Hemostasis is an essential step in wound management. Most commonly, bleeding is caused by lacerated subdermal plexus and superficial veins which can be controlled with pressure alone. When lacerations are especially deep, an artery may also be affected. In these situations, special maneuvers are often necessary to obtain adequate hemostasis.

Other than direct pressure, the first line therapy in attempting to obtain hemostasis is epinephrine mixed with local anesthetic. Lidocaine 1% with Epinephrine 1:100,000 is generally a good choice as this is easily obtained in the emergency department. Epinephrine can cause vasoconstriction of the affected vessels which can aid in hemostasis. There have not been worsened outcomes with the use of epinephrine in even digital lacerations despite common misconceptions.

There are several agents which can aid in hemostasis as well which are made of cellulose, gelatin, and collagen. These work by either expanding causing direct pressure on the source (gelatin) or by directly forming an artificial clot (collagen, cellulose).

If epinephrine and topical agents don’t work then oftentimes ligation is necessary. Ideally, one would be able to isolate the artery with a clamp and directly tie the short end with simple suture. We use 5-0 synthetic monofilament absorbable sutures (such as Monocryl™ or PDS™) in this case. Identifying the bleeding vessel is not always so simple, however, because arteries tend to retract proximally after laceration.

If you are unable to directly visualize the bleeding vessel it is appropriate to place a figure-of-eight stitch or horizontal mattress suture in the tissue surrounding the bleeding. You can ask someone to hold suction on the field so you can try to isolate the smallest area necessary to suture, as there is a theoretical risk of tissue necrosis given the direct compression of surrounding tissue.

For scalp lacerations, commercial clips are available that can be placed (Raney Clips). These are commonly used in the OR by neurosurgeons to maintain hemostasis in their field.

For more information on laceration repair, check out http://www.lacerationrepair.com.

Tichter AM, Carter WA, Stone SC. Wound Preparation. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=693&Sectionid=45915370. Accessed October 08, 2015.