Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVIII: Vascular Injuries
United States Department of Defense
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In most instances, hemorrhage from peripheral arterial an venous injuries can be controlled by a wellplaced compression bandage If a tourniquet must be placed as a lifesaving measure, it should be as distal as possible on the extremity and it should be tight enough to control both arterial and venous hemorrhage. Once applied, for control of arterial hemorrhage, the tourniquet should be left in place until removed by a medical officer, usually at the hospital in an operating room.
At the time of operation, direct pressure over the traumatized artery both proximally and distally by an assistant usually provides adequate temporary control of hemorrhage until direct control can be obtained with vascular clamps. An anatomical approach to provide adequate exposure to the injured vessels should be used regardless of the location of the wound. In large wounds, the ends of the artery may already be visible In such cases, the severed ends can be controlled directly with clamps. When the vessel ends are not exposed, proximal and distal control is usually obtained through normal tissue planes by application of umbilical tapes, silastic loops, or vascular clamps. Intraluminal control using balloon-tipped catheters is also effective and is particularly useful in the repair of false aneurysms. These devices, originally developed and field tested during the Korean War, are available in combat zone hospitals.
Noncrushing vascular clamps should be used to control hemorrhage If crushing clamps were placed under emergency conditions, they should be replaced with noncrushing clamps, and the crushed portion of artery should be resected prior to definitive repair. If noncrushing clamps are not available, atraumatic control can be achieved with double-looped cotton or silastic tourniquets or with Rummell tourniquets.
If an extremity arterial injury is distal enough to permit the use of a pneumatic tourniquet, a great deal of time and blood loss can be saved during exposure and control of the injured vessel. The tourniquet should not be inflated until it is actually needed, and it should be deflated as soon as the injured vessel is under control to allow flow through collaterals.
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