Tourniquet Application (Combat and Legality)

[usmcvet]

Thanks. I had not thought of that possibility until reading this thread.

[ICANHITHIMMAN]

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.

[Hmac]

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]

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.

[Solo1st]

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".

[Truckie]

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.

[ST911]

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]

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]

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.

[Hammer27]

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.