# Tourniquet?



## mizzouRAH (Jul 5, 2011)

So I'm going to take my NREMT written on Thursday and I'm a little confused on the use of tourniquets...

My question is, do you go straight for the tourniquet if direct pressure and elevation don't stop the bleeding?  Some of the practice test I've taken say use pressure points and some say to go straight for the tourniquet

Any help would be much appreciated... Thanks!


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## Kale (Jul 5, 2011)

If I recall correctly, NREMT wants you to apply pressure first and tourniquets only if you've failed to control the bleeding via other means (i.e. pressure). 

Because it's NREMT, none of these questions are especially contextualized so you shouldn't get some scenario presented to you where it's asking you what you'd do if you rolled up on a massive arterial bleed that had been spewing for a full five minutes prior to your arrival or something.

So yeah, pressure first. Unless something has changed since I took it, which was only about a year or so ago.


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## Nerd13 (Jul 5, 2011)

Currently if bleeding is uncontrolled by direct pressure alone you go directly to applying a tourniquet. 

NREMT skill sheet for bleeding and shock management can be located here: http://www.nremt.org/nremt/downloads/bleedingcontrolshock.pdf


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## Shishkabob (Jul 5, 2011)

As per the NREMT, it's direct pressure then directly to a TQ.  Elevation / pressure points are no longer recommended because, well... they're pointless for our purposes.  If direct pressure isn't stopping the bleeding, you don't have time to waste to see if something else will.



In reality, if you think a bleeding wound might be an issue, slap on a TQ.  You have hours to take it off without any detriment, and the outcome could be a lot worse if you hesitate using it.


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## mizzouRAH (Jul 5, 2011)

Awesome, thanks for the fast response...


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## usafmedic45 (Jul 5, 2011)

For more than you ever wanted to know about tourniquets (or if you need something more effective at putting people to sleep than Ambien):  http://www.wjes.org/content/2/1/28


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## Combat_Medic (Jul 6, 2011)

usafmedic45 said:


> For more than you ever wanted to know about tourniquets (or if you need something more effective at putting people to sleep than Ambien):  http://www.wjes.org/content/2/1/28



Wow now thats a lot TQ info.  Maybe one of these days i'll finish reading it all.


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## mycrofft (Jul 6, 2011)

*mizzouRAH, tell em what they want!*






Then follow your protocols. AND read the literature.


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## Outworld (Jul 19, 2011)

*Pressure points vs NREMT*



Linuss said:


> As per the NREMT, it's direct pressure then directly to a TQ.  Elevation / pressure points are no longer recommended because, well... they're pointless for our purposes.  If direct pressure isn't stopping the bleeding, you don't have time to waste to see if something else will.



I am all for going to the TQ and not wasting time...BUT, pressure points (and to a lesser degree) elevation is NOT pointless for our purposes..
Not recomending pressure points and elevation. Really? This is the kind of stuff that NREMT puts out because....I don't know why actually. Cause it is too hard to teach medics and EMT's to think and do lots of things all at once? 
In fact, if your patient has an arterial bleed and direct pressure does not work...pressure points might slow things down at least while you get the TQ on...and elevation helps, primarily if you think of elevation in terms of not leaving the limb dependent but rather move it to a position that is at least at the level of the heart...every little bit helps and a good medic should be able to do all of these at the same time...and that means using volunteer bystanders or your knee to apply pressure while you get the TQ on..
and....if your patient loses an arm at the shoulder pressure points are all you have.
So get good at all of 'em...you won't always have a nice TQ ready to go when you need it and best if you learn how to buy some time.


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## mycrofft (Jul 19, 2011)

*Red Cross too...no mo' pressure points and elevation.*

Personally, I've seen elevation work on very distal stuff, and I've seen lowering limbs make it easier to draw blood or start an IV. It won't affect major bleeds until the hemodynamic pressure is weak enough to be overwhelmed by the friction and gravitation resistance on that column of blood. (As they say, all bleeding stops eventually).

Pressure points are fraught with drawbacks. They work best if you are compressing the very same artery that is injured, or gone far enough proximal that it temporarily obliterates *nearly all* arterial supply to the site of insult, like a tourniquet. (E.G., the old knee in the gut to narrow the descending aorta maneuver). They hurt like the devil. They require anatomic knowledge and physical strength to do it right. And if you establish a good pressure point (never seen one more proximal than the antecubitus), you have both hands tied up. 
Maybe if the TK and the pressure and the Haemacell aren't doing it, then I'm going to try it as I try to think my way out of that corner.

OP, dig back into the book, tell them what they want, then study the protocols where you get hired.


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## Tigger (Jul 19, 2011)

What is everyone using for tourniquets right now?

At my place in CO we have the Combat Application Tourniquet, as does the local FD and AMR.

Here in MA though, all the company gives us is the same sort of elastic band that one would use as a constricting band to assist in the starting of an IV. Is the elastic band (about 3/4" wide) actually useful to stop blood flow? I'm wondering how easy it would be to remove all that slack caused by the stretch. It also seems that it would be come very narrow, which might possibly cause additional damage? The CATs are easily twice as wide.


