Advanced Trauma Life Support ATLS Student Course Manual 2018

PRIMARY SURVEY AND RESUSCITATION
151
traumatic amputation are at particularly high risk of lifethreatening
hemorrhage and may require application
of a tourniquet.
Assessment
Assess injured extremities for external bleeding, loss
of a previously palpable pulse, and changes in pulse
quality, Doppler tone, and ankle/brachial index. The
ankle/brachial index is determined by taking the
systolic blood pressure value at the ankle of the injured
leg and dividing it by the systolic blood pressure of
the uninjured arm. A cold, pale, pulseless extremity
indicates an interruption in arterial blood supply. A
rapidly expanding hematoma suggests a significant
vascular injury.
Management
A stepwise approach to controlling arterial bleeding
begins with manual pressure to the wound.
(Bleedingcontrol.org provides lay public training in
hemorrhage control.) A pressure dressing is then
applied, using a stack of gauze held in place by a
circumferential elastic bandage to concentrate pressure
over the injury. If bleeding persists, apply manual
pressure to the artery proximal to the injury. If bleeding
continues, consider applying a manual tourniquet
(such as a windlass device) or a pneumatic tourniquet
applied directly to the skin (n FIGURE 8-2).
Tighten the tourniquet until bleeding stops. A properly
applied tourniquet must occlude arterial inflow,
as occluding only the venous system can increase
hemorrhage and result in a swollen, cyanotic extremity.
A pneumatic tourniquet may require a pressure as high
n FIGURE 8-2 The judicious use of a tourniquet can be lifesaving
and/or limb-saving in the presence of ongoing hemorrhage.
as 250 mm Hg in an upper extremity and 400 mm Hg
in a lower extremity. Ensure that the time of tourniquet
application is documented. In these cases, immediate
surgical consultation is essential, and early transfer to
a trauma center should be considered.
If time to operative intervention is longer than 1
hour, a single attempt to deflate the tourniquet may
be considered in an otherwise stable patient. The risks
of tourniquet use increase with time; if a tourniquet
must remain in place for a prolonged period to save a
life, the choice of life over limb must be made.
The use of arteriography and other diagnostic tools
is indicated only in resuscitated patients who have no
hemodynamic abnormalities; other patients with clear
vascular injuries require urgent operation. If a major
arterial injury exists or is suspected, immediately consult
a surgeon skilled in vascular and extremity trauma.
Application of vascular clamps into bleeding open
wounds while the patient is in the ED is not advised,
unless a superficial vessel is clearly identified. If a
fracture is associated with an open hemorrhaging
wound, realign and splint it while a second person
applies direct pressure to the open wound. Joint
dislocations should be reduced, if possible; if the joint
cannot be reduced, emergency orthopedic intervention
may be required.
Amputation, a severe form of open fracture that results
in loss of an extremity, is a traumatic event for the
patient, both physically and emotionally. Patients with
traumatic amputation may benefit from tourniquet
application. They require consultation with and
intervention by a surgeon. Certain mangled extremity
injuries with prolonged ischemia, nerve injury, and
muscle damage may require amputation. Amputation
can be lifesaving in a patient with hemodynamic
abnormalities resulting from the injured extremity.
Although the potential for replantation should
be considered in an upper extremity, it must be
considered in conjunction with the patient’s other
injuries. A patient with multiple injuries who requires
intensive resuscitation and/or emergency surgery
for extremity or other injuries is not a candidate for
replantation. Replantation is usually performed on
patients with an isolated extremity injury. For the
required decision making and management, transport
patients with traumatic amputation of an upper
extremity to an appropriate surgical team skilled in
replantation procedures.
In such cases, thoroughly wash the amputated part
in isotonic solution (e.g., Ringer’s lactate) and wrap it
in moist sterile gauze. Then wrap the part in a similarly
moistened sterile towel, place in a plastic bag, and
transport with the patient in an insulated cooling
chest with crushed ice. Be careful not to freeze the
amputated part.
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