Arterial wrist bleed

[wareagle726]

Hey guys would love some input on this. As a new attending who trained(as most of you did) at a level one trauma center this was a hit to my ego and I'm looking for some insight on what I could have done differently. This is my 3rd shift at what I would say is mediocre as far as resources, definitely not trauma center. The case is as follows...

Elderly lady falls off bicycle and has open left distal ulna/radius fracture with what I see as ulnar artery injury with pulsatile bleeding and moderate hematoma. Not tachy or hypotensive. No other obvious injuries other than abrasions. Applied direct pressure for 15 mins and still soaking through. Called ortho who recommended tx to the higher level of care 10 mins away(same hospital system) for OR after splinting and controlling bleeding. Attempted to tie off vessel for probably 15 more mins with no success and basically entered damage control, placed tourniquette, and went ahead and ER to ER transferred. Don't know what happened on arrival to other facility but the ortho doc called and told the charge nurse that I basically shouldn't have placed the tourniquet and the patient may have revascualrization injury.

I guess in retrospect I should have called vascular at the accepting site but I don't know what else I would have done. I couldn't get passed C in the "ABC's" and I think I was doing what was the best for the lady. In residency when we accepted a patient to the ER we didn't make the transferring doc talk to all the specialists that could be involved and just accepted the patient so that is likely where I messed up and assumed it was the same.

I get that every place is different and you have to learn the dynamics of a new system but it sucks feeling like I fell back on my training and had no question about what I was doing only to get chastised about it and made to feel like I did the patient wrong.

Thanks

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[southerndoc]

Care appropriate (from someone who has been on an MCE/QA committee for years).

Revascularization injury would happen if the tourniquet is on for hours. What's the alternative? Let her bleed out? You did all you could before the tourniquet, and honestly, I probably wouldn't have done as much as you did.

Give yourself kudos, realize you have to have a tough skin from all the consultant Monday morning quarterbacking that goes on in ER, and consider this a job well done.

 

[Zebra Hunter]

I personally never attempt to tie off a vessel. If I am considering that, they need a tourniquet. Soldiers have tourniquets applied for hours without permanent injuries. 10 minute transfer time is clearly not long enough to cause permanent disability. That ortho is a clown and pretty unprofessional to make that kind of call and not even speak directly to the transferring physician.

 

[Apollyon]

Had a similar case (but not a similar pt - he was 25 y/o Samoan guy) in HI 12 years ago. Accidental stick right into R radial artery (weird story, but legit). My medical director at the time (two years of surgical residency in the 80s), who was doing paperwork, comes to "back me up". He asks me, "are you going to oversew that?" I look at him like I did when the Longhorn Steakhouse manager asked me if I wanted A-1, and told him "No, I'm calling vascular". I was at a standalone ED, and the vascular attending downtown was more than happy to take the pt.

The way I see it, vascular>>ortho. And, your ortho guy sounds like a total ****.

 

[alpinism]

See these all the time when I work in war zones with no consultants.

For major arterial bleeds just place a foley catheter into the wound.

 

[Apollyon]

See these all the time when I work in war zones with no consultants.

For major arterial bleeds just place a foley catheter into the wound.

I don't get how that would go. Wouldn't arterial pressure just blow the Foley out of the proximal end?

 

[alpinism]

I don't get how that would go. Wouldn't arterial pressure just blow the Foley out of the proximal end?

You have to suture the skin over the foley.

 

[GeneralVeers]

Manual blood pressure cuff as tourniquet. Inflate until bleeding stops. Then use big sutures and close the wound as tight as possible over the bleeding vessel. Often this is enough to allow a hematoma to form. In a wrist there isn't much potential space, so eventually the hematoma will compress the vessel enough to stop bleeding. If you can't close the wound, then I agree: Tourniquet and ship ASAP.

 

[cyanide12345678]

Hey guys would love some input on this. As a new attending who trained(as most of you did) at a level one trauma center this was a hit to my ego and I'm looking for some insight on what I could have done differently. This is my 3rd shift at what I would say is mediocre as far as resources, definitely not trauma center. The case is as follows...

Elderly lady falls off bicycle and has open left distal ulna/radius fracture with what I see as ulnar artery injury with pulsatile bleeding and moderate hematoma. Not tachy or hypotensive. No other obvious injuries other than abrasions. Applied direct pressure for 15 mins and still soaking through. Called ortho who recommended tx to the higher level of care 10 mins away(same hospital system) for OR after splinting and controlling bleeding. Attempted to tie off vessel for probably 15 more mins with no success and basically entered damage control, placed tourniquette, and went ahead and ER to ER transferred. Don't know what happened on arrival to other facility but the ortho doc called and told the charge nurse that I basically shouldn't have placed the tourniquet and the patient may have revascualrization injury.

