View Full Version : Tourniquet Application (Combat and Legality)
Curious to hear from some EMT and above types on this, especially anybody with first hand expirience.
I am military with basic medical training. Aside from the standard B.S. self aid buddy care I have been through the "old" Combat Lifesaver where you actually did saline locks and such, and (wait for it) basic life saver (CPR and Defibrillator). Not looking for cool guy points, just giving you my (brief) background.
My question(s) are about the application of tourniquets because I have conflicting training. SABC teaches (or at least it did in BMT a few years ago) that a tourniquet is a last resort, only to be used after pressure, dressing, blah blah blah has been applied and the alternative is to bleed out. The limb will most likely be lost, etc... This belief seems to still be prevalent amongst grunt types.
CLS, (an Army course), taught to just go the tourniquet in a combat situation because it was the fastest, most effective way to treat bleeding. I was also told that a tourniquet is not the fast lane to amputation and that as long as the casualty gets to "real" medics in 6-8 hours the tourniquet will not be an issue in that regard.
So my combat application question is which one is correct, or neither?
Which brings up a civilian use question, what are the legal issues with tourniquets? I carry a tourniquet on my kit where I can get to it with either arm, should it stay there in a civilian scenario?
Combat use - do not be afraid of using tourniquets (TQs) as there is no real risk that it will be the determining factor of whether the patient loses a limb or not - but not using one could well be the determining factor on whether he survives or not. When in doubt, especially in the rapid-evac combat model of today, use the TQ.
In the civilian world, the rules depend on what a "reasonable person" would within the limits of their training. While many civilian protocols still preach the old scare stories about TQ use, the bottom line is that if you cannot stop the bleeding any other way, the TQ is the treatment method of choice. As long as you can show that you have been trained to use TQs, and that you attempted to stop the bleeding using other methods before resorting to the TQ, you will be fine.
When I taught EMT as a Lab Instructor, we used to remind students that all 50 states have "good Samaritan" protections, and that as long as you do not exceed your limits of training, you may well be sued (anyone can sue anyone else for anything) but that you will not lose - and probably won't even go to trial.
Bottom line - TQs save lives in cases of serious extremity bleeds. Use them as needed in conjunction with your training. Don't be afraid of them, any more than you are afraid of direct pressure or pressure dressings.
In my paramedic class a couple years ago we were taught that if the circumstance permits you should go straight to a tourny to stop immediately life threatening bleeding. We were told new studies showed that as long as the tourney wasnt on longer than 2 hours it didnt cause any damage to the limb. Its hard to tell if a tourney use means more amputations because of the nature of the injury might warrant amputation with or without a tourney.
As far as good samaritan laws in ohio it only covers non trained personel. So as a paramedic im not covered.
From a tactical standpoint, it is "X"ABC
X - Get off the X, apply T to stop life threatening bleeding (we are talking arterial bleeds...).
A, B, C
Like others have mentioned before, surgery techniques have evolved to the point were limbs can be saved after several hours of T use.
If you're military and not a Whiskey or other medical MOS, please use a tourniquet as high up on the limb as you can that bleeding is coming from. It can be downgraded easily if needed later but the main priority is to keep as much blood inside the body as possible. Turn off the faucet to that limb if it's leaking and then continue assessing for other injuries. It will buy you valuable time if there is bleeding that cannot physically be controlled by other means than direct pressure to areas like the neck or pelvis.
Pre-Hospital Trauma Life Support (PHTLS), Advanced Trauma Life Support (ATLS) and International Trauma Life Support (ITLS) all recommend the use of a tourniquet to control life threatening bleeding.
I appreciate the feedback, thank you
Pre-Hospital Trauma Life Support (PHTLS), Advanced Trauma Life Support (ATLS) and International Trauma Life Support (ITLS) all recommend the use of a tourniquet to control life threatening bleeding.
Those curriculum revisions will also soon be seen is DOT EMT training as well. Direct Pressure --> TQ.
In general, application of the TQ depends on wound type, location, bleeding, blood loss, distance, etc.
When and how you apply the TQ, and what you do afterward, is dictated by the protocol or standard of care you are bound by and accountable to. Bystander layman's first aid is pretty permissive, and if you have no duty to act, applicable good sam law will be a help.
