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Life-threatening external haemorrhage from a limb injury — MRCEM SBA MCQ

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EasyTraumaLife-threatening external haemorrhage from a limb injuryMRCEM SBA

A 32-year-old man is brought to the emergency department 40 minutes after his forearm was caught in industrial machinery. He has a deep forearm wound with brisk bleeding. A clinician has maintained firm direct pressure with a dressing throughout handover, but blood continues to flow rapidly through it. His heart rate is 132 beats/min and blood pressure is 86/52 mmHg. No other bleeding source is apparent. Blood-component resuscitation is being started, and a vascular surgeon has been called. What is the most appropriate immediate intervention to control the external haemorrhage?

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Correct answer: B — Apply a tourniquet proximal to the wound

The persistent rapid bleeding despite sustained direct pressure, together with hypotension and tachycardia, identifies life-threatening haemorrhage from a major limb injury. NICE recommends a tourniquet when direct pressure has failed to control life-threatening bleeding from major limb trauma. Applying it proximal to the wound provides immediate external haemorrhage control while resuscitation and definitive surgical care proceed. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) A is attractive because wound packing can help control bleeding, particularly where a tourniquet cannot be applied, but it is not the best next measure for this compressible limb injury after direct pressure has failed. C repeats an approach that is already failing. D is an appropriate early adjunct for major trauma with active bleeding, but tranexamic acid does not replace immediate mechanical control of this visible haemorrhage. E may provide definitive control, but transferring the patient without first attempting the immediately available tourniquet would leave substantial bleeding uncontrolled during the delay. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations))

Reference: Major trauma: assessment and initial management — Recommendations (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations Major trauma: assessment and initial management — Recommendations (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations