# Tourniquet Placement- Where do YOU Place a Tourniquet?



## EsotericBravo (May 11, 2016)

I have heard several compelling arguments with contradictory conclusions on tourniquet placement. 

One crowd argues furiously that tourniquets have been found to effectively stop bleeding when applied to a distal extremity, despite the preferable anatomy of a proximal extremity for tourniquet function. Application as such has shown to be equally reliable, thus warranting placement which may effect less tissue and decrease morbidity. Tourniquets exert pressure on all areas under the strap and around the limb. The tissue between a tibia and fibula, for example, is adequately compressed by the tissue directly beneath the tourniquet. Despite functional superiority of placement around a single large bone, experience shows no failure of a properly tightened tourniquet on distal extremities, thus no measurable benefit to subjecting more tissue to the effects of a tourniquet. 2-3 inches proximal to the wound, with the exception of joints, is how I was recently taught straight from the EMT-B book.

The other crowd argues that tourniquets are more effective when placed on a proximal extremity because the tissue between bones on a distal extremity is inadequately compressed. I have not seen any statistics that show the other way is ineffective, but it is believed that the risk of tourniquet-related morbidity is minimal and worth the increased effectiveness of proximal extremity placement. I saw a video of an artificial arm continuing to "bleed" after placement on the lower arm. The bleeding was controlled after placement on the upper arm, just above the elbow.

There is also an argument for placement as far proximal as possible in the case of gunshot wounds and blast injuries, because fragments may have traveled up the arm rupturing vessels proximal to the visible wound. Transport time is typically short, and in prolonged situations Medical Direction can advise whether or not you may relocate tourniquets or switch to less aggressive methods such as direct pressure and hemostatic agents.

All of these methods assume injury on the distal aspect of the extremity as the differentiating factor.


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## usalsfyre (May 11, 2016)

It depends entirely on the injury and the location. It's one of those things that can't be distilled down into a checklist.

Generally 2-3" away from the wound, however if it's "exsanguinating in 2 mins" vs "exsanguinating in 20 minutes" it's going high and tight with a second one behind it if there's any bleeding present after placement.

A video of an artificial arm shouldn't be your deciding factor. Seek out evidence and those who have experience in actual hemorrhage control. If you know any 68Ws or corpsmen who have been downrange they're usually a great resource.


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## EsotericBravo (May 11, 2016)

That's exactly my thought. I was not buying the test on the artificial arm because I could not find real life evidence showing ineffectiveness. Last I heard the 18D course is teaching placement just proximal to the wound unless placing high for obvious reasons. I should mention it was 68Ws, 18Ds, and HMs arguing against the necessity of placement around a single large bone. I'm interested in hearing what different practices are used by various EMTs/Medics on this board, and whether or not it is protocol.


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## Underoath87 (May 11, 2016)

Just don't put it around a joint or real close to the wound.


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## ERDoc (May 11, 2016)

I think the best place to put it is where ever you can get it so that it stops the bleeding and doesn't get in the way.  There is probably no evidence or science to back any specific method, just opinions.


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## Jim37F (May 11, 2016)

Depends on your local protocols. At work the County says 2-3 inches above the wound, unless that puts the TQ on a joint, then place the TQ above the joint.

For the Army, since I am not a 68W or 18D or any other medical MOS, as a CLS (Combat Life Saver, simply an advanced first aid course pretty much everyone gets) its simply as high up in the armpit/groin as it'll fit, and if you need a second, add the second one just below the first (since if you did the first one right there's no more room above it).

In both cases, once it's placed, crank down on the windlass until the bleeding stops. Leave it uncovered and mark the time you placed the TQ for higher level medical staff and otherwise leave it alone, evac the casualty as soon as possible (diesel bolus to Trauma Center or 9-Line MEDEVAC)


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## hosejockey (May 11, 2016)

When you think about the bodies anatomy, you have veins and arteries going throughout your body to create the closed pressure system. They break down into arterioles and venules which go to capillaries to perfuse tissues.

If you cut a closed pressure system fluid (blood) exits through that area until the clotting cascade takes effect.

If the area is too large (amputation, evisceration, etc.) then you utilize the tourniquet to close the system to that area. (which is why we don't take it off either, causes lactic acid buildup)

If you're looking at an extremity, for this purpose, lets say.. leg. and it's avulsed (traumatic amputation) (hanging on by a few pieces of tissue and muscle fiber). What will putting a distal tourniquet do?
Well, it will definitely stop that lower extremity from bleeding even though it has little to no blood flow.