I guess in retrospect I should have called vascular at the accepting site but I don't know what else I would have done. I couldn't get passed C in the "ABC's" and I think I was doing what was the best for the lady. In residency when we accepted a patient to the ER we didn't make the transferring doc talk to all the specialists that could be involved and just accepted the patient so that is likely where I messed up and assumed it was the same.

I get that every place is different and you have to learn the dynamics of a new system but it sucks feeling like I fell back on my training and had no question about what I was doing only to get chastised about it and made to feel like I did the patient wrong.

Thanks

That's what i would do. Completely appropriate care. Had an arterial leg bleed from a bleeding fem-pop bypass. Blood all over. Tourniquit, vascular, blood, transfer stat.

Revascularization injury happens after 4 hours. Make sure to put the time on the tourniquit when it was applied. But yeah.... Been there done that.

10 minute transfer is nothing. It's more interesting when you have an arterial bleed, 1.5 hours away from a trauma center, and bad weather so no flight

 

[GeneralVeers]

10 minute transfer is nothing. It's more interesting when you have an arterial bleed, 1.5 hours away from a trauma center, and bad weather so no flight

Not that interesting. You can only do what you can do. Better to lose a limb than a life.

 

[bravotwozero]

Manual blood pressure cuff as tourniquet. Inflate until bleeding stops. Then use big sutures and close the wound as tight as possible over the bleeding vessel. Often this is enough to allow a hematoma to form.

Yup, most of the time just suturing it is enough to tamponade the bleeding vessel. Have had so many midlevels freak out on me when I tell them to just suture the wound and observe when there's a little bit of brisk bleeding from a small vessel.

 

[Groove]

I would try blood pressure cuff and tie off bleeder (There are very few vessels that I can't tie off this way and it is infinitely easier than trying to identify and tie off an actively bleeding vessel.). If unsuccessful, quikclot pressure bandage with coban. If that's unsuccessful, I would have no problem placing a tourniquet. Call vascular next time instead of ortho but it probably wouldn't have changed your management. Otherwise, good job. Everyone loves to Monday morning quarterback.

 

[wareagle726]

Thanks for the replies. Glad to know I wasn't out in left field. Figuring out logistics in a non-tertiary care setting is definitely going to take some getting used to.

 

[deleted547339]

Thanks for the replies. Glad to know I wasn't out in left field. Figuring out logistics in a non-tertiary care setting is definitely going to take some getting used to.

You did fine. Welcome to EM, where the accepting attendings can blast you for doing the right thing.

 

[RustedFox]

Great discussion.
Anyone want to share their favorite techniques for tying off bleeders (beyond figure-of-eight), or any other approaches (I never would have thought about foley in the wound; brilliant).

I just want to stir discussion.

 

[dadaddadaBATMAN]

Great discussion.
Anyone want to share their favorite techniques for tying off bleeders (beyond figure-of-eight), or any other approaches (I never would have thought about foley in the wound; brilliant).

I just want to stir discussion.

I have never had much success with figure of 8s. Ever since residency when an older attending showed me it I have taken the veers approach: bp cuff if it’s an extremity, big fuc**n needle and suture and tie that sucker tight. Most things tamponade quickly that way, as long as it’s not in a spot where they can get compartment syndrome I don’t worry too much.

 

[RustedFox]

I have never had much success with figure of 8s. Ever since residency when an older attending showed me it I have taken the veers approach: bp cuff if it’s an extremity, big fuc**n needle and suture and tie that sucker tight. Most things tamponade quickly that way, as long as it’s not in a spot where they can get compartment syndrome I don’t worry too much.

Hmm.
Good point. I have always used the BP cuff tourniquet technique as well.
Anyone got a scheme for a scalp bleeder? (Besides throwing a lot of lido w/epi into it and stapling it down)

 

[Fox800]

Hmm.
Good point. I have always used the BP cuff tourniquet technique as well.
Anyone got a scheme for a scalp bleeder? (Besides throwing a lot of lido w/epi into it and stapling it down)

Big figure of eights. Raney clips suck.

 

[turkeyjerky]

I'm a little confused with the clinical scenario from the OP. Was it active massive external hemorrhage refractory to direct pressure? Was pressure correctly applied, eg small piece of gauze, 1 finger, hard enough to make the old lady cry? Or did it keep soaking through a "pressure dressing" that the nurse kept "reinforcing"?

Also, a "10 minute transfer" time is typically more like 60-90 min in my experience.

