Varicose Veins

Varicose veins are the superficial veins in your legs that return blood to the heart. (They can appear in other places, but they are most commonly in the legs.) Some people don’t have any, some have a few, and some have a lot. Occasionally, they bleed. And they can bleed a lot!

The most important thing to do is to put direct pressure on the bleeding. Most often, literally putting a finger on it stops the bleeding. They are not under high pressure like arteries. This doesn’t require someone kneeling on your leg like the junctional arterial bleeding in the movie Black Hawk Down. This is more like putting your finger in a dike to stop a steady but low-pressure water leak.

What I see in practice is patients who come to the ER after they have left a bloody mess all over the floor and bystanders have wrapped the wound with towels, rags, or paper towels. Occasionally EMS does the same thing. None of these things solve the problem—they just cover it up.

I had a patient who had an abdominal hernia with varicose veins and one of them bled. He called 911 but then drove himself to the ER with towels wrapped around his abdomen. Dispatch called the ER to advise us that someone “bleeding from their abdomen” was on the way. In the small ER where I was working, that got everyone pretty excited. We presumed something like a chainsaw injury, table saw, or high-speed grinding wheel—something actually serious.

The patient arrived covered in blood and dripping blood from his truck to the ER, only for me to discover it was a varicose vein that was bleeding. I solved it with a finger as explained above. The end. There was nothing heroic. Packing a bunch of rags or towels on something like this soaks up blood, but it does not actually put pressure on the thing that is bleeding.

I’ve seen the same thing happen with head wounds, most often in the case where an elderly person falls and cuts their head. Bystanders or EMS will wrap their head in a turban worthy of admiration, but the wound is still bleeding underneath. Elderly patients who fall with a head wound very often get expedited to the CT scanner to rule out a head bleed or C-spine fracture. Occasionally, the still-bleeding head wound is not discovered until much later when the dressings are removed and the puddle of blood is found. This is not ideal.

In the case of varicose veins, there’s not much to do in the ER, especially if it has stopped bleeding. Can I make it worse by trying to do some invasive wound care? Yes. Regardless of what we do, is there a chance it will bleed again? Also yes. The veins are very superficial and most often occur in patients who have years of damaged vessels from a whole host of metabolic diseases. The veins aren’t getting healthier during the time it takes for an ER visit. The anatomy of the veins is not changeable—they remain close to the surface of the skin and at risk for bleeding from minor trauma or even sometimes spontaneously.

Sometimes we put tissue adhesive on them. Putting sutures in them risks causing more damage to tissue that is already fragile. Usually we just put a pressure dressing over the site of bleeding and monitor the patient for a while. This is different from a fluffy dressing meant to soak up blood. A pressure dressing, as the name implies, puts pressure on the actual area that is bleeding. Most commonly this is a gauze pad folded on itself to be thicker and firmer, then wrapped with Coban or an ACE wrap or some kind of elastic tape.

My takeaway: When things bleed, put direct pressure on them. Don’t hide the wound with dressings and towels. Very often a finger is all you need.