# Tourniquet Protocol?



## EpiEMS (Feb 13, 2012)

I'm enrolled in an EMT-B/WEMT course but haven't started yet, so I've been reading my textbook etc. While reading about external bleeding, I remember having heard something about how the military has moved tourniquet use to the first-line treatment — before direct pressure — for substantial extremity bleeding. I'm curious, then, why EMT-B protocols (I looked at CT, NY, and NH) don't seem to suggest immediate application of the tourniquet, for, say, traumatic amputation due to an MVA or something, whereas the military CLS and 68W guidelines suggest immediate application, as far as I can tell.

Perhaps it's because in a civilian EMS setting you'd expect closer proximity to a hospital with early life/limb-saving surgery that can reattach it?

I haven't started my class yet, so this is really just a question from somebody with a undergraduate-level understanding of biology.


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## Veneficus (Feb 13, 2012)

EpiEMS said:


> I'm enrolled in an EMT-B/WEMT course but haven't started yet, so I've been reading my textbook etc. While reading about external bleeding, I remember having heard something about how the military has moved tourniquet use to the first-line treatment — before direct pressure — for substantial extremity bleeding. I'm curious, then, why EMT-B protocols (I looked at CT, NY, and NH) don't seem to suggest immediate application of the tourniquet, for, say, traumatic amputation due to an MVA or something, whereas the military CLS and 68W guidelines suggest immediate application, as far as I can tell.
> 
> Perhaps it's because in a civilian EMS setting you'd expect closer proximity to a hospital with early life/limb-saving surgery that can reattach it?
> 
> I haven't started my class yet, so this is really just a question from somebody with a undergraduate-level understanding of biology.



Let me see if I can say this in a simple way.

First and most importantly, most EMS treatments are based on thinking from at least 20 years ago and closer to 40.

Prior to advancements in microvascular treatments and understanding of cellular inflammatory processes, it was thought that a TK would result in loss of the distal tissue or that in order to limit systemic response it would need to be amputated.

This is simply not the case.

Civillian and military medicine have very little overlap. Particularly in trauma and trauma systems. 

First, from the system standpoint, there is rapid identification, treatment, and a highly choreographed move through a chain of experts the civillian world cannot devote similar resources to.

There is also the battlefield/remote aspect of treatment. In a situation where superior firepower is the first aid of best result, the faster you definitively manage a wound, the better it is for all.

Wound dynamics.

All wounds are not created equal. 

The body has numerous molecular responses to wounds (which I don't feel like typing out now because I am reading about compliment activation by TLRs and NfKb signalling in sepsis)

but suffice to say that military GSW and blast wounds have different characteristics than more "civillian wounds" like truamatic amputations.

Even the types of gunshots makes a difference.

The high velocity rounds and blasts cause more diffuse tissue disruption that marginalizes most endogenous hemostatic mechanisms. ( larger lengthwise disruption, secondary cavitation etc.)

Some civillian rounds are designed to do the same thing by a different mechanism, glazers and hollow points to name a couple.

The combination of the environment, method of tissue destruction, and surgical resources of the military predispose to the use of TKs.

In the civillian world they are losing the stigma of a "last resort" but it is slow, particularly in EMS which moves well behind modern medicine.

The combination of rarely seeing wounds that require a TK over direct pressure along with proximity of definitive trauma resources in urban and suburban environments makes the TK really a device of rural providers and the rarest of grevious civillian injuries.

a TK is simply a tool in the bag. Like any tool, it is better for some jobs and not others. The military environment predisposes to the use of the TK. The civillian to direct pressure. It is not to say that there are not times when these tools are effectively applied in the opposite environment.

"Don't use a cannon to kill a mosquito"


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## TheGodfather (Feb 13, 2012)

in the traumatic amputation scenario, direct pressure with a gloved hand is usually all that is needed (besides common sense) to tell that direct pressure will not suffice in stopping hemorrhage. 

other bleeds (absent of the realm of amputation/partial amputation) may appear to be major and uncontrollable, but you'd be surprised at what you can do with a trauma dressing and firm pressure. (scalp lacerations being a prime example in this situation - obviously you cant TQ the neck, but those generally flow pretty good and are stopped fairly easy with direct pressure [or alligator clips if for some god forsaken reason you have them])

^^ darn it! there venificus goes making my response look preschool


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## Veneficus (Feb 13, 2012)

TheGodfather said:


> in the traumatic amputation scenario, direct pressure with a gloved hand is usually all that is needed (besides common sense) to tell that direct pressure will not suffice in stopping hemorrhage.
> 
> other bleeds (absent of the realm of amputation/partial amputation) may appear to be major and uncontrollable, but you'd be surprised at what you can do with a trauma dressing and firm pressure. (scalp lacerations being a prime example in this situation - obviously you cant TQ the neck, but those generally flow pretty good and are stopped fairly easy with direct pressure [or alligator clips if for some god forsaken reason you have them])
> 
> ^^ darn it! there venificus goes making my response look preschool



What is an alligator clip?