NinjaMedic
12-23-10, 21:15
If you come across someone civilian or otherwise with a hole in the them bad enough to make you say "damn thats ****ed up" or "shit thats a lot of blood" and there is room on the limb to put a tourniquet, put the tourniquet on the limb.
Most people grossly overestimate the loss of blood. This works in our favor and lowers the threshold for placement of a tourniquet. THIS IS A GOOD THING. If you guess wrong, oh well, too bad, someone can remove the tourniquet later from the still living person.
crashbubba
12-24-10, 01:25
Tourniquet use after direct pressure has been on the NREMT skill sheet for bleeding control since last year. Last year's Brady Book also had the change.
Lots of medicine science is coming out of OEF/OIF that leads to changes on the EMS side. Some don't directly correlate but the benefits are there.
I just took NAEMT's TCCC course. It was interesting to see the military techniques that are now being presented en mass to the EMS community. It was painful to see career medics try and wrap their heads around the austere environments that these techniques were originally developed for.
There is a reason that the military has gone to tourniquets as a first line defense against exsanguination. By the time you go through the levels of treatment escalation for bleeding your patient is near death. To many people died needlessly because the medical responders were afraid to use tourniquets. It takes hours before a limb suffers significant tissue damage from lack of blood. We all operate under the one hour "Golden Rule" for trauma. The way I see it, use a tourniquet first to stop the bleeding then evacuate after treating any other life threatening injuries. I also think that if you have a tourniquet in place long enough to cause loss of limb because of delayed evac in the field, then you needed a tourniquet to begin with.
If you come across someone civilian or otherwise with a hole in the them bad enough to make you say "damn thats ****ed up" or "shit thats a lot of blood" and there is room on the limb to put a tourniquet, put the tourniquet on the limb.
Most people grossly overestimate the loss of blood. This works in our favor and lowers the threshold for placement of a tourniquet. THIS IS A GOOD THING. If you guess wrong, oh well, too bad, someone can remove the tourniquet later from the still living person.
Factor in the "Golden Hour" and the patient will likely keep the limb too.
NinjaMedic
12-24-10, 15:32
The current medical literature is now showing 8-12hrs of viability for the limb with tourniquet use so definitely no concern there in most any reasonable civilian setting.
Gutshot John
12-25-10, 09:56
With the recent war on terror and the influx of medical data as a result, there have been several studies that show that the risk of amputation even after a tourniquet has been applied for several hours has been vastly overstated.
Here is one:
http://journals.lww.com/annalsofsurgery/Abstract/2009/01000/Survival_With_Emergency_Tourniquet_Use_to_Stop.1.aspx
Coupled with a significant improvement in survival rates for applying the tourniquet early on and you understand why the military has gone to the tourniquet as a first line treatment for extremity hemorrhage.
http://brownems.org/2009/08/tourniquet/
Civilian EMS has lagged behind this realization but the change will happen.
Failure2Stop
12-26-10, 01:34
In my experience, it's not a matter of whether or not to use a tourniquet, but rather how many tourniquets to use.
In my experience, it's not a matter of whether or not to use a tourniquet, but rather how many tourniquets to use.
Amen Brother. You can never have to many rounds or use to many tourniquets.
fireftrjef
12-26-10, 09:28
Tourniquet use after direct pressure has been on the NREMT skill sheet for bleeding control since last year. Last year's Brady Book also had the change.
Indeed. I got my NREMTP license in the fall of '09 and it was one of our skill sheets. Pretty basic... Direct pressure - still bleeding - apply tourniquet.
As mentioned above, USE A TOURNIQUET. period. TCCC and PHTLS guidelines, as well as most physician, pa, emt, instructors will teach you to use/apply one or more than one if the situation requires it.
As mentioned above, USE A TOURNIQUET. period. TCCC and PHTLS guidelines, as well as most physician, pa, emt, instructors will teach you to use/apply one or more than one if the situation requires it.
When you're talking about multiple T's is it for one wound or several ie a leg and arm.
When you're talking about multiple T's is it for one wound or several ie a leg and arm.
It depends. Sometimes a lower extremity wound may require two trqts, if both upper and lower extremity wounds are suffered then one would place a trqt on both the right arm and left leg for example.
Thanks. I had not thought of that possibility until reading this thread.
ICANHITHIMMAN
01-23-11, 09:51
My wifes department is re training all it officers to use TOURNIQUETS. I remember 4 years ago when she got the job we were discusing the use of them and she said we are not ever allowed to do it.
