EMS Deployment of Tourniquets

[SwissEMT]

Hey ALS,

I decided to start this discussion in this section due to the fact that I felt it most fitting.

With the Iraq and Afghan war we've seen the use of TQs for bleed management on the rise. Though prior to this war, there was the notion that any limb that is TQed will be lost, many cases have proven otherwise. As is the trend with Prehospital medicine, we draw a lot from our military counterpart. So, it's only a matter of time- I'm sure- before Tourniquets will be added to ALS protocols for severe bleed management and believe it to be a good move as a last ditch option. A lot of good medicine is coming out of such a bad place as Iraq, so let's talk about it!

What are your thoughts on the issue? I look forward to discuss this with some of you greatly.

-SwissEMT

 

[Ridryder911]

War is the only place we can adequately learn about trauma. Neuro, traumatic amputations (which they have seen a lot, & use of tourniquets), TBI,..etc.

Here is a link to New England Journal of Medicine, discussion.

http://content.nejm.org/cgi/content/full/351/24/2471

 

[Summit]

perhaps we will see widespread prehospital use of hemostatics as well as a result of the positive military experience with HemCon bandages

 

[SwissEMT]

perhaps we will see widespread prehospital use of hemostatics as well as a result of the positive military experience with HemCon bandages

I hope so. It's also worth mentioning that a lot of the bad fuzz regarding Quikclot might be irrelevant with their new release of the non exothermic pads. They had a free sample opportunity which I missed out on a few months back.

 

[DT4EMS]

The early use of Tourniquets is part of the new PHTLS Course. "Damage Control" is the military basis of their early use.
The idea was to save as many RBC's as possible.

 

[bstone]

Don't we already use tourniquets? Two BP cuffs, one proximal and one distal to the wound?

 

[Ridryder911]

Don't we already use tourniquets? Two BP cuffs, one proximal and one distal to the wound?

? Why would one place two tourniquets, especially on both sides. If you were to shut off the blood supply there would be no blood supply to the wound and no blood supply posterior the wound.

 

[SwissEMT]

Don't we already use tourniquets? Two BP cuffs, one proximal and one distal to the wound?

You place only a single TQ above the site of injury.

And thus why TQs should be taught in our protocols. Glad to see them being added to PHTLS. Sounds like some people are using their brains.

 

[Ridryder911]

Well, before we start endorsing tourniquet use, we need to be aware of the injuries and MOI such as blast injuries, which is not common in civilian practice. I believe they are great for such injuries, but not for all common severe lacerations. I personally have only seen a couple of times for indications for usage in the civilian world. These were related to the OKC bombing, and farm machinery degloving/amputation.

R/r 911

 

[bstone]

I seem to recall being taught that we occlude blood flow both proximal and distal. Of course I have never actually done it nor known anyone who has. As such, I am open for re-education.

 

[DT4EMS]

According to the PHTLS 6th Edition, here is what is being taught about Tourniquets…..

1) Direct Pressure is applied first to attempt to control bleeding.
2) The use of elevation is now discouraged. According to the PHTLS book, there is no evidence to prove elevation does anything to control the hemorrhage.
3) A pressure dressing is supposed to be applied when your hands are needed for something else. The guidelines are suggesting bleeding control takes precedence over IV.
4) If the bleeding cannot be controlled by direct pressure a Tourniquet is to be applied.
According to the data, “Used properly, tourniquets are not only safe, but also lifesaving”.

As far as a time limit, “Arterial tourniquets have been used safely for up to 120-150 minutes in the OR without significant nerve or muscle damage”. –PHTLS 6th Ed. Pg181-182

This is a whole new way of thinking. But now there is the science to back it up. If you have not seen the “Damage Control Rescue” presentation from the military, you need to check it out. The idea is to save as many RBC’s as possible. It makes total sense to a guy like me, who is not as smart as many others. 

 

[Guardian]

Makes sense to me and is another example of those “dumb” military guys being on the cutting edge.

 

[Ridryder911]

If you occlude above the site (proximal) you would immediately shut off blood supply distal from the wound, since there is no blood flow past the tourniquet. Hence only one is needed.

R/r 911

 

[Luno]

TKs like most other things have their place. In some classes, we don't even bother with elevation or pressure points, direct pressure then tk. But for those classes the priorities are different, and generally tks are self-applied.

 

[SwissEMT]

we don't even bother with elevation or pressure points

That :censored::censored::censored::censored: never worked anyways.

 

[Ridryder911]

I totally disagree, I have yet seen in very and rarely extreme cases tourniquets are ever needed. Usually, because very few know how to apply adequate pressure to pressure points. I have seen the initial steps control 99% of hemorrhaging. In very few incidences and occurrences, I have ever seen it not work.

I have even worked a triple amputation on three separate individuals (3 on a motorcycle) at thigh level and never needed one. Vasoconstriction occurs rapidly and thus usually prevents bleeding. One of the few times I ever applied a true tourniquet was on one of the OKC bombing victims, and it was blasting injury.