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## TheGodfather (Feb 13, 2012)

Veneficus said:


> What is an alligator clip?



not generally used prehospital - they are surgical clips used to clip together the skin on the scalp before throwing stitches in it, or if you are in a pinch.

we got to play around with them in ATLS when i was involved in it

and im almost certain i confused the name with the ekg clips used to clip on the needle of a pericardiocentesis... lol but either way...


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## Veneficus (Feb 13, 2012)

are you talking about the preformed metal clips a few mm in length applied with a forcep?


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## TheGodfather (Feb 13, 2012)

Veneficus said:


> What is an alligator clip?



correction. they are called *raney* clips. my mistake!


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## Veneficus (Feb 13, 2012)

Thanks.

Technical name helps.

and so does the picture


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## EpiEMS (Feb 13, 2012)

I was gonna say...I always thought alligator clips were for wires, not people 

Thanks for the enlightening response, Veneficus!

I had always thought that tourniquets were the last resort because of the possible permanent damage to distal tissues. I guess I can't say I know much about microsurgery.

Would you say that, eventually, tourniquets could start to become a first-line way to stanch extremity hemorrhage?


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## Veneficus (Feb 13, 2012)

EpiEMS said:


> I was gonna say...I always thought alligator clips were for wires, not people
> 
> Thanks for the enlightening response, Veneficus!
> 
> ...



Never.

The volume of wounds requiring such are simply too few outside of the remote/war environments.


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## jwk (Feb 13, 2012)

Veneficus said:


> *Let me see if I can say this in a simple way.*
> The body has numerous molecular responses to wounds (which I don't feel like typing out now because I am reading about compliment activation by TLRs and NfKb signalling in sepsis)
> 
> The high velocity rounds and blasts cause more diffuse tissue disruption that marginalizes most endogenous hemostatic mechanisms. ( larger lengthwise disruption, secondary cavitation etc.)



  Sorry, couldn't help myself.


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## Veneficus (Feb 13, 2012)

jwk said:


> Sorry, couldn't help myself.



no worries, for me that was simple.


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## Melmd (Feb 13, 2012)

TheGodfather said:


> correction. they are called *raney* clips. my mistake!



This picture seems disturbing, is that a bloodied un protected hand holding a surgical equipment??? Ughh!


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## EpiEMS (Feb 13, 2012)

The hand right in the center looks gloved to me. Same fellow's left hand is gloved.


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## Fish (Feb 13, 2012)

EpiEMS said:


> The hand right in the center looks gloved to me. Same fellow's left hand is gloved.



Yeah, just looks like extremely tight and thin gloves


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## RocketMedic (Feb 13, 2012)

I've always wondered if tourniquets on the lower extremities in arrests would improve CPR.


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## EpiEMS (Feb 13, 2012)

Apparently, application of PASG/MAST could help — old article from NAEMSP. Would the same principle of "tourniqueting" lower extremities apply here?
See: http://www.naemsp.org/documents/EvaluationofPASGinVariousClinicalSettingscopy.pdf
page numbered as pg. 40


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## Handsome Robb (Feb 13, 2012)

I've also heard of PASG/MAST pants being used for hemorrhage control. We don't carry them and honestly I've only seen them once and that was in my medic school's "History of EMS" lecture.


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## EpiEMS (Feb 13, 2012)

I was sorta just throwing the idea out there- I haven't actually USED MAST/PASG, but I get the concept behind it. Ending up with more blood flow to the brain couldn't hurt. I guess I'll ask a EMT-P, ED RN, PA or EM MD/DO.


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## Handsome Robb (Feb 13, 2012)

EpiEMS said:


> I was sorta just throwing the idea out there- I haven't actually USED MAST/PASG, but I get the concept behind it. Ending up with more blood flow to the brain couldn't hurt. I guess I'll ask a EMT-P, ED RN, PA or EM MD/DO.



It makes sense in theory, I've just never seen a study to prove or disprove it. 

Your best bet is asking an MD/DO with a study to back it not someone with "Well in my experience...." type approach.