Regardless, the orthopod sounds like an asshat. I don't think anyone would actually fault you for your care. And no reason to delay transfer further to talk to vascular at the referral center.

 

[RustedFox]

Regardless, the orthopod sounds like an asshat. I don't think anyone would actually fault you for your care.

Gasp! Ortho?! Being condescending, rude, and short-sighted?!

The hell you say.

 

[WheezyBaby]

Out of curiosity, do you all have a specific approach to a bleeding AV fistula? I've only encountered a significant bleed twice; Kcentra solved one and vascular surgery solved the other. My salvage would just be tourniquet to temporize for vascular but I hate to do that to a fistula arm if there are other good alternatives if pressure doesn't work

 

[Zebra Hunter]

Out of curiosity, do you all have a specific approach to a bleeding AV fistula? I've only encountered a significant bleed twice; Kcentra solved one and vascular surgery solved the other. My salvage would just be tourniquet to temporize for vascular but I hate to do that to a fistula arm if there are other good alternatives if pressure doesn't work

figure of eight. Stay superficial. Talk w/ vascular after to let em know that pt will need a fistulogram.

 

[turkeyjerky]

Out of curiosity, do you all have a specific approach to a bleeding AV fistula? I've only encountered a significant bleed twice; Kcentra solved one and vascular surgery solved the other. My salvage would just be tourniquet to temporize for vascular but I hate to do that to a fistula arm if there are other good alternatives if pressure doesn't work

1. Direct pressure (piece of 2x2 gauze pushed down with a fingertip for 20 minutes. No peaking.)
2. Correct coagulopathy (desmopressin, protamine)
3. Manual BP cuff blown up proximally to control bleeding and then place a superficial stitch if possible. Apply topical hemostatic over this to stop the capillary oozing from the needle stick sites (not that these are a source of significant bleeding, but it confuses the picture)
4. Call vascular

 

[CliveStaples]

I've had good success tying off bleeding vessels with figures-of-eight myself. I do think that using a tourniquet to buy yourself time on a big arterial bleeder in the wrist is a sound strategy as long as you can still find your vessel to tie off. This also goes for my scalp bleeders.

 

[namethatsmell]

Figure of 8s are like ED ducttape. Multipurpose and simple. Bleeding scalps love them. Extremity bleeds love them. Bleeding fistula's love them. Gaping wounds also love them but that's for a different thread (sunday punday).

When one figure of 8 isn't enough, put in a second and upgrade to a figure of 16.

 

[thegenius]

Out of curiosity, do you all have a specific approach to a bleeding AV fistula? I've only encountered a significant bleed twice; Kcentra solved one and vascular surgery solved the other. My salvage would just be tourniquet to temporize for vascular but I hate to do that to a fistula arm if there are other good alternatives if pressure doesn't work

I have put in several sutures into a bleeding AV fistula that doesn't stop with compression. I usually consult vascular or interventional nephrology and they all say the same thing. It's usually one or two interrupted stitches.

 

[Dr Mantis Toboggan]

I have put in several sutures into a bleeding AV fistula that doesn't stop with compression. I usually consult vascular or interventional nephrology and they all say the same thing. It's usually one or two interrupted stitches.

Figure of 8 for the win. Have to have an assistant compress proximally and distally hard. Covid PPE is helpful, did one the other day and would’ve got blood to the face but luckily already all covered up.

 

[Dr Mantis Toboggan]

I have never had much success with figure of 8s. Ever since residency when an older attending showed me it I have taken the veers approach: bp cuff if it’s an extremity, big fuc**n needle and suture and tie that sucker tight. Most things tamponade quickly that way, as long as it’s not in a spot where they can get compartment syndrome I don’t worry too much.

quick clot gauze. If your system doesn’t stock, buy it on amazon for your shifts/house/car. works perfectly for wrist arterial bleeders. Had a guy the other month, advanced head and neck CA. (Should’ve been comfort care but wasn’t ready to let go). Tumor ate into carotid, 1 liter blood loss at least PTA. Could see the hole in the carotid which you could compress with a finger, but had to get the guy downtown. Quick clot was money. Guy lived to get to the OR and be discharged. I assume he’s dead by now but he got a few more weeks at least.

 

[thegenius]

figure of eight. Stay superficial. Talk w/ vascular after to let em know that pt will need a fistulogram.

Why do they need a fistulogram after closing? Just curious.

 

[namethatsmell]

Why do they need a fistulogram after closing? Just curious.

To check for possible fistula occlusion and/or damage

 

[Groove]

Bleeders:

1) Direct Visualization (Large vessel) : Clamp end and then Stick tie suture or regular tie off suture.

