Here's one for y'all...
Middle age woman lacerated her left radial artery accidentally. Lost about a quart of blood, hand and forearm are wrapped in a blood soaked towel on arrival. Vitals are tachycardic but otherwise normal. The hand is hanging limp and you see spurting blood of an indeterminate bloody color. Laceration is deep and wide, messy.
What do you do?
From a
purely BLS standpoint, this one is easy. Continue having someone hold direct pressure until you've got your own hemorrhage control stuff ready to go. In this case, I'd apply fairly heavy direct pressure
and a tourniquet because I'm pretty certain direct pressure isn't going to do it on its own. Once the TK is in place and doing its job, I can then change the dressing out for my own dressing and bandaging and this will also ensure that I get a good look at the wound. If I don't take a look at it, there's no way I can describe it to the receiving facility. I note a limp hand and the spurting blood from earlier so I would expect that this isn't just a laceration to an artery, the wrist flexors are involved so that just bumps things up a notch in terms of complexity. This patient is going to need vascular surgery, possibly neurosurgery, and trauma surgery consults and to start reperfusion of the limb within a few hours or she'll certainly lose it. That means she's going to a trauma center, a level II or level I. If the "right" services are immediately available at a level III, I would consider transport there.
From an ALS standpoint, all I'd add to it is starting a saline lock or two, one of which should be an 18g, and attempt to provide pain control. Otherwise she's almost purely BLS. This is also a code-2 (non-RLS) transport. While she's at risk of losing a limb, that's several hours off. I would only upgrade transport to RLS or flight pickup only if the destination facility is too distant in terms of time that there might be benefit in a more rapid transport. Where I used to work, I'd hope the ambulance crew would fly her from the scene. Arranging even a priority 1 IFT can take an hour or more and ground transport can take upwards of 90 minutes, so with initial workups and the like, I'd much rather attempt to get a flight from the scene as I'd be shaving at least an hour, maybe as many as 3 hours from injury to arrival at a trauma center. We sometimes got lucky and managed to fly people out from the hospital within 30 minutes of arrival at the door...
Where I am now, there's nowhere in the County that I'd fly this patient from... RLS ground from some places, but no flights for her here. Why? There are 4 Trauma Centers that I can get her to any one of them within 30-40 minutes from anywhere in the county by ground. In certain places, I have a choice of 3, all within 30 minutes...