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## bigdogems (Feb 14, 2012)

So the NREMT skills checkoff is as follows. BSI of course. Direct pressure, Tourniquet, treat for shock. You can get the skills sheets of their website so it's no secret. I wouldn't say that Civilian and Military don't overlap. War is the proving ground for medicine. With that, it is where we started with the idea that using a tourniquet will mean an amputation of a limb. So if we flash back to the Civil War... Leg gets blown off... Tourniquet applied.... Spend a couple days at a medical unit before a doc looks at your leg... By that time infection has set in and you lose your leg. Nobody should ever die from an extremity injury. I have a friend that was a Cpt with the 101st in Afghanistan. They would go out on patrol with a tourniquet on each limb. With any traumatic extremity would they would immediately lock down the tourniquet until they got back to a medical unit. And its easy to find BDUs that have them built in.

With all that said. It will be hard to find a time you really need to use them. As said above direct pressure can work wonders. Even in traumatic amputations the  veins will vaso constrict  and direct pressure can usually stop the last of the bleeding


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## Veneficus (Feb 14, 2012)

bigdogems said:


> I wouldn't say that Civilian and Military don't overlap. War is the *experimenting* *ground for medical device manufacturers and medicine*.



Fixed it for you.

There have been lots of medical advances in war, there is even some overlap.

I didn't mean to suggest there was none. (every now and again a blast in jury)

But just because the military uses or does something does not make it the blanket solution for the civillian world. 

Not to be a smart ***, but I am not going out and buying a pair of sweatpants with a TK built in incase I get hit by a bus.

I keep hearing about extremity wounds where bleeding cannot be controled. 

How often in the civillian world is tha exactly? 1:1000, 1:100000 1:inept providers who saw a tk used on the military channel, or 1rovider who made a 1/2 assed effort at direct pressure because they don't actually have experience or know what an uncontrolled bleed looks like?

Back to the military environment. 

How often do they need a TK in Afghanistan in a day? 3? 4? 10? (depending on how bad the day right?)

How many would you estimate are needed in the whole continental US in a day? 

How many do you think would be applied if we made it the blanket first line in extremity hemorrhage control?

I could just see EMS bring somebody into an ED with a TK applied to a partial thickness extremity wound 2-3 cm in length with less blood than when I cut myself shaving. (and I don't use chemical clotting agents for that either.)


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## MedicBrew (Feb 15, 2012)

Interesting?!?!?(No sarcasm intended)

We utilize a commercially made tourniquet for our extremity injury protocol, based on evidence published in the PHTLS 6th ed, as well as other sources. I’ve read somewhere (sorry, don’t recall) of the application of tourniquets on the battlefield for up to 6 hrs with no residual effects attributed to the tourniquet. Granted, it’s a rescue measure when all else fails. 

Did a search and found a lot of information and studies to support their application. Have a buddy that just returned from Afghanistan and another getting ready to re-deploy and they both state that tourniquets are 1st line for hemorrhage control (both are medics). Seems a bit excessive to me, but I don’t work in the desert or mountains with people shooting at me. 

It never ceases to amaze me how different treatment modalities are in different areas of the same country. 

Good discussion!


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## EMDispatch (Feb 15, 2012)

Veneficus said:


> Fixed it for you.
> There have been lots of medical advances in war, there is even *some* overlap.



I agree current overlap is limited, but historically it has brought us:
-The "Golden Period" 
-Dedicated ambulance services and prehospital providers 
-Triage system

Those are some pretty significant overlaps.


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## Veneficus (Feb 15, 2012)

MCERT1 said:


> I agree current overlap is limited, but historically it has brought us:
> -The "Golden Period"
> -Dedicated ambulance services and prehospital providers
> -Triage system
> ...



Burn care
IO needles
whole blood transfusion
infection control

Many more and significant advances for me to recall at the moment.


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## EMDispatch (Feb 15, 2012)

My question is what will transfer over from the Iraq and Afghanistan wars?

As a relatively lay person on the subject I'd assume work with traumatic brain injuries would be the area to watch.


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## EpiEMS (Feb 15, 2012)

For some reading about the research that the military is doing and experience of military medicine in Iraq and Afghanistan, I suggest this: http://www.bordeninstitute.army.mil/
There's some really interesting case studies.

I'd wager that beyond TBIs, there's a lot of seriously good work in PM&R that's gonna come out of these conflicts because of the nature of extremity injuries.


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## Veneficus (Feb 15, 2012)

Have copies, read them last year. 

War surgery in Iraq and Afg. was by far my favorite, but after witnessing military medicine in action, they get a thumbs down.