2) Direct Visualization (Small vessel) : I grab it with small forceps and lock them...then let go. If bleeding has stopped, I slip a suture around the base and tie it off with one or two hands.

3) Indirect Visualization: Figure 8 stitch for almost 80-90% of my bleeders with almost 100% success. If one doesn't quite do it, a second usually does. 10-20% of the time I use a double loop mattress suture.

Scalp Bleeders:

1) Figure 8.

2) You can also use the large stapler and press it down just proximal to the bleeder until you find the feeding territory and the bleeding slows or stops. You can then punch a large staple for hemostasis.

3) Running locking suture if the bleeder is superficial or the wound edges continuously ooze.

AVF:

1) Figure 8.

2) Purse string.

Figure 8:


Double Loop Mattress:


Running Locking:


Purse String:

 

[Mr. Vandemar]

Out of curiosity, do you all have a specific approach to a bleeding AV fistula?

I like the following bottle cap keyring technique, but haven't actually used it.

Controlling bleeds from a fistula or graft

About controlling bleeds from a fistula or graft: what to do if your fistula or graft bleeds, and information about Kidney Care UK’s bottle top keyring for managing bleeds

www.kidneycareuk.org

I have had two of these in residency and just put a figure of 8, trying to stay superficial, and then let vascular know. Has worked both times.

 

[Rendar5]

I’ve had about 8 AV fistula bleeders in my career (as in shooting 6 feet across the room when I let go of pressure). Never had to tourniquet or do any coagulation reversal or anything like that. There’s not really a point to it, it’s just a gap in the skin that needs to be closed. Figure 8 in the subcutaneous tissue (not into the fistula) worked on 7 of them. The last one i tried a purse string suture and it worked much better because I never had to take pressure off the opening and could visualize the entire suture.

 

[Zebra Hunter]

I like the following bottle cap keyring technique, but haven't actually used it.

Controlling bleeds from a fistula or graft

About controlling bleeds from a fistula or graft: what to do if your fistula or graft bleeds, and information about Kidney Care UK’s bottle top keyring for managing bleeds

www.kidneycareuk.org

I have had two of these in residency and just put a figure of 8, trying to stay superficial, and then let vascular know. Has worked both times.

I have seen a ton of people post this on twitter, but I still don't see the utility of this in the ER. You are eventually going to need to remove the clot, and when you do, there is a high probability of a re-bleed. This is fine to use if you have vascular in house 24-7, but out in the community, you are the one that has to manage these. This might be a trick I teach patients on how to manage these bleeds if it happens at home, however.

 

[CliveStaples]

I have seen a ton of people post this on twitter, but I still don't see the utility of this in the ER. You are eventually going to need to remove the clot, and when you do, there is a high probability of a re-bleed. This is fine to use if you have vascular in house 24-7, but out in the community, you are the one that has to manage these. This might be a trick I teach patients on how to manage these bleeds if it happens at home, however.

Just curious, at your community shop what would you be doing with these after controlling the bleeding somehow? For me, whether I stitch it shut or put a bottle cap over it, as long as it is stable I'm going to have to ship it to the tertiary care center anyways for definitive management from Vascular Surgery.

 

[Dr Mantis Toboggan]

Just curious, at your community shop what would you be doing with these after controlling the bleeding somehow? For me, whether I stitch it shut or put a bottle cap over it, as long as it is stable I'm going to have to ship it to the tertiary care center anyways for definitive management from Vascular Surgery.

I call vascular after placing the stitch and they tell me to send them home and they see them in the office the next day

 

[Zebra Hunter]

I call vascular after placing the stitch and they tell me to send them home and they see them in the office the next day

Same

 

[CliveStaples]

My regional vascular guys must be very conservative. Maybe if I had in-house Vascular instead of the nearest being academic vascular surgeons with a cadre of in-house residents, my experience would be different.

 

[RuralEDDoc]

... I basically shouldn't have placed the tourniquet and the patient may have revascualrization injury.

Maybe she will. But remember you didn’t cause her to fall off her bike and bust her arm open. You tried to stabilize as best you could, sought expert opinion, and practiced standard of care medicine. It’s healthy to think through tough cases and try and consider what plan B could have been, but only to a certain extent. We work in an imperfect system where resources are concentrated at tertiary care centers and then tertiary care centers with all the resources **** on the sending docs. It’s the way the work works. Don’t lose any sleep over this one.

 

[RoyBasch]

The amount of trouble you could get in ligating a vessel as an ER physicians seems significant.