I tried telling her at the time it was not as bad as they make it sound. I think the medical advances from overseas have influnced her departments decsion to reverse there policy.
The current medical literature is now showing 8-12hrs of viability for the limb with tourniquet use so definitely no concern there in most any reasonable civilian setting.
Let's not confuse "viability" with "total lack or morbidity" or "100% functionality post-injury". I know you're not saying that, but I wouldn't want anyone to get the idea they can just slap a tourniquet on for 8-12 hours without consequence. Acidosis, myoglobinuria, nerve damage, compartment syndrome and healing of the fasciotomies that would be necessary after totally occluding blood flow for that period of time all need to be taken into account. Some degree of those problems will occur with any lack of limb perfusion.
Direct pressure still allows for collateral circulation and at least some venous return. Tourniquets don't. I agree that transfer times in a typical civilian EMS setting are certainly going to be less than 8-12 hours, but that only serves to emphasize some of the vast difference between combat EMS and civilian EMS. The military has shown us that use of tourniquets in extremity trauma is not necessarily the boogeyman it's been assumed to be, but let's not let the pendulum swing too much in the other direction. Those combat lessons, valuable as they are, are not 100% applicable in the civilian world.
As the guy that will have to deal with that post-ischemic leg in the OR and in the ICU, let me plead to all of you civilian EMTs to please try direct pressure first before applying the tourniquet and shutting off ALL perfusion to the limb. It makes my job easier and improves the chances that the patient will heal quickly and have a good functional limb.
ICANHITHIMMAN
01-23-11, 12:39
Let's not confuse "viability" with "total lack or morbidity" or "100% functionality post-injury". I know you're not saying that, but I wouldn't want anyone to get the idea they can just slap a tourniquet on for 8-12 hours without consequence. Acidosis, myoglobinuria, nerve damage, compartment syndrome and healing of the fasciotomies that would be necessary after totally occluding blood flow for that period of time all need to be taken into account. Some degree of those problems will occur with any lack of limb perfusion.
Direct pressure still allows for collateral circulation and at least some venous return. Tourniquets don't. I agree that transfer times in a typical civilian EMS setting are certainly going to be less than 8-12 hours, but that only serves to emphasize some of the vast difference between combat EMS and civilian EMS. The military has shown us that use of tourniquets in extremity trauma is not necessarily the boogeyman it's been assumed to be, but let's not let the pendulum swing too much in the other direction. Those combat lessons, valuable as they are, are not 100% applicable in the civilian world.
As the guy that will have to deal with that post-ischemic leg in the OR and in the ICU, let me plead to all of you civilian EMTs to please try direct pressure first before applying the tourniquet and shutting off ALL perfusion to the limb. It makes my job easier and improves the chances that the patient will heal quickly and have a good functional limb.
Thanks for this, its good the here it from the guys that have to fix it after the hand off.
and one additional caution.
The loss of limb issue was NOT primarily due to TIME of application, it was due to innapropriate choice of tourniquet material. Too thin material = crushing the underlying tissue.
That issue is still 100% valid. With the headlong rush to return to tourniquet use, make sure that you are using a wide ( >1.5 inch) band. Those that only remember "tourniquet = good", and then choose makeshift materials to improvise one, will have issues.
Pick one of the top 5 or so commercially available ones, and train with it.
The automatic jump to tourniquet application is perfectly appropriate in a Care Under Fire setting.
HMAC's advice to first try direct pressure in a civilian, first aid type setting is advice worth listening to. In 20 years of .civ EMS, air medical, and trauma center work I have used a tourniquet once, for a failed dialysis shunt. A standard BP cuff did a great job as it was immediately available, and plenty wide to avoid any tissue damage.
There is more to this than " just go straight to a tourniquet".
Sorry to post a dead thread. But, I felt the want to add my 0.01.
I've been in this business long enough to see the tourniquet in favor, fade from favor, become taboo, and now resurrected.
Dr. Hmac hit points that I was gearing toward prior to reading his post.
The military has long driven the trends of emergency medicine. This TQ issue is no exception. We must bear in mind that the military calculates injury in terms of hours to even days before definitive care is rendered to the injured.
Note: yes I know that the military has evac to an art form these days. I'm thankful for our soldiers that is the case. However, it is still in terms of hours in many instances.
