Management of the Mangled Extremity

Annotation for Point A

Control of ongoing blood loss should be initiated on arrival. Direct control of ongoing hemorrhage via manual pressure or a pressure dressing should be undertaken expeditiously. If ongoing life-threatening hemorrhage cannot be controlled through the use of direct pressure, early use of tourniquet may prove life saving in the prevention of serious additional bleeding from the limb.^15,16 Tourniquet use will be most successful in distal limb injuries. It should be used as a temporizing measure to aid resuscitation and allow rapid diagnostics, but should be kept to the shortest duration possible to minimize the possibility of worsening ischemia. Operative tourniquet systems, commonly used during operative orthopedic procedures, are preferable to field tourniquets whenever available. It is advisable to provide appropriate inflation of these pneumatic devices, because pressures below systolic may substantially increase venous pressure (creating a “venous tourniquet”), worsen subsequent extremity swelling, and potentially increase pressure within the muscular compartments of the extremity without affecting the desired occlusion of arterial hemorrhage.

Level of Supporting Evidence: Level 4