# Tourniquets - Back in Fashion



## MedicDelta (Sep 26, 2014)

Hey guys, 

What are your thought on tourniquets? Personally, I couldn't support them more. And I believe that if you don't then you probably need to get some more education on them or you have a out of date thought process. Tourniquets are back in fashion, and are not just for tactical medicine. Studies have proven their effectiveness and that it would take 4 hours or more for a limb not getting any blood to actually have to be amputated. Most modern tourniquet protocols involve removing the tourniquet every 20 minutes or so anyways. So what's your take on tourniquets? Does your EMS agency carry them on their rigs? I personally have 2 in my own kit, they're one of the most important pieces of equipment out there in my opinion. 





Here's an awesome video by an EMT-P/SWAT medic about tourniquets. If you don't know much about them, want to know more, or don't believe in them I encourage you to watch this video.


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## DesertMedic66 (Sep 26, 2014)

We carry them but don't get used often at all. In 3+ years I have never needed to apply one. Direct pressure works wonders when applied correctly.


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## TransportJockey (Sep 26, 2014)

Used three of them in the last six months. I'm a big fan of them


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## Akulahawk (Sep 26, 2014)

A good friend of mine really introduced me to tourniquets as a method of bleeding control. Although I had been introduced to them back in EMT school way back when, it really wasn't until a few years ago that I came to appreciate the CAT and similar tourniquets. He's a Corpsman and a good one  at that. He teaches first aid and then some... I have to say that the "newer" commercial tourniquets are generally easier to use and apply and usually will stop someone from bleeding out... well at least from extremity wounds. As a result of what I've learned from him, I'm much more likely to use a tourniquet early on than I used to be.


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## chaz90 (Sep 26, 2014)

Yep. Used them 2x in my career so far and they've worked where pressure alone did not both times. On each occasion I've also utilized a hemostatic dressing. Our agency carries one commercial tourniquet in each set of gear, meaning there are 2x per truck. Every BLS ambulance has a few available as well.


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## MedicDelta (Sep 27, 2014)

DesertEMT66 said:


> We carry them but don't get used often at all. In 3+ years I have never needed to apply one. Direct pressure works wonders when applied correctly.


Absolutely, it usually does in the civilian pre-hospital world where GSWs and major trauma are more rare than in a combat environment. But hey, if you ever need them then they're there.


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## TransportJockey (Sep 27, 2014)

Tqs work amazingly well in industrial accident type settings. Oil rig accidents are two of the three times I've used them.


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## MedicDelta (Sep 27, 2014)

TransportJockey said:


> Used three of them in the last six months. I'm a big fan of them


Does your agency carry the Combat Application Tourniquet(CAT)?


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## MedicDelta (Sep 27, 2014)

Akulahawk said:


> A good friend of mine really introduced me to tourniquets as a method of bleeding control. Although I had been introduced to them back in EMT school way back when, it really wasn't until a few years ago that I came to appreciate the CAT and similar tourniquets. He's a Corpsman and a good one  at that. He teaches first aid and then some... I have to say that the "newer" commercial tourniquets are generally easier to use and apply and usually will stop someone from bleeding out... well at least from extremity wounds. As a result of what I've learned from him, I'm much more likely to use a tourniquet early on than I used to be.


That's awesome man, they really are a very effective tool that could potentially save someone's life. Life over limb any day.


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## TransportJockey (Sep 27, 2014)

MedicDelta said:


> Does your agency carry the Combat Application Tourniquet(CAT)?


Yep. We carry four of the orange CAT TQs on each truck. Two in our first in bag and two on the truck


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## MedicDelta (Sep 27, 2014)

chaz90 said:


> Yep. Used them 2x in my career so far and they've worked where pressure alone did not both times. On each occasion I've also utilized a hemostatic dressing. Our agency carries one commercial tourniquet in each set of gear, meaning there are 2x per truck. Every BLS ambulance has a few available as well.


Hemostatic agents can really work like a charm as well. Stuff like QuikClot or Celox has really advanced over the years.


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## STXmedic (Sep 27, 2014)

OP, have you messed with the IT Clamp at all for moderate bleeds or in conjunction with Combat Gauze?


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## MedicDelta (Sep 27, 2014)

TransportJockey said:


> Yep. We carry four of the orange CAT TQs on each truck. Two in our first in bag and two on the truck


4 is a good number. I'm a firm believer when something is that important, 2 is 1 and 1 is none. Meaning if it's that important, carry 2... Or 4, even better.


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## MedicDelta (Sep 27, 2014)

STXmedic said:


> OP, have you messed with the IT Clamp at all for moderate bleeds or in conjunction with Combat Gauze?


