Classification of bleeding
To correctly select a method of hemostasis, it is necessary to accurately determine the nature of the blood loss. In clinical practice, bleeding is classified according to several key features.
- By type of damaged vessel: arterial, venous, capillary, parenchymatous, and mixed bleeding are distinguished.
- By localization (direction of blood outflow):
- External — blood pours directly into the external environment through a defect in the skin.
- Internal — the accumulation of escaped blood occurs in closed body cavities, internal organs, or within tissue thickness.
- Mixed — combines the features of both external and internal bleeding.
- By time (stage of care): hemostasis is divided into temporary and definitive.
Methods of temporary hemostasis
Temporary hemostasis is necessary for the emergency cessation of blood loss prior to full surgical intervention, and is also actively used by surgeons directly in the surgical wound to visualize anatomical structures.
- Pressure bandage. Effective for venous, capillary injuries, and mixed bleeding from small wounds. In some cases, a properly applied pressure bandage can lead to definitive hemostasis.
- Rubber tourniquet. Used exclusively for massive arterial bleeding on the limbs. The most important rule: the tourniquet is always applied proximal (above) to the injury site.
- Cessation in the surgical wound. The surgeon can temporarily compress the bleeding area with a finger or gauze sponge. However, the most frequent, convenient, and reliable method is the application of a special hemostatic clamp to the damaged vessel.
Methods of definitive hemostasis
The goal of this stage is to reliably and permanently close the vascular wall defect, preventing recurrent bleeding. The choice of a specific method depends on the caliber of the vessel, its location, and the physical properties of the surrounding tissues.
- Vessel ligation. Performed primarily directly at the injury site, somewhat less frequently — along the course of the vessel. The technique consists of grasping the vessel with a clamp followed by ligating it with a ligature. Silk, catgut, or synthetic threads (capron, lavsan, dacron) are used as material.
- Tissue suturing. The method of choice for rigid (dense) tissues where it is technically impossible to isolate the vessel and apply a clamp. In such a situation, the bleeding area is sutured with a surgical thread directly through the thickness of the tissue.
- Treatment of the mesentery of the intestine or omentum. For reliable hemostasis in these areas, two clamps are applied in parallel, the tissue between them is transected, after which the formed segments are ligated together with the blood vessels running inside them.
- Diathermocoagulation (electrosurgical knife). Widely used to stop bleeding from small and medium-sized vessels. This method significantly saves operating time. It is especially advisable and effective in operations on parenchymatous organs (liver, lungs, brain).
- Vascular suture. Vital in trauma to large main vessels, when the cessation of blood flow through them is unacceptable. Performed manually or mechanically. An alternative option in the form of ligation of a large vessel is extremely rarely used in modern surgery.
Briefly: answers to topical questions
What methods of definitive hemostasis exist?
Definitive hemostasis is classified into mechanical, physical, chemical, biological, and combined methods. The main methods include:
- Vessel ligation — grasping the vessel with a clamp and tying with a ligature.
- Tissue suturing — used in rigid tissues, the bleeding area is sutured through the thickness of the tissue.
- Ligation in the intestinal mesentery or omentum — application of two clamps and ligation of tissue along with vessels.
- Diathermocoagulation — using an electrosurgical knife for small and medium-sized vessels.
- Vascular suture — used in case of damage to large vessels (manual or mechanical).
What types of hemostatic clamps are used for temporary hemostasis in the wound?
Straight and curved hemostatic clamps are used for temporary hemostasis in the wound. The main types of instruments:
- Kocher clamp — has teeth at the ends of the jaws, grasps vessels along with surrounding tissues for firm fixation.
- Billroth clamp (or Pean) — has cross-striations on the jaws, without teeth, acts less traumatically.
- Halsted clamp ("mosquito") — a small clamp for stopping bleeding from small vessels.
- Dissector (Fedorov clamp) — used to pass a ligature under a vessel.
- Vascular clamp ("Bulldog", Blalock) — for temporary clamping of blood flow without injuring the wall.
At which anatomical points is digital compression of arteries performed?
Digital compression of arteries is performed at points where the vessel is located superficially and close to the bone. Anatomical landmarks for compression:
- Carotid artery (a. carotid communis) — against the carotid tubercle of the transverse process of the VI cervical vertebra.
- Subclavian artery (a. subclavia) — against the 1st rib.
- Brachial artery (a. brachialis) — against the humerus on the inner surface of the shoulder.
- Femoral artery (a. femoralis) — against the pubic bone (os pubis).
- Facial artery (a. facialis) — against the lower border of the mandible.
- Temporal artery (a. temporalis) — against the temporal bone in front of the tragus of the ear.
- Axillary artery (a. axillaris) — against the head of the humerus in the axilla.
What types of manual vascular sutures exist?
Manual vascular sutures are used in trauma to large vessels to restore the patency of main arteries while ensuring high tightness. The following main options for manual suture placement are distinguished:
- Interrupted nodal sutures (Carrel method).
- Single U-shaped sutures.
- Continuous overhand suture.
- Continuous U-shaped suture.
What biological preparations are used for local hemostasis?
Special biological preparations are used for the local cessation of capillary and parenchymatous bleeding. They include:
- Thrombin — a powder derived from donor blood plasma (used topically only).
- Hemostatic sponges — collagen and gelatin (serve as a mechanical matrix for blood coagulation).
- Fibrin film.
- Biological antiseptic tampon.
- Hemostatic gauze ("Oxycelodex").
- Gauze impregnated with preparations — thrombin solution, hemophobin, epsilon-aminocaproic acid, or "Caprofer".
What are the rules for applying a tourniquet for arterial bleeding?
When managing arterial bleeding on the limbs, the rules for applying a tourniquet must be strictly observed. The basic requirements include:
- The tourniquet is applied above the injury site (proximal to it).
- Before application, the injured limb is elevated.
- The tourniquet is applied as close to the injury site as possible.
- A soft padding must be placed under the tourniquet.
Tourniquet rule: in case of arterial bleeding on the limbs, a rubber tourniquet is always applied ABOVE (proximal to) the injury site.
Class and exam questions
In what cases is tissue transfixation used instead of conventional ligation?
Transfixing through tissue thickness is used in rigid tissues where their density makes it impossible to grasp a bleeding vessel with a surgical clamp.
When is it most appropriate to use diathermy?
An electrosurgical knife is optimal for rapid arrest of bleeding from small and medium-sized vessels. This method is particularly recommended for operations on parenchymal organs such as the liver, lungs, and brain.
What do surgeons do in case of major trunk vessel injury?
The main method of definitive hemostasis in such cases is the placement of a manual or mechanical vascular suture. Simple ligation of a major vessel is extremely rare due to the risk of tissue ischemia.
Which method of temporary hemostasis is most frequently used directly in the surgical wound?
During surgery, temporary hemostasis is most commonly achieved by applying a hemostatic clamp directly to the damaged vessel.
What else to study on this topic
- Technique of rubber tourniquet application and time monitoring
- Properties of suture materials: silk, catgut, nylon, lavsan, Dacron
- Differences between manual and mechanical vascular sutures
- Anatomical rationale for vessel ligation in continuity
- Features of diathermy on parenchymal organs
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