Author: Josh Bucher, MD (EM Attending Physician and EMS Fellow, Morristown Medical Center) // Edited by: Jennifer Robertson, MD, MSEd, Alex Koyfman, MD (@EMHighAK)

Case:

A 27-year-old male with no medical problems presents to the emergency department (ED) with a chief complaint of a finger amputation. He reports he was using a circular saw when his hand slipped and the saw accidentally cut his finger. He is complaining of severe pain and a hand deformity. On exam, his left third digit has an obvious amputation at the proximal interphalangeal (PIP) joint, and the distal portion of the finger is mangled beyond repair. This site also demonstrates pulsatile and venous bleeding, both of which have not stopped with direct pressure.

Hemorrhage control:

Hemorrhage control is an important aspect of both the treatment of and evaluation of any wound. Wounds that are actively bleeding require treatment. In addition, persistent hemorrhage can make the exam very difficult, such as assessing for full tendon function and visualization.

In a 2015 article, Thai et al. published a set of guidelines on hemorrhage control of forearm arterial lacerations. This is the first set of published, evidence-based guidelines on this topic.1

Hemorrhage control should first be attempted with direct pressure. All wounds deserve an attempt with direct pressure for 5 – 15 minutes.2 In the event that 15 minutes of direct pressure does not work, other steps, as noted below, can be attempted.

First, a tourniquet can be used to attain a bloodless field. There are commercially available tourniquets made specifically for the finger, such as the T-Ring™ (http://pmedcorp.com/). This can allow you to locate a specific area of bleeding and then attempt hemorrhage control of a specific vessel. Academic Life in Emergency Medicine has a blog posting (http://www.aliem.com/trick-of-trade-hemostasis-of-finger/) and video (https://www.youtube.com/watch?v=QuogjNsjOag) about a simple technique called a “glove tourniquet,” which can be done with a simple exam glove. Both the T-Ring or glove tourniquet can be employed to attain a bloodless field.

A simple blood pressure cuff can also be used to achieve hemorrhage control. The cuff can be inflated up to 250 mm Hg in adults and 100 – 200 mm Hg in children.3 This can help achieve a bloodless field to locate areas of bleeding that require treatment. Likewise, a commercial tourniquet, such as the Combat Tourniquet™ (C-A-T; http://combattourniquet.com/), can be used to allow a bloodless field.

After the field is bloodless, care should be taken to inspect all underlying structures, including tendons, to assess if repair is needed. Furthermore, any tourniquet can be loosened to help visualize bleeding areas or vessels. When a bleeding vessel or area is located, there are several methods to repair it and stop the bleeding.

Wounds can be anesthetized with an anesthetic such as lidocaine and epinephrine. Epinephrine works by constricting blood vessels through alpha receptor stimulation. If hemostasis is not achieved, primary closure of the wound may stop the bleeding. For wounds of the hand and fingers, 5-0 or 6-0 suture size should ideally be utilized for best wound healing.4 The fear of causing digital ischemia with epinephrine is greatly exaggerated and studies have not shown any significant adverse events from using epinephrine in hand or digital wound repair.6,7

There are other methods for wound hemostasis if the above techniques are inadequate or you want to avoid sutures. Topical tranexamic acid (TXA) has been demonstrated in multiple studies to be effective in hemorrhage control. An excellent Cochrane review article by Ker et al. evaluated these studies and their positive findings of topical TXA in the cessation bleeding.5 Most of the studies were conducted in the operating room for elective surgeries, but the data can be extrapolated towards bleeding from trauma, as surgical incisions are similar to local tissue trauma.

Another option is topical thrombin. Topical thrombin is a biologic agent that cleaves fibrin into fibrinogen which leads to hemostasis. There are many biologic brand name thrombin agents that are readily available. Thrombin has been proven to be effective for surgical hemostasis, and its use can be extrapolated to the ED for traumatic wounds.8

Through any combination of the above methods, hemostasis can be achieved readily.

Case Conclusion:

Using an exam glove, a finger tourniquet is placed on the patient, and luckily, the bleeding stops. The wound is repaired with sutures and lidocaine with epinephrine is used for analgesia. The patient is discharged without complications.

References / Further Reading

Thai JN, Pacheco JA, Margolis DS, et al. Evidence-based Comprehensive Approach to Forearm Arterial Laceration. The western journal of emergency medicine. 2015;16(7):1127-1134. Sharif MA Wyatt MG. Vascular trauma. Surgery. 2012;30(8):5. Kragh JF, Jr., Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. The Journal of emergency medicine. 2011;41(6):590-597. Abraham MK, Oh JS. Recent Advances in Wound Care. Trauma Reports. 2010;11(4). Ker K, Beecher D, Roberts I. Topical application of tranexamic acid for the reduction of bleeding. The Cochrane database of systematic reviews. 2013;7:CD010562. Chowdhry S, Seidenstricker L, Cooney D, et al. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plastic and Reconstructive Surgery 2010; 126 (6): 2031-34. Firoz B, Davis N, Goldberg LH. Local anesthesia using buffered 0.5% lidocaine with 1:200,000 epinephrine for tumors of the digits treated with Mohs micrographic surgery. Journal of the American Academy of Dermatology 2009; 61 (4): 639-43. Lew WK, Weaver FA. Clinical use of topical thrombin as a surgical hemostat. Biologics. 2008;2(4):593-599.