this may represent graft infection or anastomotic complications requiring specialized management 1, 5

Adjunctive Hemostatic Measures

While maintaining direct pressure and arranging definitive care:

• Hemostatic agents (topical thrombin, fibrin sealants) may be considered as adjuncts but should never replace direct pressure or definitive vascular control 6, 7
• These agents are most effective for oozing or venous bleeding, not high-pressure arterial hemorrhage 6
• Correct any underlying coagulopathy, treat infection/sepsis, and address anemia as these factors directly impair hemostasis 1