Angle grinder kickback: a spurting wound and a casualty on warfarin
14:20 in a fabrication workshop. A 58-year-old cutter has taken an angle grinder kickback across his left forearm. There is a deep laceration about 8 cm long, and bright red blood is spurting from it in time with his heartbeat, pooling quickly on the floor. A 3 cm fragment of cutting disc is embedded at the wound edge. He is pale, sweating and anxious, says he feels cold and dizzy, and his radial pulse feels fast and thready at around 120. He tells you he takes warfarin for a mechanical heart valve. He is sitting on a stool, leaning forward, and asks for water. The nearest clinic is 7 km away; the ambulance ETA is 18 minutes. The first aid kit contains nitrile gloves, assorted dressings, bandages and a triangular bandage - no tourniquet and no haemostatic dressing. Two colleagues are standing and watching.
1. What are your priorities in the first three minutes, and why in that order?
Read the worked answer
This is catastrophic arterial bleeding with early shock. The order is: protect yourself, stop or slow the bleeding, get help moving, treat for shock.
- Gloves on first - you are about to be covered in another person's blood, and once you start you cannot stop to put them on.
- Direct pressure immediately. Apply the thickest sterile dressing in the kit firmly over the wound and press hard with both hands, or with a knee if you need your hands free. Arterial bleeding is controlled by pressure at the point of bleeding, not by elevation alone. Do not press on the embedded fragment.
- Get the ambulance moving now, before you have finished dressing the wound. The call-taker needs to know: severe arterial bleed, on warfarin, signs of shock, 18-minute ETA. Ask them for the nearest trauma-capable destination - a 7 km clinic may not be able to manage this.
- Treat the shock. Lay him down, keep him warm, raise his legs if there is no leg injury, reassure him and keep him still. Loss of circulating volume is what will kill him, not the wound itself.
- Delegate: one colleague to the gate, one to clear the area and find the accident book.
Seconds spent deciding who does what are seconds of blood loss.
2. How do you deal with the embedded fragment and the bleeding with the equipment available, and when would you improvise a tourniquet?
Read the worked answer
Leave the fragment where it is. Pulling it out can release the vessel wall it is partly plugging and turn a controlled leak into an uncontrolled one, and it may be the only thing tamponading the artery. Pack dressings on either side of it and bandage firmly over them, building pressure around the object rather than on top of it.
Apply a firm pressure bandage over the original dressing, then check the fingers: colour, warmth, capillary refill and sensation. If they become pale, cold or numb, the bandage is too tight and must be loosened slightly. Once the dressing is on, do not lift it to "see if it has stopped" - that strips the forming clot, and with warfarin the clot is fragile and slow to form. Add more dressings on top if blood strikes through.
Improvise a tourniquet only if bleeding is life-threatening and not controlled by firm direct pressure and a pressure bandage - for example, blood still spurting after two to three minutes of correct pressure. Use the triangular bandage as a wide band about 5–7 cm above the wound, never over a joint, with a pen or screwdriver as a windlass. Tighten until the bleeding stops, record the exact time on the skin or a note, and do not loosen it. A tourniquet is painful and carries risk, which is why it is the fallback, not the first move.
3. He asks for water and wants to sit up. How do you manage him and monitor him until the ambulance arrives?
Read the worked answer
Refuse the water, gently but clearly. He may need surgery and a general anaesthetic, and any fluid in the stomach increases the risk of vomiting and aspiration. Offer only to wet his lips with a damp swab if he is thirsty - thirst is itself a symptom of shock and will not be fixed by drinking.
Do not let him sit up. Sitting increases pooling of blood in the legs and reduces venous return to a heart that is already under-filled. Lay him flat with his legs raised about 20–30 cm, provided there is no suspected leg or pelvic injury, and cover him with a foil blanket or coats. Keep the environment quiet and give him short, factual reassurance - anxiety increases heart rate and worsens the shock picture.
Monitor and record every few minutes:
- responsiveness (AVPU) and whether he is becoming drowsy or confused;
- breathing rate and depth;
- radial pulse rate and strength - a pulse that becomes impalpable at the wrist is a late and ominous sign;
- skin colour, temperature and capillary refill;
- the time each dressing was applied and whether it is striking through.
Be ready to move to CPR if he becomes unresponsive and stops breathing normally. Hand over the mechanism, the anticoagulant, the timings of pressure and any tourniquet, and his deterioration trend.