Battlefields also are MCI incidents. Most soldiers opertional in current theaters are being injured by explosives; multiple limbs and body systems immediately effected. The CLSs and CMs must quickly stablize life-threatening issues and move on to the next soldier.
Civilian trends like to follow military studies. This has happened since WWII. Remember MAST? Also coming back in favor secondary to further military studies.
Civilian EMS continues to enjoy the "Golden Hour." Barring castrophy, the civilian side affords the luxury of time from injury to definitive care being measured in minutes. Thus, the TQ also can gain favor in the "minute" environment/system.
I'll close my 0100hrs babble with this thought. I have stopped a lot of bleeding over my years. The only bleeding I couldn't stop with direct pressure was femoral or jugular... and in either circumstance, a TQ would be of no use anyhow.
The jugular bleeds probably could have been controlled with d-pressure if not for airway compromise. One of those cases bore Kellys for ease of management and air emboli concerns. The femorals were slowed enough to preserve life using d-pressure. In two of those cases, I clamped one patient, and pinched the artery on another. Both of those injuries were superior thigh, in the groin.
Tourniquets are gaining favor. But, know when you need 'em, and when you really don't. I could have applied a TQ in many cases but, have never truly needed one.
Remember MAST? Also coming back in favor secondary to further military studies.
This was a topic of discussion at a recent conference I attended. All that is old is new again.
LUCKY MEDIC25
03-30-11, 14:44
Since were talking about tourniquets I would just like to reiterate DO NOT apply a tourniquet around a neck....
On a serious note, one of my casualties had 5 tourniquets on him. Each leg had 2 and an arm had the fifth. So yes, more than one is definitely necessary, especially in a combat environment.
Gutshot John
03-30-11, 14:58
Since were talking about tourniquets I would just like to reiterate DO NOT apply a tourniquet around a neck....
On a serious note, one of my casualties had 5 tourniquets on him. Each leg had 2 and an arm had the fifth. So yes, more than one is definitely necessary, especially in a combat environment.
They can be especially in multiple injuries, but 5 on one injury (which I've seen in pictures from the sandbox) are excessive and indicate improperly application... one properly applied TQ works far better than 5 improperly applied ones. Having seen several traumatic amputations, two TQs worked perfectly well on a mid thigh/femoral bleed.
Another note on the military side of things is that "the best medicine is fire superiority." Taking someone out of the fight to hold down a pressure bandage can cost more lives when you could apply a tourniquet and keep that person fighting.
Some of this has been said, but to add some formality to it:
Tourniquets should be carried and can save lives, but their use is still inherently risky. Some prehospital tourniquets are relatively safer than others and proper application of these models helps mitigate the risks.
While modern prehospital care has gotten over the old belief that any limb with a tourniquet applied must be amputated, tourniquets are still a last-resort tool with good reason.
Medical research going back to at least the 1970s shows serious nerve damage in cases of prolonged pressure to tissue. Note that this example from the journal Transactions of the American Neurological Association uses a pneumatic cuff, which is considered less damaging than the narrow, manually tightened cuffs in modern military tourniquets due to the pneumatic cuff's relatively even pressure over the tissue. Pneumatic cuffs are typically used in surgical situations.:
Using a cuff inflated to 1000 mm Hg round- the leg of the baboon for 1 to 2 hours, it had been found that the anatomical lesions were concentrated under the edges of the cuff, with sparing in the centre . Furthermore, the lesions themselves involved displacement of structures within the nerve fibres, suggesting that there had been axoplasmic movement from the site of compression towards uncompressed tissue.(Ochoa, Fowler, Danta, and Gilliatt, 1971) In other words, the edges of the tourniquet compressed the tissue with enough pressure to pinch the long part of the neuron (the axon), causing damage.
One reason I highlight this is that there's a difference in pressure distribution (and absolute amount) caused by different types of tourniquets. Most notably, elastic band tourniquets can cause extremely high pressures. Many law enforcement agencies select this variety because they are typically cheaper.
Rather than try to re-characterize it all, I'll just share how Tacmedsolutions' blog reported quite clearly the additional risks of elastic band tourniquets:
As noted in the Journal of Medicine and Biomedical Research, “[t]he pressure induced by the rubber bandage increases at a rate of 3 to 4 times the initial pressure when the bandage is stretched after each wrap.”(1)(3) This is dangerous due to the shearing effect generated on the underling tissues, specifically the nerves. In fact, Graham et al found that at above 300mm Hg shearing forces increased exponentially.(2)(3) With RBTs this is concerning as “[t]he pressure applied to the limb could easily exceed the safe limits and put the limb at risk of complications because the rubber bandage is capable of generating pressures in excess of 1000mmHg beneath it.” “At such extremely high pressure,” Ogbemudia continues, “neurovascular damage becomes likely and makes the use of the RBT relatively unsafe.”