The ones I encountered seemed to have forgotten the whole hippocratic oath. 

As such, true to its word, they have brought discredit upon themselves as doctors.


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## EpiEMS (Feb 15, 2012)

I've no personal experience with military medicine, but the books have been interesting reads. Frankly, they and books on medicine/public health in austere environments are what motivated my interest in epidemiology and taking an EMT-B/WEMT course.

Guy I know is aPM&R MD —:censored:I gotta ask him what he thinks about the rehab side of military medicine.


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## Bullets (Feb 15, 2012)

Weve just gotten TKs moved up in our bleeding control protocol. Now its direct pressure->TK

And our local SWAT unit wears BDUs with TKs built in, they stay secure under a velcro flap, rip and twist. pretty slick IMO


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## zmedic (Feb 15, 2012)

I'd just point out that the clips in that picture aren't for holding the wound edges together. They clip onto the cut edges of the scalp to prevent it from bleeding, allowing your to work on the skull underneath. At the end of the case you take the clips off and sew the scalp back together. 

I'm all for TKs in certain situations. I'm just not sure that there have been that many people in the civillian world that have bled out from extremity wounds. Just keep in the back of your mind that the companies that make these things want to convince you that you should have one in your pocket, one in your jump back, and 2 more in the ambulance. $$$$

(Clearly there are people who should be carrying them on their person. SWAT, maybe police in general)


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## RocketMedic (Feb 15, 2012)

zmedic said:


> I'd just point out that the clips in that picture aren't for holding the wound edges together. They clip onto the cut edges of the scalp to prevent it from bleeding, allowing your to work on the skull underneath. At the end of the case you take the clips off and sew the scalp back together.
> 
> I'm all for TKs in certain situations. I'm just not sure that there have been that many people in the civillian world that have bled out from extremity wounds. Just keep in the back of your mind that the companies that make these things want to convince you that you should have one in your pocket, one in your jump back, and 2 more in the ambulance. $$$$
> 
> (Clearly there are people who should be carrying them on their person. SWAT, maybe police in general)



Our unit's practice is to place a tourniquet on a penetrating extremity wound if the medic thinks that there may be vascular compromise. The classic example given is a rifle round to the thigh that leaves a small entry wound and no exit wound, yet cuts the femoral. Bleeding will be profuse and internal for the most part.


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## Tigger (Feb 15, 2012)

Bullets said:


> Weve just gotten TKs moved up in our bleeding control protocol. Now its direct pressure->TK
> 
> And our local SWAT unit wears BDUs with TKs built in, they stay secure under a velcro flap, rip and twist. pretty slick IMO



Supposedly the built in TKs are going to be a part of the next set of BDUs for our soldiers, can anyone on here confirm?


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## 911bru (Feb 16, 2012)

TD work wonders and I have seen someone have one on for about 5 hours without any damage when removed. There are people who have had them on longer without any problems. 
    I expect for them to become more prominent in protocols in the next few years. 

Army veteran
2006-2011
OEF-A 2008


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## DPM (Feb 16, 2012)

Tigger said:


> Supposedly the built in TKs are going to be a part of the next set of BDUs for our soldiers, can anyone on here confirm?



I wouldn't have thought so. In Afghanistan around 50% of our casualties came from IED's and these have a tendency to shred your trousers as well as the rest of you. Likewise, where is the TK sewn in? Above the knee, bellow it? If it's built in then you've really only got one option for where you want to place it, and if the wound is in the wrong place then you're stuffed. 

If you think the time it takes to remove a TK from a MOLLE loop / pouch is going to make the difference between life and death then this fella is probably going to die anyway.


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## Desette (Feb 23, 2012)

DPM said:


> I wouldn't have thought so. In Afghanistan around 50% of our casualties came from IED's and these have a tendency to shred your trousers as well as the rest of you. Likewise, where is the TK sewn in? Above the knee, bellow it? If it's built in then you've really only got one option for where you want to place it, and if the wound is in the wrong place then you're stuffed..



The ones that I have seen have 4 in the pants (One lower leg below knee and one high on the thigh) and you can also move the pants up and down depending on where you need it. There are shirts as well that have 4 as well.

The destruction of them in an IED is a very good point, another good reason for a back up  

Video below on the pants

http://www.youtube.com/watch?v=SKSx6952ya4


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## Veneficus (Feb 23, 2012)

Maybe it's just me...

But if your battle dress is better with built in hemorrhage control devices, you may want to re-evaluate your strategy and tactics.


