Evaluation and Management of Peripheral
Annotation for Point B
In the field or in the emergency center (EC), hemorrhage from the injured peripheral vessel is controlled by direct pressure on the wound using a finger or pressure dressing or compression of the proximal artery (‘‘pressure point’’). Application of a proximal tourniquet on the injured extremity to control hemorrhage is now widely practiced in current military conflicts. Depending on local prejudices, experience, and transit times, it is likely that the use of tourniquets by civilian emergency medical services will increase in the future.5-9 Tourniquets should be removed in the EC as soon as possible by the trauma surgeon, however, as digital control is usually successful and eliminates complete limb ischemia. The intravenous administration of heparin (100 U/kg) to the injured patient in the EC is appropriate when there is a peripheral arterial occlusion resulting in distal ‘‘cold ischemia’’ (inadequate or no collateral flow).10 Contraindications include near exsanguination (coagulopathy may ensue), a traumatic brain injury, a traumatic false aneurysm of a torso artery, or computed tomographic documentation of an injury that has the potential for cavitary hemorrhage.