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## mycrofft (Jul 19, 2011)

*A venous torniquet is inappropriate and unacceptable*

Not only will it not tighten down properly to stop bleeding, but it can actually speed bleeding (hence its use by phlebotomists).


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## AJ Hidell (Jul 21, 2011)

Outworld said:


> I am all for going to the TQ and not wasting time...BUT, pressure points (and to a lesser degree) elevation is NOT pointless for our purposes..
> Not recomending pressure points and elevation. Really? This is the kind of stuff that NREMT puts out because....I don't know why actually.


Because, it's what the evidence suggests is best practice.  Reading the studies should tell you that.

The biggest problems with pressure points is that damn few EMTs outside of a combat zone will ever use them enough to become or stay competent at it, thus wasting precious time and blood.

And of course, if you are in a combat zone, you have neither the time or extra hands to hold manual pressure on one wound for the next 30 mins or more.  Consequently, tossing out those other steps is an intelligent move, and one I made close to 20 years ago.  NR(and EMS in general) tends to be slow on the uptake.


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## Trevor (Jul 22, 2011)

We use the CAT also. Our protocols are fairly open and essentially state, any life threatening hemorrhage that can not be controlled by other means... OR, in the presence of any other life threatening condition where control of the hemorrhage, with a tourniquet, is faster then by other means...


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## 325Medic (Jul 22, 2011)

P.A. S.O.P.'s allow for the usage of T.Q.'s as leading off if severe hemmorage is noted with unstable v/s. @ MY F.T. gig, we use the SOFT-T's and have used one already with good results. We also use them on the tac. team / USAR team.

F.M.


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## Stingray91 (Jul 22, 2011)

There was a question in classroom that I thought was kind of unfair. It basically asked what comes after direct pressure. 
Well, the book we were studying out of said apply the tourniquet immediately after if direct pressure doesn't stop the bleeding. So that was the answer that I picked since it was from my study guide. Well, half the class put that too, and got it wrong. 
Correct answer: Direct pressure, elevation, pressure point, tourniquet. Which is the correct answer for the state level & not national :wacko:


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## Outworld (Jul 27, 2011)

AJ Hidell said:


> Because, it's what the evidence suggests is best practice.  Reading the studies should tell you that.
> 
> The biggest problems with pressure points is that damn few EMTs outside of a combat zone will ever use them enough to become or stay competent at it, thus wasting precious time and blood.
> 
> And of course, if you are in a combat zone, you have neither the time or extra hands to hold manual pressure on one wound for the next 30 mins or more.  Consequently, tossing out those other steps is an intelligent move, and one I made close to 20 years ago.  NR(and EMS in general) tends to be slow on the uptake.



I have read the studies....they assume that you have the pratical ability to produce and deploy a TQ quickly. Goodo, when you can achieve that that is a swell solution. I'm all for it. I am happy to see the destruction of all the myths that have prevented application of TQ's for decades.
The 'evidence' from your studies that you cite would have us exclude all those pesky MCI's, disaster responses, isolated locations, dropped off the roof TQ's and the hundreds of other opportunities to spend valuable time screwing around building, finding and deploying a TQ with NO other intervention than direct pressure.
And I agree with all the points made that it is difficult and requires some (modest) knowledege of anatomy. 
I just disagree with 'tossing those steps out' because they are pesky and hard to learn..... 
As for only needing them in a combat zone, and not being able to apply a pressure point in a tactical situation..you make an awful lot of assumptions.


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## TroyOck (Jul 28, 2011)

i was told tourn's are sorta last resort. They can cause more damage than help if used incorrectly


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## BrickEMT (Jul 28, 2011)

I just took the homeland security course for medical preparedness and response to bombing and those instructors HIGHLY suggested the use of tourniquets even in situations where it may be able to control bleeding with direct pressure. According to them if you have to ask yourself whether you can stop the bleeding, you should just slap on a tourniquet. They cited a lot of info coming in from Iraq and Afghanistan and said there was a soldier who had a tourney on for 12 hours and had no loss of function nor vascular or nerve damage.


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## guttruck (Jul 28, 2011)

according to GA fire its direct pressure,pressure point,then tourny.......but that is out extreemly outdated


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## AJ Hidell (Jul 28, 2011)

Outworld said:


> I have read the studies....they assume that you have the pratical ability to produce and deploy a TQ quickly.


It weighs three ounces and you can fit a dozen in one BDU pocket.  EVERYONE has the practical ability to quickly deploy one if they really want to.  Funny how nobody has trouble deploying a BVM when it comes time to do CPR.


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## 325Medic (Jul 29, 2011)

As our brothers and sisters on here can atest too: OIF / OEF shows that having a T.Q. on for more that 4-6 hours usually is not detremental. I was taught in the Army / now civ. tac medic that if the ext. is that damaged, you will prolly lose it anyway and OF COURSE, bleeding MUST be stopped.

325.


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