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## mycrofft (Feb 23, 2012)

*Short shots*

I was taught by a former US Army nurse who served at Pleiku than many if not most TK's used during Vietnam conflict were medically unnecessary. Maybe battle-hasty expedient. 

(I thought they rejected the built-in TK uniforms years ago?).

Public Radio article said yesterday they now have a TBI "center" at KAF (Afgahnistan/ Kandahar). Now use multiple versions of TBI eval cards because troops were memorizing them!

Some approaches are later found not to be panaceas, like clotting agents.

At Kandahar, the biggest inroads I saw were mandatory hand washing before dining, and hand washing means available at toileting facilities. As well as disposable utensils and plates, and real live sewage and trash/garbage control, and bottled water in sanitary packaging.

R.O.T., 85% of war casualties are disease and accidents.


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## DPM (Feb 23, 2012)

To add to the tourniquet trousers idea, I've been in contact in a PB wearing a pair of gym shorts and body armour. If I'd been hit in the legs then my mates would have had to put my trousers on me to get the tourniquets working! All of our guys carry two a piece, team medics had a couple more. That's more than enough to go round.

The trousers in the vid look cool but that's it really. In the UK all troops carry their tourniquets and field dressings in the same place, their mates know where they are and how to use them. It's cheaper, more effective and probably more comfortable.


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## Bullets (Feb 23, 2012)

I actually just got a pair of those blackhawk pants (for free, natch) seem comfortable, ripstop is sweet, lots of deep pockets. Even without the TKs, a well made pair of pants

And im not saying stop carrying a separate TK if they switch to a built in style


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## Veneficus (Feb 23, 2012)

mycrofft said:


> I was taught by a former US Army nurse who served at Pleiku than many if not most TK's used during Vietnam conflict were medically unnecessary. Maybe battle-hasty expedient.
> 
> (I thought they rejected the built-in TK uniforms years ago?).
> 
> ...



If you are interested, when I was researching medical issues there, I read something that said most of the Russian casulaties were from disease and public health issues.


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## DPM (Feb 23, 2012)

I don't doubt that well made, though I'm not a huge fan of rip-stop. I lost the arse out of a pair of ripstop trousers climbing a fence in NI!

To me it just looks like a fancy extra gimmick. I'm a big fan of Kaizen (the Japanese system of continuous improvement) so I'll never have a go at some one for trying to innovate... but in this case though I can see several instances where these built in devices would work, I don't see them being enough of an improvement to justify $159 trousers. The CAT works better and it's cheaper.


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## mycrofft (Feb 23, 2012)

Kaizen. Or "Total Quality Management" as their mentor W.E. Demings called it. At least we beat them to SOMETHING!

Veneficus, does drinking oneself to death count as a public health issue?


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## EPFD112 (Mar 5, 2012)

Bullets said:


> Weve just gotten TKs moved up in our bleeding control protocol. Now its direct pressure->TK
> 
> And our local SWAT unit wears BDUs with TKs built in, they stay secure under a velcro flap, rip and twist. pretty slick IMO



EMT student in NY here, and this protocol was just changed for us before I started my class. It's now:

Direct Pressure -> Direct Pressure again -> Pressure Bandage -> TK. 

Arterial Pressure points used to come before the TK but have since been removed from protocol in NY.


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## DPM (Mar 5, 2012)

EPFD112 said:


> Arterial Pressure points used to come before the TK but have since been removed from protocol in NY.



We tried them in the Army and I was never a fan. You have to put a lot of pressure on there for a long time, and that's essentially what a TK does anyway.

The biggest improvement we say in TK use in theater was teaching people that they only needed to tighten it until bleeding was controlled. And now we have triple amputees surviving, not that it's necessarily a good thing...


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## Shishkabob (Mar 5, 2012)

Pressure.

Pressure not working?  TQ.

TQ not working?  You did TQ wrong.




Don't be afraid to do a TQ... you can even waste ~5 hours and still have little chance of any long term damage being done to the extremity.  When in doubt, throw on the TQ and take them in.


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## EMT91 (Mar 6, 2012)

In Nevada, at least in my area, we are not allowed to use tqs.


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## docmoods (Mar 21, 2012)

Bullets said:


> And our local SWAT unit wears BDUs with TKs built in, they stay secure under a velcro flap, rip and twist. pretty slick IMO



They're great till the injury passes over or is above one :censored:

-Moods


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## NYMedic828 (Mar 21, 2012)

I think it was already mentioned but NYS and NYC have changed their protocol to direct pressure, pressure dressing, tourniquet. 

2-3 inches proximal to the injury sight, atleast 1" in diameter.


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