[1] Ogbemudia A et al. Adaptation of the rubber bandage for the safe use as tourniquet. Journal of Medicine and biomedical Research 2006; Vol. 5 No. 2 pp-69-74.
[2] Graham B et al. Perinerual pressures under the pneumatic tourniquet in the upper and lower extremity. Journal of Hand Surgery 1992: 17B: 262-6.
[3] McEwen J. A. and Casey V. Measurement of hazardous pressure levels and gradients produced on human limbs by non-pneumatic tourniquets.
In other words, tourniquets can cause lasting damage if they apply too much pressure to the tissue. Elastic band tourniquets are, by nature, most prone to inadvertent overtightening. While any tourniquet is better than no tourniquet if circumstances require one, if you have the option to carry the relatively safer models, and you use them properly and only when needed, your patient's outcome will likely be better.
Some of this has been said, but to add some formality to it:
Tourniquets should be carried and can save lives, but their use is still inherently risky. Some prehospital tourniquets are relatively safer than others and proper application of these models helps mitigate the risks.
While modern prehospital care has gotten over the old belief that any limb with a tourniquet applied must be amputated, tourniquets are still a last-resort tool with good reason.
Medical research going back to at least the 1970s shows serious nerve damage in cases of prolonged pressure to tissue. Note that this example from the journal Transactions of the American Neurological Association uses a pneumatic cuff, which is considered less damaging than the narrow, manually tightened cuffs in modern military tourniquets due to the pneumatic cuff's relatively even pressure over the tissue. Pneumatic cuffs are typically used in surgical situations.:
Using a cuff inflated to 1000 mm Hg round- the leg of the baboon for 1 to 2 hours, it had been found that the anatomical lesions were concentrated under the edges of the cuff, with sparing in the centre . Furthermore, the lesions themselves involved displacement of structures within the nerve fibres, suggesting that there had been axoplasmic movement from the site of compression towards uncompressed tissue.(Ochoa, Fowler, Danta, and Gilliatt, 1971) In other words, the edges of the tourniquet compressed the tissue with enough pressure to pinch the long part of the neuron (the axon), causing damage.
One reason I highlight this is that there's a difference in pressure distribution (and absolute amount) caused by different types of tourniquets. Most notably, elastic band tourniquets can cause extremely high pressures. Many law enforcement agencies select this variety because they are typically cheaper.
Rather than try to re-characterize it all, I'll just share how Tacmedsolutions' blog reported quite clearly the additional risks of elastic band tourniquets:
As noted in the Journal of Medicine and Biomedical Research, “[t]he pressure induced by the rubber bandage increases at a rate of 3 to 4 times the initial pressure when the bandage is stretched after each wrap.”(1)(3) This is dangerous due to the shearing effect generated on the underling tissues, specifically the nerves. In fact, Graham et al found that at above 300mm Hg shearing forces increased exponentially.(2)(3) With RBTs this is concerning as “[t]he pressure applied to the limb could easily exceed the safe limits and put the limb at risk of complications because the rubber bandage is capable of generating pressures in excess of 1000mmHg beneath it.” “At such extremely high pressure,” Ogbemudia continues, “neurovascular damage becomes likely and makes the use of the RBT relatively unsafe.”
[1] Ogbemudia A et al. Adaptation of the rubber bandage for the safe use as tourniquet. Journal of Medicine and biomedical Research 2006; Vol. 5 No. 2 pp-69-74.
[2] Graham B et al. Perinerual pressures under the pneumatic tourniquet in the upper and lower extremity. Journal of Hand Surgery 1992: 17B: 262-6.
[3] McEwen J. A. and Casey V. Measurement of hazardous pressure levels and gradients produced on human limbs by non-pneumatic tourniquets.
In other words, tourniquets can cause lasting damage if they apply too much pressure to the tissue. Elastic band tourniquets are, by nature, most prone to inadvertent overtightening. While any tourniquet is better than no tourniquet if circumstances require one, if you have the option to carry the relatively safer models, and you use them properly and only when needed, your patient's outcome will likely be better.
