Blood squirting everywhere!

Lady attends urgent care centre with arterial bleed

Typically 5 minutes before I am meant to finish my 12 hour shift a lady comes in with a significant bleed from her left wrist having cut it on a broken glass in the dishwasher at work. She said she works in a restaurant and the blood was shooting across the room so they rushed her straight over.

The triage nurse pressed the alarm button and we all rushed in to help. The lady was holding several rags and trying to apply pressure to the whole wrist, but the wound was still bleeding profusely.

We elevated her arm and continued to apply pressure whilst transferring her onto a trolley to take a better look. It was still actively bleeding but not shooting across the room any more. Fingers looked pink and she had a good capillary refill time (less than 2 seconds). The wound was close to but not over the radial artery. She had no loss of sensation to fingers or hand so I could confidently say at present she was neurovascular intact.

My colleague brought over some 1% lidocaine and I knew roughly where the bleeding was coming from so I installed the lidocaine generously around the 6cm wound.

The bleeding appeared to stop after this, as the addition of extra fluid to the subcutaneous space must have created some compression over the bleeding vessel.

I put 6 sutures in and the wound appeared to be closed well. I then proceded to check for any underlying tendon injury as this was likely at the palmer aspect of the wrist. She had good flexion and extension of the wrist and each finger with normal power and range of movement.

I felt after lots of movement and a period of observation that I was now safe to discharge her, so I applied a dressing and allowed her to go home with wound care advice.

After a few minutes she came running back into the room blood shooting out of the dressing again. Having her arm down for a while had started the bleeding again. I was now able to see exactly where the blood was pumping out from. We applied direct pressure directly over the small arteriole that was bleeding at the top of the wound with one finger as this is much more effective than trying to squeeze the whole wrist.

The bleeding site was an area I had not sutured as the other sutures were holding it together. The local anesthetic was still active so I simply applied another suture over the bleeding site then a matress suture over it to apply direct pressure and stop it from bleeding again. We dressed it again and put the arm in a high arm sling.

The horizontal matress suture is done by going through the skin as normal but rather than tying the knot you step across and go back through to the other side again then tye the knot which creates a little compression to the blood vessels in that area. It is also very useful for highly tensile areas as it meets the need for high tensile strength. The disadvantages of this are if it is done too tightly it can create tissue ischaemia so needs to be done with caution.

Other considerations of these types of deep wounds are antibiotic cover and Tetanus boosters, however this wound was created by a clean glass out of the dishwasher so this was felt unnecessary.

If there was a vascular compromise- fingers/hand had a delayed capillary refill time, a large artery was ruptured (radius/ulnar), fingers looked blue/grey/dusky then I would have managed this by applying direct pressure only over the artery that was bleeding, and wait for an ambulance to take her to a centre with Vascular surgeons on standby.

If there was a los of sensation and I suspected a nerve injury, or loss of power/strength/movement and I suspected a tendon injury then she would have required an Orthopaedic/ Plastics review.

As it was I was happy with the nerves, vessels and tendons but after rushing the closure due to active bleeding I felt it wise to refer to the Fracture Clinic as an out-patient for them to review and ensure nothing was missed.