M2E Too! Mellick's Multimedia EduBlog

The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Wednesday, May 30, 2012

Tourniquets and Bleeding Varicose Veins

A large varicose vein ruptured on the back of this 37-year-old man’s lower leg. He had been afflicted with chronic lymphedema and large varicose veins for years. The bleeding was vigorous. A coworker created a makeshift tourniquet by wrapping his belt around the thigh. Unfortunately, the bleeding continued unabated for 20 minutes, and did not stop until the paramedics arrived and applied pressure dressings.

Nevertheless, the prehospital providers applauded the coworker’s efforts and went so far as to give him credit for saving his colleague’s life. Was that a correct attribution? Is it possible that the proximal tourniquet aggravated the bleeding? Observers said the blood continued to flow unabated from the ruptured varicose vein.

Is a bleeding varicose vein that big a deal? Should it be managed differently? Interestingly, multiple case reports in the literature describe patients who have died from a varicose vein hemorrhage. (1-7) Many of these are forensic investigations of deceased elderly patients found in their homes surrounded by pools of blood. One report described a deceased patient found with three makeshift tourniquets wrapped around his leg in an unsuccessful attempt to stop bleeding from a ruptured varicose vein. (1)

I want to make it clear that I am firm believer in the value of tourniquets. The military has the greatest experience with tourniquets, and the benefit of tourniquets for traumatic extremity bleeding is now well established. (8-13) But the military has also recognized that stemming blood flow with thigh tourniquets can be a challenge, and failures are not uncommon. (14) Two thigh tourniquets are frequently required to stop blood flow.

Very little discussion of the unique issues potentially associated with bleeding from varicose veins is available. A tourniquet can help stem the flow of blood, but if it is not properly or effectively applied (i.e., arterial flow completely stopped), it can enable continued hemorrhage. The layperson with a bleeding varicose vein will typically be elderly, and needs practical, easily remembered advice for stopping venous bleeding.

The simple application of direct pressure by the patient or a family member should be taught. A simultaneous 911 call for help should also be stressed. Discourage the well intentioned application of makeshift tourniquets for bleeding veins. Yes, tourniquets are effectively used in varicose vein surgery (15), but the controlled setting of an operating room with a supine patient and specifically designed tourniquets are a very different setting and situation. The obese elderly patient with well-endowed thighs who is bleeding from a spontaneously ruptured varicose vein is a much different patient and setting. Applying a tourniquet without rapid confirmation of success will be difficult because the venous system will continue to bleed until the leg is exsanguinated even after applying the tourniquet.

Based on the available evidence, here are some M2E Too! tips for the management of bleeding varicose veins. Health care providers should teach patients to manage bleeding by:

  1. Applying a pressure dressing directly over the bleeding vein and follow-up with a circumferential dressing.
  2. If a tourniquet is used for a bleeding varicose vein, apply tourniquets below the vein for venous control and directly above for control of arterial flow.
  3. Elevating the limb.

The instructions for the layperson should include:

  1. Apply direct pressure over the bleeding vein with a washcloth.
  2. Call 911.
  3. If possible, apply a constricting band directly over the bleeding vein and around the wash cloth.

Watch a video  of this patient’s treatment for varicose vein bleeding.


  1. Hejna P. A case of fatal spontaneous varicose vein rupture—An example of incorrect first aid. J Forensic Sci 2009;54(5):1146.
  2. Doberentz E, Hagemeier L, et al. Unattended fatal haemorrhage due to spontaneous peripheral varicose vein rupture—Two case reports. Forensic Sci Int 2011;20;206(1-3):e12-6.
  3. Evans GA, Evans DM, et al. Spontaneous fatal haemorrhage caused by varicose veins. Lancet 1973;15;2(7842):1359.
  4. Sauvageau A, Schellenberg M, et al. Bloodstain pattern analysis in a case of fatal varicose vein rupture. Am J Forensic Med Pathol 2007;28(1):35.
  5. Racette S, Sauvageau A. Unusual sudden death: Two case reports of hemorrhage by rupture of varicose veins. Am J Forensic Med Pathol 2005;26(3):294.
  6. Cittadini F, Albertacci G, et al. Unattended fatal hemorrhage caused by spontaneous rupture of a varicose vein. Am J Forensic Med Pathol 2008;29(1):92.
  7. Ampanozi G, Preiss U, et al. Fatal lower extremity varicose vein rupture. Leg Med (Tokyo). 2011;13(2):87.
  8. Beekley AC, Sebesta JA, et al; 31st Combat Support Hospital Research Group. Prehospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes. J Trauma 2008;64(2 Suppl):S28; discussion S37.
  9. Kragh JF Jr, Walters TJ, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 2008;64(2 Suppl):S38; discussion S49.
  10. Mabry RL. Tourniquet use on the battlefield. Mil Med 2006;171(5):352.
  11. Kragh JF Jr, Walters TJ, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009;249(1):1.
  12. Kragh JF Jr, O'Neill ML, et al. Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: Research, history, and reconciling advocates and abolitionists. Mil Med 2011;176(7):817.
  13. Kragh JF Jr, Littrel ML, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med 2011;41(6):590.
  14. Taylor DM, Vater GM, et al. An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage. J Trauma 2011;71(3):591.
  15. Rigby KA, Palfreyman SJ, et al. Surgery for varicose veins: Use of tourniquet. Cochrane Database Syst Rev 2002;(4):CD001486.