In addition to direct to nerve and muscle injury from the localized pressure of a carelessly applied tourniquet, the lack of limb perfusion has a significant deleterious effect on the muscle. You can take a wide-based, double-cuff, pneumatic tourniquet like we use in the OR and if you leave it on long enough (much over an hour) you'll get significant lactic acidosis in the limb, with muscle and nerve damage from the ischemia. When the tourniquet is released, that results in a significant acid load to the system which can cause dysrhythmia or worse, as well as myoglobin from damaged muscle which has to be filtered through the kidney, which isn't good for the kidney...as in renal failure. Additionally, the subsequent swelling in the soft tissues once the limb is re-perfused will create high limb compartment pressures which in turn can cause more muscle and nerve damage and will inevitably require multi-compartment fasciotomies...a morbid problem in itself.
Now, all of that is better than bleeding to death, so don't take this as me being opposed to tourniquets. Let's just make sure we carefully learn this particular life-saving-but-potentially-dangerous tool. I have little concern for misuse by qualified pre-hospital personnel, but I do start to get a little worried when I see little tourniquet sets being issued to police officers and highway workers. I know how paramedics are trained, not so sure about the others.
Hmac makes good points. My brother is an orthopaedic surgeon (20 years) and informed me that pneumatic cuff tourniquets, which distribute the pressure of the tourniquet well, are used in nearly all total knee replacements. They are typically inflated and in place for 45 to 90 minutes at about 300 mmHg (about 6 psi). He claims that 400 mmHg (about 7 psi) should be the absolute maximum that the tourniquet is inflated to and at that pressure he feels that 30 minutes might be the time limit. According to him, if the surgery runs longer than expected they are typically deflated after 90 minutes to allow blood flow for a few minutes and then re-inflated. He states that the 300 mmHg pressure is enough to stop virtually all macroscopic blood flow, but still allows a slight microscopic flow. This aids in preventing hypoxia and Deep Vein Thrombosis (DVT). He thinks it can also reduce the buildup of cellular debris and reduce vaso-constriction distally, which typically occurs at the time the tourniquet pressure is applied. His advice to me was to try to utilize a tourniquet that distributes the pressure across a wider band than that of a belt or nylon pack strap and only apply the moderate pressure required to halt major blood flow. This echoes what I was taught in school.
JBJS has a few interesting white papers on this subject as it applies to wound healing and range of motion post-op:
http://web.jbjs.org.uk/cgi/reprint/81-B/1/30.pdf
http://web.jbjs.org.uk/cgi/reprint/83-B/1/40.pdf
If there are measurable differences in the use of a surgical tourniquet vs non use of one, there is surely concern with the use of the "stick and strap" methods. Proper training and emphasis on recognizing when to apply it, what kind to apply and where to apply should be part of an LE agency's routine training cycles, but it rarely is.
Gutshot John
04-01-11, 08:27
Per TCCC there is ample evidence from the battlefield that a proper tourniquet properly applied can be in place for multiple hours with only a minimal chance of long-term neurological deficits. IIRC the percentage thrown out was only that 3% had any longer term issues and most of those included numbness etc. It is something of a myth that a TQ restricts all blood flow and they are certainly a good tool for anyone to have in their kit.
There is almost no chance of someone losing a limb if a tourniquet is of a proper width of 2". I disagree with the premise that a TQ shouldn't be used by lay people, this isn't a needle decompression where you have the potential to kill someone if you do something wrong. There is far greater danger in not doing anything.
In terms of the proper amount of pressure, you keep tightening until the hemorrhage either ceases or there is no distal arterial pulse.
The issue of width is only relevant to improvised TQs and that does require proper training. Most commercially available TQs are of proper width (CAT-T/SOF-T) and are comparatively idiot proof, the exception being a SWAT-T which does require some training/understanding in order to use properly.
The current trend is for increasing/more aggressive use of a TQ earlier on in treatment protocols. This is trickling down to civilian EMS from the military experience in the sandbox where the number 1 cause of preventable death is penetrating trauma to the extremity and so generally a TQ gets applied in those cases even before you do any ABCs.
There is almost no chance of someone losing a limb if a tourniquet is of a proper width of 2". I disagree with the premise that a TQ shouldn't be used by lay people, this isn't a needle decompression where you have the potential to kill someone if you do something wrong. There is far greater danger in not doing anything.