Even on a deep laceration with profuse bleeding, arterial blood will have more pressure behind it, veins use a system of valves and are low pressure. So putting a tourniquet distal will stop the venous return, but you still have high pressure arterial blood pushing through that opening.

It doesn't make sense to me to put it distally. You cut off a low pressure system but leave a high pressure system open.

Tl;dr : follow local protocol.


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## usalsfyre (May 11, 2016)

I think he's talking distal as in lower leg vs thigh, and upper arm vs forearm. 

Lactic acid buildup also isn't the reason you don't remove an extremitiy tourniquet, it's because hemorrhage requiring a tourniquet usually requires surgical control or take a very long time to achieve hemostasis. We routinely remove tourniquets placed prior to transport to check if they're still needed.


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## hosejockey (May 11, 2016)

usalsfyre said:


> I think he's talking distal as in lower leg vs thigh, and upper arm vs forearm.
> 
> Lactic acid buildup also isn't the reason you don't remove an extremitiy tourniquet, it's because hemorrhage requiring a tourniquet usually requires surgical control or take a very long time to achieve hemostasis. We routinely remove tourniquets placed prior to transport to check if they're still needed.


At least here and in my setting (and this is California.) Our protocols tell us we're not allowed to remove them. On top of that our nearest trauma is over an hour if we can't get an airship. There have been instances even recently where the doctors removed the tourniquet and sent the patient into arrest.

It's also the cellular breakdown toxins, potassium. metabolic acidosis and potassium can cause arrest.


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## usalsfyre (May 11, 2016)

hosejockey said:


> At least here and in my setting (and this is California.) Our protocols tell us we're not allowed to remove them. On top of that our nearest trauma is over an hour if we can't get an airship. There have been instances even recently where the doctors removed the tourniquet and sent the patient into arrest.
> 
> It's also the cellular breakdown toxins, potassium. metabolic acidosis and potassium can cause arrest.


From a couple of hours with an extremitiy tourniquet Tourniquets are used thousands of time in surgery daily without issue. I think you're confusing crush syndrome (which there's debate if that's even a K+ issue or just a loss of hemostasis) with tourniquet use. 

I work in the CCT environment. If docs are pulling tourniquets off and the patient coding they're doing it wrong.


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## hosejockey (May 11, 2016)

http://www.emsworld.com/article/10364651/ems-recap-tourniquets
An article to cover tourniquet use in regards to bleeding. I got off subject, my apologies


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## Underoath87 (May 11, 2016)

hosejockey said:


> When you think about the bodies anatomy, you have veins and arteries going throughout your body to create the closed pressure system. They break down into arterioles and venules which go to capillaries to perfuse tissues.
> 
> If you cut a closed pressure system fluid (blood) exits through that area until the clotting cascade takes effect.
> 
> ...




Did you just go through all that trouble to explain why a tourniquet shouldn't be placed distal to the injury itself? lol
As usalfyre pointed out (though you didn't seem to understand), we're talking about placing the TQ near the wound vs as high as possible on the limb. 

PS: blood reaches the venules after the capillaries.


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## hosejockey (May 12, 2016)

Underoath87 said:


> Did you just go through all that trouble to explain why a tourniquet shouldn't be placed distal to the injury itself? lol
> As usalfyre pointed out (though you didn't seem to understand), we're talking about placing the TQ near the wound vs as high as possible on the limb.
> 
> PS: blood reaches the venules after the capillaries.


Pretty much. And I get what he was saying, when I read the topic it sounded like he was saying place the tourniquet on a distal extremity to the injury. I've had a massive migrane the last few days and reading that really threw me off. By the time I actually figured it out I ran out of time to edit it.


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## MackTheKnife (May 28, 2016)

From actual experience, get the TQ as high as possible. You get better effect and you have room to convert to a pressure dressing without interfering with the TQ if the tactical situation permits. Remember, you are compressing/occluding the vessels against bone. The bigger the bone, the better. Proximal humerus, proximal femur.

Sent from my XT1585 using Tapatalk


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## Bullets (May 30, 2016)

Initial application is high and tight, then a second one closer to the wound as if needed


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## RedAirplane (Jun 4, 2016)

Around the neck to control epistaxis.


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## StCEMT (Jun 5, 2016)

RedAirplane said:


> Around the neck to control epistaxis.


Finally someone with the right idea!

At work though, one of our training folks says high and tight, so I do what the boss people say. Never had to yet though.


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