55.2 Definitive treatment for severe arterial bleeding

If you have temporarily controlled bleeding by the methods in the previous section, you will now have to explore a patient’s wound and tie or try to repair his injured vessel, depending upon its collateral circulation. You can usually safely tie: (1) The smaller arteries below his elbow and his knee. (2) His profunda femoris artery. (3) His internal iliac artery. (4) His subclavian artery. But his limb may become gangrenous, especially if he is old, if you tie: (1) his axillary artery, (2) his brachial artery, (3) his femoral artery above the origin of its profunda branch, or (4) his popliteal artery. Try to repair these if you can, by the methods in Section 55.6.

You may have great difficulty finding his injured artery, because his wound may look just like so much meat, and his artery may be contracted and very thin. To find it you may have to release the tourniquet or the proximal clamp, and look for bleeding, or feel for pulsation.

A LIMB ARTERY BLEEDS SEVERELY

IMMEDIATE TREATMENT

Take the patient to the theatre, and make sure you have good light. Place a pneumatic tourniquet (3.8) loosely round his injured limb high above his wound so that you can inflate it in a hurry later if you need to. Anaesthetize and drape him. Drape any site you may need to take a graft from. Gently remove the dressings, and explore his wound.

If most bleeding has stopped, you will be able to explore the wound without further trouble.

If his wound bleeds profusely, blow up the tourniquet while you explore it. Try to find the torn artery. Try to apply an arterial clamp above the tear.

If you cannot find the tear, enlarge the wound if necessary, or release the proximal clamp, and feel for pulsation.

If his wound is so high up his limb that you cannot apply a tourniquet or a clamp, be prepared to expose and temporarily clamp his subclavian (3.4) or external iliac artery (3.5).

When you have controlled the bleeding and explored the patient’s wound, you will have to decide whether to tie his injured artery or to try to repair it. Below his elbow and knee tie it. Above them try to repair it (55.6).

ALTERNATIVELY, blow up the tourniquet from the start. If you don’t find the vessel (unusual), complete the wound toilet and any other repairs, then deflate the tourniquet and look for bleeding from the injured artery.