Of course there's a far greater danger in doing nothing. But that doesnt give license to be careless or for someone to use that tool with incomplete training or understanding. The survival of the patient and not having lost the limb does not necessarily equal successful or appropriate and safe use of a tourniquet. There's a whole lot more that happens to that patient in the days and weeks after he's been dropped off alive at the ER. That the patient has survived is certainly a victory. That victory is less than complete if the patient is left with a limb whose function is unnecessarily impaired because of casual misuse of that particular tool. And like many such tools, that's a very real possibility that may not be in any way apparent to the EMTs who will never see or hear of that patient again after he's left the ER for the OR.
Gutshot John
04-01-11, 09:19
Of course there's a far greater danger in doing nothing. But that doesnt give license to be careless or for someone to use that tool with incomplete training or understanding. The survival of the patient and not having lost the limb does not necessarily equal successful or appropriate and safe use of a tourniquet. There's a whole lot more that happens to that patient in the days and weeks after he's been dropped off alive at the ER. That the patient has survived is certainly a victory. That victory is less than complete if the patient is left with a limb whose function is unnecessarily impaired because of casual misuse of that particular tool. And like many such tools, that's a very real possibility that may not be in any way apparent to the EMTs who will never see or hear of that patient again after he's left the ER for the OR.
Improper application of the TQ invariably results in ineffectual control hemorrhage/shock/death, not neurologic/limb damage. Given that a TQ is almost never on a limb in the civilian EMS setting as long as it is on a military setting means this it is even less of an issue.
http://www.ncbi.nlm.nih.gov/pubmed/12768129
Conclusion from the above study:
Tourniquet application is an effective and easily applied (by medical and nonmedical personnel) method for prevention of exsanguination in the military prehospital setting.
http://journals.lww.com/annalsofsurgery/Abstract/2009/01000/Survival_With_Emergency_Tourniquet_Use_to_Stop.1.aspx
Results/Conclusions of the above study which refers to civilian setting.
There were 31 deaths (13%). Tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; P < 0.001). Prehospital tourniquets were applied in 194 patients of which 22 died (11% mortality), whereas 38 patients had ED application of which 9 died (24% mortality; P = 0.05). The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used (P < 0.001). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet. No amputations resulted solely from tourniquet use.
Conclusions: Tourniquet use when shock was absent was strongly associated with saved lives, and prehospital use was also strongly associated with lifesaving.
There are many studies that have reached the same conclusion. This is why you will see increased use of TQs in the prehospital EMS setting.
It is also why there is almost no risk to the application of TQ assuming it isn't made of piano wire. Training is certainly valuable since it's the best way to prevent hemorrhage, "careless" application is certainly ineffectual because if fails to control bleeding, but it almost never results in long-term damage to the limb.
Gutshot John
04-01-11, 09:25
From JEMS.
http://www.jems.com/article/patient-care/return-tourniquets-original-re
The BMC/BEMS cohort study indicates that prehospital tourniquets can be appropriately applied to control life-threatening hemorrhage from an extremity injury, and that their use isn't associated with neurovascular complications. In similar case series, some of the patients we've described appear to have died because of inadequate hemorrhage control. It's thus quite unlikely that a well-controlled clinical trial could be conducted to truly determine the safety and efficacy of this intervention. Nevertheless, our findings emphasize the need to re-evaluate the standard teaching that tourniquets are to be used only as a last resort because of safety concerns.
The long and short of this is that TQs should be more aggressively applied and more universally available to lay medics. The potential to save lives far outweighs the minimal risk of neurologic damage even with improper use. The principle of "do no harm" doesn't really apply here. Civilian EMS is far slower in coming to this conclusion than the military but it is changing.
Funny this is coming up. This week spent a day at Jefferson discussing TQs to students. There are a lot of misconceptions, and I'm glad to finally see the stigma of the tourniquet start to wash away.
As has been said, the PROPER application of a TQ is the best way to control exsanguinating bleeding. It's better to get the TQ on and bleeding controlled than to waste time and the patient's blood trying to control the same bleed with direct pressure.
I remember in Boy Scouts as a kid being told the tourniquet is the last resort. But as a Scout, we didn't have proper medical training. Besides, EMS practices evolve often times from the Medics' and Corpsmans' experiences in combat zones. The use of tourniquets is just one example.
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