# tourniquets



## EMT11KDL (Jan 25, 2013)

http://www.military1.com/all/article/283337-soldiers-save-fellow-service-member-run-down-by-train


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## Clare (Jan 25, 2013)

Ouch, hope the bloke hit by the train is ok.  Tourniquets were introduced in NZ in 2009 and the 3 times I have seen then used I must say I felt they were not appropriate eg not life threatening haemorrhage uncontrollable with direct pressure


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## EpiEMS (Jan 25, 2013)

Clare said:


> Ouch, hope the bloke hit by the train is ok.  Tourniquets were introduced in NZ in 2009 and the 3 times I have seen then used I must say I felt they were not appropriate eg not life threatening haemorrhage uncontrollable with direct pressure



I think that's the worry -- then again, it seems like there's lots of data that has come from military use in Iraq and Afghanistan indicating that limbs aren't irretrievable after tourniquet use. Not sure if that is reflective of unnecessary application (say, bleeds that are controllable pre-hospitally via direct pressure but a provider applies a tourniquet) or not.


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## Code 3 (Jan 25, 2013)

EpiEMS said:


> I think that's the worry -- then again, it seems like there's lots of data that has come from military use in Iraq and Afghanistan indicating that limbs aren't irretrievable after tourniquet use. Not sure if that is reflective of unnecessary application (say, bleeds that are controllable pre-hospitally via direct pressure but a provider applies a tourniquet) or not.



I think overall, regardless of unnecessary application, you'll find that tourniquets are not limb threatening in the pre-hospital setting. From what I've read, and correct me if I'm wrong, tissue death due to a tourniquet cutting off circulation can occur as early as *2 hours* after application. I'm sure the vast majority of us are at a hospital well before that time frame.

In addition, the NREMT has also changed the "Bleeding Control Shock Management" skill to use a tourniquet immediately if the wound continues to bleed after direct pressure. Interesting to see how things have changed:

*Bleeding Control Shock Management (Old)*

Apply direct pressure
Elevate the extremity
Apply additional dressing
Apply pressure to the arterial pressure point

*Bleeding Control Shock Management (Current)*

Apply direct pressure
Apply tourniquet


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## STXmedic (Jan 25, 2013)

Our assistant medical director (who is a military trauma surgeon and spoke at the most recent trauma symposium) has told me multiple times that tourniquets can be left on for up to 6 hours and still be reversible. So for prehospital, unless you're somewhere very rural and in the middle of a blizzard, I wouldn't be too concerned. I'm not saying go straight to tourniquets on any significant extremity bleed, but if you have coworkers that you feel put them on unnecessarily once in a while, I don't think it would be too detrimental.


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## EpiEMS (Jan 25, 2013)

Code 3 said:


> *Bleeding Control Shock Management (Current)*
> 
> Apply direct pressure
> Apply tourniquet



Ooh I haven't seen the new NREMT skill sheet for this, thanks!




PoeticInjustice said:


> Our assistant medical director (who is a military trauma surgeon and spoke at the most recent trauma symposium) has told me multiple times that tourniquets can be left on for up to 6 hours and still be reversible. So for prehospital, unless you're somewhere very rural and in the middle of a blizzard, I wouldn't be too concerned. I'm not saying go straight to tourniquets on any significant extremity bleed, but if you have coworkers that you feel put them on unnecessarily once in a while, I don't think it would be too detrimental.



Interesting! My scene time and transport time are usually pretty short, especially for trauma. Thanks! I'm gonna look up some research on this topic -- I think the Borden Institute at USAMEDD has some info.


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## Code 3 (Jan 25, 2013)

EpiEMS said:


> Ooh I haven't seen the new NREMT skill sheet for this, thanks!



No problem! I'm not sure when they instituted the change, but I'm sure someone who knows will chime in. You can download the skill sheet directly from here: https://www.nremt.org/nremt/about/psychomotor_exam_emt.asp


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## EpiEMS (Jan 25, 2013)

Code 3 said:


> No problem! I'm not sure when they instituted the change, but I'm sure someone who knows will chime in. You can download the skill sheet directly from here: https://www.nremt.org/nremt/about/psychomotor_exam_emt.asp



I just took a look, seems like a reasonable change to make, considering that pressure points are useless, as is Trendelenburg.


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## mycrofft (Jan 25, 2013)

*Gotta surface here.*

Has to be a proper tourniquet.

If it is too loose, it will potentially speed bleeding by sealing off just veins (lower pressure than arteries) and cross-circulatory routes will pump more blood to the bleeder, like a phlebotomist's TK.

If it is too narrow, too tight, or too close to the wound it will crush tissue irretrievably.

And it is to be used when other modes don't work.

A good tool we had taken away because it was abused partly because first aid sources taught people to improvise. (Ever actually try to make one out of a belt?).

Back to lurk mode.


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## EpiEMS (Jan 25, 2013)

mycrofft said:


> Has to be a proper tourniquet.
> 
> If it is too loose, it will potentially speed bleeding by sealing off just veins (lower pressure than arteries) and cross-circulatory routes will pump more blood to the bleeder, like a phlebotomist's TK.
> 
> ...



What's your favorite TQ? My service uses the MAT, which is pretty good: http://www.mooremedical.com/index.cfm?PG=CTL&FN=ProductDetail&PID=13918


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## Household6 (Jan 25, 2013)

PoeticInjustice said:


> Our assistant medical director (who is a military trauma surgeon and spoke at the most recent trauma symposium) has told me multiple times that* tourniquets can be left on for up to 6 hours and still be reversible.* So for prehospital, unless you're somewhere very rural and in the middle of a blizzard, I wouldn't be too concerned. I'm not saying go straight to tourniquets on any significant extremity bleed, but if you have coworkers that you feel put them on unnecessarily once in a while, I don't think it would be too detrimental.



That's exactly what they teach in CLS and Level 1 Warrior Skills --6 hours.. For a partial or complete amputation of a limb they skip pressure and Chitosan and go straight to a Combat application tourni. Soldiers trained for the battlefield aren't concerned about tissue death. Apply a CAT tourni, mark a "T" on the patients forehead with pen, mud or blood, then move on to the next causality.. If someone needs CPR, skip them and move on.

The training I went through with the military is so different from what we're being taught in school..


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## 9D4 (Jan 25, 2013)

Code 3 said:


> No problem! I'm not sure when they instituted the change, but I'm sure someone who knows will chime in. You can download the skill sheet directly from here: https://www.nremt.org/nremt/about/psychomotor_exam_emt.asp


I was told the skill sheets changed in late 2011/ early 2012, not sure exactly of which. But our instructors said we were the first class that they were having to teach tourniquets to again. 
I dunno, though. I've never actually seen a tq, let alone used one. Besides phlebotomy class, that is  and I don't think the lavender scented tourniquets we use in there are applicable to ems... haha


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