I think the standard of care in our specialty if extremity hemorrhage uncontrolled with direct pressure is placement of a tourniquet and calling a vascular surgeon if you have one or arranging transfer if you dont. Maybe if you are in a really remote site with a really bad ass general surgeon they could maybe help, but probably not. If there's a lacerated or transected 'named' vessel that needs to be renastamosed, your going to want vascular.

 

[TelemarketingEnigma]

I do think that using a tourniquet to buy yourself time on a big arterial bleeder in the wrist is a sound strategy as long as you can still find your vessel to tie off. This also goes for my scalp bleeders.

I know this isn't what you meant, but I initially read this as you using a tourniquet for a scalp bleed and I was... concerned...

 

[Vandalia]

I know this isn't what you meant, but I initially read this as you using a tourniquet for a scalp bleed and I was... concerned...

Concerned? Why? Such an approach would be incredibly effective at stopping the bleeding. From any site.

There was a retrospective study done by Albert Pierrepoint that confirmed this.

We will see if anyone gets that reference. No cheating by going to Google.

 

[Miles Gloriosus]

Hey guys would love some input on this. As a new attending who trained(as most of you did) at a level one trauma center this was a hit to my ego and I'm looking for some insight on what I could have done differently. This is my 3rd shift at what I would say is mediocre as far as resources, definitely not trauma center. The case is as follows...

Elderly lady falls off bicycle and has open left distal ulna/radius fracture with what I see as ulnar artery injury with pulsatile bleeding and moderate hematoma. Not tachy or hypotensive. No other obvious injuries other than abrasions. Applied direct pressure for 15 mins and still soaking through. Called ortho who recommended tx to the higher level of care 10 mins away(same hospital system) for OR after splinting and controlling bleeding. Attempted to tie off vessel for probably 15 more mins with no success and basically entered damage control, placed tourniquette, and went ahead and ER to ER transferred. Don't know what happened on arrival to other facility but the ortho doc called and told the charge nurse that I basically shouldn't have placed the tourniquet and the patient may have revascualrization injury.

I guess in retrospect I should have called vascular at the accepting site but I don't know what else I would have done. I couldn't get passed C in the "ABC's" and I think I was doing what was the best for the lady. In residency when we accepted a patient to the ER we didn't make the transferring doc talk to all the specialists that could be involved and just accepted the patient so that is likely where I messed up and assumed it was the same.

I get that every place is different and you have to learn the dynamics of a new system but it sucks feeling like I fell back on my training and had no question about what I was doing only to get chastised about it and made to feel like I did the patient wrong.

Thanks

Was the open wound large? What you can do is soak a lap or sponge with 1%lido with 1:100000 epi and stick it in the wound. Then place a stack of gauze and wrap the wrist as a pressure dressing. Also, if it’s a blood bath when trying to tie off vessel, can be helpful to apply BP cuff to arm and inflate it while you explore and suture. You can then let it down to see if your tie worked. Gives you temporary control of bleed and avoids long tourniquet time.

 

[Zebra Hunter]

Damn, sure enough, first shift after replying to this thread and my first patient was an AV fistula bleed. Figure of 8 and had them follow up next day with vascular.

 

[Cinclus]

I call vascular after placing the stitch and they tell me to send them home and they see them in the office the next day

Yup. I was somehow sent two bleeding AV fistula patients yesterday. Only had to stitch one with a figure-of-8 (which I have never seen not work for these - done a ton, as I trained at the ESRD capital of the world). Called the patient's vascular surgeon and he saw her this morning. Tried direct pressure first, then topical hemostatic, then grabbed the suture when it was still firing across the room. I always make sure I tell the patient I may possibly destroy the fistula by suturing, but that I don't have many more options to stop the bleeding.

 

[betamale]

Great discussion.
Anyone want to share their favorite techniques for tying off bleeders (beyond figure-of-eight), or any other approaches (I never would have thought about foley in the wound; brilliant).

I just want to stir discussion.

I just use figure of 8.

 

[WilcoWorld]

The Perchik button works well if you're able to have someone hold direct pressure while you first remember how to spell "Perchik" and second wait for it to come from central stores.

 

[Groove]

Also, it's worth asking if your OR has a pneumatic tourniquet that they could send down. Most OR's have them if you have orthopods doing surgery there (I think ours is a Stryker). They make life so much easier for those messy arm or leg lacs where hemostasis can be challenging. I also use it for bier blocks. Love those things.

 

[Tuloste]

Just place some cylindrical or round object on the bleed site beneath the tourniquet. You'll have an open radial artery and enough psi on the ulnar artery to stop the bleeding. Edit in a disclaimer: haven't tried this method myself.