Hemostasis
Wounds often bleed actively, particularly during assessment and
exploration. In addition to the problem of adequate wound visualization with
active bleeding, hematomas can cause an increase in the rate of wound infection
and can delay the healing process.
The simplest and most
effective way to stop bleeding is to apply direct pressure to the wound with
handheld surgical 4 × 4 sponges. Continuous pressure has to be applied for a
minimum of 10 minutes. Because of the time involved, sponges secured with an
Ace wrap can be substituted if the wound is in an anatomic area that lends
itself to wrapping.
An epinephrine-moistened (1:100,000) sponge applied, also with
pressure, to the wound for 5 minutes often suffices in cases in which direct
pressure fails. Epinephrine is contraindicated, however, for use on the
fingers, toes, ears, penis, and tip of the nose. Packing the wound with topical
hemostatic agents, such as Gelfoam, Surgicel, and others, is another hemostatic
strategy. These agents are useful for persistent oozing or minor capillary
bleeding. Arterial “pumpers,” even small ones, can wash these agents out of the
wound. Use of these agents should be considered only if all other methods fail.
These products can have adverse effects such as interference with suture
closure and foreign-body reactions.
Direct clamping with a
hemostat and a hand-tied ligature with an absorbable suture is reserved for
larger, single-bleeding vessels that can be directly visualized under optimal
conditions of lighting, instrument preparation, and operator comfort. Because
blood vessels often travel with nerves and arteries, “blind” clamping in a
bleeding wound, in the hope of grasping the bleeder, is strongly discouraged.
Unnecessary tissue damage can occur, particularly in areas where important
structures such as nerves and tendons are likely to be found.
Tourniquet Hemostasis
Definitive hemostasis of the extremity can be achieved by the use
of tourniquets. Strict observance of proper technique and the time limits of
application is imperative. Complications of tourniquets include ischemia of the
extremity, compression damage of blood vessels and nerves, and jeopardy to
marginally viable tissues.
Technique for Large-Extremity Tourniquet
Application
Before placing a single-cuff sphygmomanometer, the extremity is
elevated for approximately 1 minute. The
cuff is inflated to a pressure higher than the patient’s systolic pressure or
to a point when the bleeding stops. However, the pressure should not exceed 250
mm Hg. The clinician clamps the cuff tubing with a hemostat instead of closing
the air release valve to prevent slow leakage of air and to ensure a rapid
release method if needed. Patient discomfort becomes apparent by 30 to 45
minutes of cuff time.11 The maximal cuff inflation time is 2
hours, although a limit of 30 to 60 minutes is recommended to ensure patient
safety.
Technique for Digital Tourniquet
Application
A digital tourniquet is often
used to repair finger wounds. Lacerated fingers can bleed profusely and
visualization is difficult. The clinician unfolds a 4 × 4 gauze sponge to its
fullest length and folds it in half so it appears to be an 8-inch band. The
band is moistened with saline. The clinician wraps the band firmly around the
finger, starting at the tip and proceeding to the base. A Penrose drain is
stretched around the base of the finger in a slinglike fashion, and a hemostat
is applied to the drain to form a tight “ring” at the base of the finger. The
sponge wrapping is removed. A Penrose drain also can be substituted for the
gauze sponge wrap. A digital anesthetic block is recommended before applying
the tourniquet.
There are preformed disposable tourniquets (Tourni-Cot, T-Ring)
that “roll” or slide onto the finger and exsanguinate it before coming to rest
at the digit base.After use, they can be easily removed. These tourniquets are
easier to apply and are effective in most cases in which the digit
circumference can accommodate them. The maximal allowable tourniquet time for a
finger is 20 to 30 minutes.
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