No I haven't used something like that, I actually had to look up what that was. Hemostatic agents like QuikClot Combat Gauze I'm familiar with though.


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## STXmedic (Sep 27, 2014)

We're about to start trialing it where I'm at. Just had to sit through a train the trainer program a few days ago. If it works like they claim it does, it sounds interesting.


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## MedicDelta (Sep 27, 2014)

STXmedic said:


> We're about to start trialing it where I'm at. Just had to sit through a train the trainer program a few days ago. If it works like they claim it does, it sounds interesting.


Is it for BLS and ALS providers?


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## STXmedic (Sep 27, 2014)

MedicDelta said:


> Is it for BLS and ALS providers?


It's simple enough for BLS providers, but our initial contract is only outfitting our ambulances, which run dual paramedics. The rep voiced several times though that the USMC was in the process of signing a contract to get them put in all of their soldier's IFAKs.


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## MedicDelta (Sep 27, 2014)

STXmedic said:


> It's simple enough for BLS providers, but our initial contract is only outfitting our ambulances, which run dual paramedics. The rep voiced several times though that the USMC was in the process of signing a contract to get them put in all of their soldier's IFAKs.


Ahh I see. Well if the military is looking at them they must be fairly effective. I'll have to do some more research on them, find out more about them.


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## Handsome Robb (Sep 27, 2014)

We carry the SWAT-T. Used it more than a few times. My favorite part is if you don't need it as a TQ it makes an awesome pressure bandage to free up hands. 

I'll try to find the source but a military helicopter pilot went down and had a TQ on his "cyclic" arm for like 16+ hours before he was rescued and delivered to a surgical center. Took ~ two years but he's flying again with no deficits in that arm.

Does anyone carry junctional TQs?


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## EpiEMS (Sep 28, 2014)

Handsome Robb said:


> We carry the SWAT-T. Used it more than a few times. My favorite part is if you don't need it as a TQ it makes an awesome pressure bandage to free up hands.
> 
> I'll try to find the source but a military helicopter pilot went down and had a TQ on his "cyclic" arm for like 16+ hours before he was rescued and delivered to a surgical center. Took ~ two years but he's flying again with no deficits in that arm.
> 
> Does anyone carry junctional TQs?



Glad to hear you like the SWAT-T, I've never had occasion to use it, but it seems like a very convenient option (small, cheap, and multipurpose).

 I'm definitely a fan of the MAT, has a nice ratcheting action -- I find it to be easier to place (at least, in practicing with it) than the CAT. Curious if anybody uses the MAT.


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## anthonyccamargo (Oct 27, 2014)

I just got back from Afghaniland and yea the CATs are sweet, but the plastic bends and snaps  when tightened to much. As for the Swat-ts, the metal pieces are much better but at the same time, it takes far to long to apply. There are new Swats coming out called Swat-W or swat Wide. Can be used much quicker and more effectively. 

Also CATs are better used not double looping. Going through one loop allows the ability to tight the TQ much tighter as well as much quicker. I can promise that you can put it on completely effectively in under 10 seconds. As for anyone who says that it wont be secure. Well your supposed to tape it anyways so yea. We used them in this fashion and they worked amazingly. Just try not to use it more then once lol. 

We used to carry 2 for each limb and a couple backups. But that was due to a possible MASCAL situation so that applies differently lol

Im a huge supporter of TQs, and sometimes you need those hands to do other things other then holding direct pressure.


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## cprted (Oct 27, 2014)

The BC Ambulance service is slowly making a move to rolling them out.  The plan is to have the TQs in our cars but not in our kits.  

The logic behind it is conventional direct pressure should always be the first line of defence to control haemorrhage, and if the bleed is severe and not able to be controlled with direct pressure, putting the TQs in the car will help instil that these patients ultimately require a trauma surgeon and to not delay transport.


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## gronch (Oct 27, 2014)

SOFTT-W is a good TQ.  People who have blowout kits are dorky, but I'd be happy to save them first.


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## MedicDelta (Oct 28, 2014)

cprted said:


> The BC Ambulance service is slowly making a move to rolling them out.  The plan is to have the TQs in our cars but not in our kits.
> 
> The logic behind it is conventional direct pressure should always be the first line of defence to control haemorrhage, and if the bleed is severe and not able to be controlled with direct pressure, putting the TQs in the car will help instil that these patients ultimately require a trauma surgeon and to not delay transport.


When I did my EMR with the JIBC I asked my instructor if they carried tourniquets on their rigs and I was honestly surprised when she said no. Good to hear they're getting them though.


