Acute external haemorrhage – vascular surgery, penetrating trauma
Theory
Penetrating trauma requires urgent resuscitation, stabilisation and surgical exploration.
If the patient remains unstable, life-threatening haemorrhage may need to be managed surgically, simultaneously with ongoing resuscitation.
Haemorrhage following vascular surgery can be controlled with focal pressure over the bleeding point until definitive help arrives.
Immediate intern management
Attend patient and make rapid assessment.
If large volume haemorrhage, call MET code.
Airway
- Secure.
Breathing
- Give oxygen by mask.
- Ensure no pneumothorax (if penetrating trauma).
- If pneumothorax present, patient needs urgent chest tube (call code MET while organising chest tube setup).
Circulation
- Elevate bleeding site.
- Put pressure focally over site of bleeding.
- Obtain IV access (X–Match lost blood volume + extra two units), (FBE, U&E, LFT, INT).
- Fluid resuscitate – 500 ml Gelofusine stat, followed by N. Saline 1 L stat.
- Reverse reversible clotting abnormality.
Assessment
- Clinical history.
Other
- Call surgical registrar and unit registrar.
- Nil orally.
- Notify ICU about patient.
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Clinical features (obtain rapidly)
History
- Reason for bleeding
- Trauma/stabbing
- Post-surgery (nature of surgery)
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- Site and estimate of blood loss
- Penetrating trauma – site/implement/direction/force
- General symptoms related to possible organs injured
- History of reversible clotting abnormality (for example, Warfarin therapy or other blood thinning agents)
Examination
- Haemodynamic status
- Site of blood loss
- Relationship to major neurovascular structures
- Site and path of penetrating trauma
- ? Depth (difficult to determine)
- Status of possible organs injured – lung/heart/liver/spleen/kidney
Other (obtain later)
Neurological features distal to injuries
Further definitive management
Airway/breathing
Circulation
- Pressure over bleeding point
- Bandage (+/- pressure dressing)
- IV access and resuscitation
- Gelofusine
- Crystalloid
- Blood
- X-Match and book theatre
Assessment of injury, mechanism and possible injuries
Surgical exploration
- Arterial tourniquet for limb bleeding
- Extend wounds and assess injured/devitalised structures
- Proximal and distal control for bleeding major vessels
- Conservative debridement devitalised tissues
- Second look and exploration 24–48 hours
- Reconstruction
Other
- Rehabilitation
- Counselling for trauma
Techniques for resuscitation
- Multiple large bore IV cannulas (>16 G)
- Increase height of IV pole
- Infusion pumps/Imed pumps
- Rapid volume infuser
- Use crystalloid, colloid or blood once available
(especially after 1.5 L of fluid resuscitation)
- For large volume resuscitation, consider warming fluids
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