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## TransportJockey (Oct 28, 2014)

We used two CATs on a patient a few weeks back and damn near broke the plastic windlass. I wound up making one out of a cravat and a penlight that worked better and didn't break.


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## redundantbassist (Oct 28, 2014)

I'm glad we're shifting away from the ARC's "don't use a tq or your arm will fall off" mindset. Patients have lost a lot more blood than they should have due to a rescuers reluctance to apply a tourniquet. We carry 2 CATs on every rig, and although they don't get used a lot, they are a godsend when they're needed.


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## redundantbassist (Oct 28, 2014)

TransportJockey said:


> We used two CATs on a patient a few weeks back and damn near broke the plastic windlass. I wound up making one out of a cravat and a penlight that worked better and didn't break.


May I ask, were you using the old style cat or the new ones with the reinforced windlass?


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## TransportJockey (Oct 28, 2014)

When I get to work I'll have to check. We use an orange CAT that we get from boundtree... but since I don't do ordering I'm not sure the exact one we get


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## TimRaven (Nov 5, 2014)

Or you could consider a second TQ to spread the pressure if tighten the first one became a problem.


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## gronch (Nov 17, 2014)

Don't let this thread die.


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## MackTheKnife (Nov 26, 2014)

Handsome Robb said:


> We carry the SWAT-T. Used it more than a few times. My favorite part is if you don't need it as a TQ it makes an awesome pressure bandage to free up hands.
> 
> I'll try to find the source but a military helicopter pilot went down and had a TQ on his "cyclic" arm for like 16+ hours before he was rescued and delivered to a surgical center. Took ~ two years but he's flying again with no deficits in that arm.
> 
> Does anyone carry junctional TQs?


Haven't seen any other than in a training video.


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## MackTheKnife (Nov 26, 2014)

TKs are great tools. Direct pressure, as stated before, doesn't always work. DP is good for slowing a bleed down while placing a TK. QCK and Celox do work well in areas that are not amenable to a TK. And of course, this is all dependent in the environment you find yourself in. Tactical, non tactical, etc.


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## ExpatMedic0 (Dec 9, 2014)

Does anyone have a decent source for advantages/disadvantages to using a hemostatic agent versus a tourniquet for extremity bleeds?


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## Munkyfu (Jan 4, 2015)

I'm curious about pediatric TQs. In reference to the marathon bombing in Boston, you never know when and where that could happen, and to whom... with a pediatric casualty, would you just apply direct pressure? Is it okay to slap on a regular CAT (or whatever) and just be mindful of the pressure you're applying? Are there any pediatric TQs...if so, do they work well?


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## STXmedic (Jan 4, 2015)

I wouldn't be averse to a tourniquet in a pediatric. Just be mindful of the amount of pressure you're applying- apply enough to stop the bleeding and you should be fine. The only issue I could think of is if the pediatric's extremity would be too skinny for the tourniquet to be applied appropriately. In that case, there are of course other methods to control bleeding. Pressure points should be easy enough to tamponade on a pedi while you manage the wound.


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## Munkyfu (Jan 4, 2015)

okay, thank you!


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## Summit (Jul 4, 2018)

gronch said:


> Don't let this thread die.


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## ExpatMedic0 (Jul 4, 2018)

So how about  The Abdominal Aortic Tourniquet? Looks very interesting


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## Summit (Jul 4, 2018)

Expensive, large, and potential complications. But it can also save previously unsalvagable patients...






This one shows it is equal to REBOA in swine: https://www.ncbi.nlm.nih.gov/pubmed/29661286

Interesting proposition for us in CPR in hemorrhagic arrest validated in a swine model:
https://www.ncbi.nlm.nih.gov/pubmed/28885969

Seems like it would also be efficacious in most non-traumatic arrests as a temporizing measure since it should boost perfusion pressure with a smaller effective systemic circuit to pressurize through compressions.


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## Summit (Jul 4, 2018)

Regional protocols including metro areas now have tourniquets allowed as soon as direct pressure fails.

Relevant section of 
Chang, R., Eastridge, B., and Holcomb, J. (2017) Remote Damage Control Resuscitation in Austere Environments



> Given the effectiveness of tourniquets in controlling extremity hemorrhage, the 2015 Hartford Consensus emphasized the need for civilian preparedness in responding to mass casualty incidents, a major component of which is rapid hemorrhage control with the appropriate use of tourniquets and hemostatic dressings by professional first responders.74 Emerging data suggest that tourniquet application reduces blood loss and shock75 with a low risk of ischemic limb loss in civilian trauma patients.76,77,78. In a single-center retrospective review of 326 tourniquets placed on 306 patients for extremity injuries, delayed tourniquet placement (in the trauma center) was associated with an increased likelihood of exsanguination (OR 8.5, 95% CI 1.1 – 68.9) compared to prehospital tourniquet placement.77 However, in the austere environment where definitive hemorrhage control is delayed, prolonged tourniquet application could result in detrimental limb ischemia. A study using porcine models found that neuromuscular recovery was well-preserved when tourniquet application was ≤3 hours but significantly diminished at 6 hours.79 Current TCCC guidelines recommend reassessing every 2 hours and to convert the tourniquet to a hemostatic or compression dressing if the following criteria are met: 1) patient is not in shock, 2) limb was not amputated, and 3) it is possible to monitor the wound closely for bleeding.80 Periodic loosening of the tourniquet to reperfuse the limb results in increased blood loss without any benefit (possibly worsening the ischemia-reperfusion injury)81 and should be avoided. Because of the risk of reperfusion syndrome, removal of a tourniquet which has been applied for ≥6 hours should be done only when close monitoring and laboratory capability are available.80



And relevant section from:

Pikoulis et al (2017). Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting



> A prospective study analyzing 428 tourniquets placed on 309 injured limbs showed that early tourniquet use before the onset of shock was associated with a 90% survival rate versus 10% survival if the application was delayed until the casualty was in shock (21).
> 
> Retrospective studies have examined the use of prehospital tourniquets in civilian trauma. In a 2007 review of tourniquet use in the prehospital setting, it was found that immediate application of a tourniquet may be justifiable in: (a) life-threatening limb hemorrhage, amputation, or a mangled extremity, (b) life-threatening limb hemorrhage not controlled by simple methods, (c) entrapment of a limb preventing access to a point of hemorrhage, (d) multiple casualties with extremity hemorrhage and inability to perform simple methods of hemorrhage control, or (e) benefits of prevention of death outweigh limb loss from ischemia caused by use of a tourniquet (22).
> 
> ...


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## VFlutter (Jul 4, 2018)

Really wish i had the SAM Junctional tourniquet. Doubles as a traditional pelvic binder as well as useful for device related bleeds (i.e IABP) which makes it more attractive. Holding  direct pressure on a junctional injury is not ideal when you only have two providers and a lot of other interventions to do.


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## soflomedic14 (Jul 9, 2018)

Love them and use them quite often as the area I work in we tend to get a ton of calls where a tourniquet definitely comes in handy. I’ve used both the MAT and SWAT-T and many others. SWAT-T tends to be more convenient in regards to time.


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## StephenLewisreuw (May 28, 2020)

In my entire career, I've used them twice, I think. I agree with DesertMedic66 that direct pressure works better when applied correctly. However, if they are used for tactical medicine, their utility is proven, but if the purpose is another, then I won't recommend using them. They are not clothes to be worn as a fashion element, and someone can harm himself if the tourniquet is used wrong. I think that they are made only for tactical medicine. Thank you for sharing the video, I enjoyed watching it, and I found it very informative.


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## VFlutter (May 28, 2020)

StephenLewisreuw said:


> In my entire career, I've used them twice, I think. I agree with DesertMedic66 that direct pressure works better when applied correctly. However, if they are used for tactical medicine, their utility is proven, but if the purpose is another, then I won't recommend using them



Going to have to strongly disagree with you. In my career I have used tourniquets numerous times, in a non-tactical environment, that would have been difficult or impossible to control by other means. That mentality creates preventable deaths.


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## AHenriques (Sep 22, 2020)

VFlutter said:


> Going to have to strongly disagree with you. In my career I have used tourniquets numerous times, in a non-tactical environment, that would have been difficult or impossible to control by other means. That mentality creates preventable deaths.


Could not agree more!
Im a emt in Portugal and in my 9 years of experience i've used CAT multiple times!! Im several dozen miles of an hospital on a rural area where many accidents with heavy machinery happen and CAT is 1st option!!! Theres not many things that can replace it in this environment and its not tactical at all, just bloody, thats all


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## CCCSD (Sep 22, 2020)

There is no difference between “tactical “ bleed outs and “civilian” bleed outs. Both are preventable.


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## MackTheKnife (Sep 22, 2020)

VFlutter said:


> Going to have to strongly disagree with you. In my career I have used tourniquets numerous times, in a non-tactical environment, that would have been difficult or impossible to control by other means. That mentality creates preventable deaths.


Couldn't agree more.  From another reply, if DP and a compression bandage works, great.  But there are times where a TQ is what's required.  Yes, I have used them.  They work.


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## johnrsemt (Sep 24, 2020)

I smiled at the OP statement of tourniquets are back in style:  they never went out of style with us.  In 3 states over 24 years


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