Again, blast injuries and the injuries that are occurring in war time and those in civilian cannot always be comparable. There is large difference in mechanism and injuries of a projectile with shrapnel then a laceration and tearing from civilian occurrence trauma.

Before we make too many assumptions, let's remember where delayed care to O.R. was started at, MAST originally started from. We will need to review and study any changes methodically and in detail before changing routine care. We don't want to have another red face, like before.

R/r 911

.

 

[SwissEMT]

Well you'll have to excuse my skepticism regarding the use of pressure-points and elevation as steps to control the bleeding, but I guess I haven't received adequate training in their employment. I'm not one to stick by my opinions if someone who's forgotten more than I know says otherwise, so I'm all ears.
I'm an EMT-B, so I fear that my education was generally inadequate to teach me the proper implementation. Do a lot of people share the same view? Do you have an article or resources which I could take a look at? I'm always looking for improving my skillsets.

 

[Ridryder911]

I understand, but look at it this way.. I have seen more and more local EMS arriving with tourniquets lately because of someone has read or heard tourniquets are in style. Remember, once a tourniquet is applied all blood supply is ceased below or distal to the wound. Meaning you have decided for amputation for anything below that site.

Understand that in cath labs (albeit a nice clean puncture) arterial bleeding is routine. It takes a lot of pressure to push down on a pressure point and "clamp it down" to cease blood flow. That is why they usually have a large tech hold weight and pressure for at least 5-10 minutes, then we place a "mechanical clamp" ( looks like a C clamp) on the site or sand bags for hours without movement. Still then there is a chance of internal bleeding and cause of a hematoma. Applying pressure to pressure points is NOT as easy as one thinks because it takes a deep continuous pressure (especially in the femoral area) and a lengthy amount of time, that many do not realize. You are basically squeezing the artery shut, causing cessation of blood supply of that specific artery (not all blood supply, such as the use in tourniquets).

I am not saying tourniquets are never necessary, especially for those specific wounds they see in a war zone. However; the lacerations, avulsions, pedicle tears, we routinely see in civilian trauma can almost be always be stopped by simple methods direct pressure and pressure bandages.

Projectory wounds that have shrapnel and multiple "tumbling" effect causes multiple deep tissue injuries sites, along with multiple arterial tears and lacerations. These types of explosions are most commonly from IED type devices, and it is not unusual to receive partial to complete amputations of the extremities. Other routine associated injuries are deep imbedment of shrapnel into cavities such as the chest, abdomen and cranial vaults.

I have discussed with those over there (medics, nurses, physicians) the type of wounds, some newer treatment regime and outcomes. Tragically, the only good thing about war, is that we learn how to decrease morbidity and increase trauma care ten fold than in civilian peace time.

I am very impressed on many of the learned trauma care. I am excited of some of the progression we are learning. Especially new traumatic brain injury (TBI) treatments of actually making a window (removing part of the skull and implanting into an abdominal wall to allow blood circulation to the skull portion) to allow cerebral edema to occur and when the edema reduces, placing the skull portion back on. Other treatment od chest wounds, repairing of organs and other radical treatments that would took decades to develop and test in civilian peace time.

Again, I am amazed of what, how, is being learned and tested and as well honor those that are developing new and radical treatments to save lives and the sacrifices of those that received such wounds and injuries.

Yes, it may be that we see tourniquets are the new way to control bleeding in multiple type injuries. I don't doubt it. Yet, we need to see exactly what protocol and regime they were best used on. Unfortunately most learned treatment will be a few years from now, before it is considered to be placed into the private world. Until then be sure, we follow steps that are in the curriculum and considered standard of care.

R/r 911

 

[Ian Philbrick]

EMS use of tourniquets

In SA, our protocols state that the use of tourniquets is for amputation only.

Our first aiders and ems trainees are still being taught:

1. Direct Pressure
2. Indirect Pressure (pressure points)
3. Elevation
4. Splinting/Immobilisation

The new AHA guidelines say as said before that elevation has no proven benefit. This is also appears in the the PHTLS manual as I recall form on of the posts.

I must disagree on the routine use of tourniquets, as they should be a last resort, and then only really for amputations where there is a ragged wound (blasts, some shark bites etc.)

I have been in the EMs for nearly 20 years now and can count on on hand (excluding thumb!) the number of times I have needed to use a tourniquet.

The problem is as some have alluded to: this has been picked up by some/many as the "in thing". Poorly applied tourniquets often increase the bleeding due them not being tight enough and only causing venous blockage.

The rational behind their use in the military, I believe, is:

1. The types of wounds inflicted often need tourniquets.
2. Tourniquets are a quick to apply under fire.
However, once the victim is moved away from the danger zone, I am sure that convential methods of bleding control can take place.

This does not necessarily extrapolate to the same need in the civilian environment.

My 14 cents (2 cents US)

IAN

 

[Luno]

Rid/Ian, I completely concur... (I think that's a doctor word... ;P) the times in civi EMS that I've seen the need for a TK have been, uhhhhh ZERO. Yes, we do teach TKs in Tactical Medicine, because if you elevate, you're probably in the line of fire now, it you need pressure, guess what, something's gotta apply that pressure, so either you do, and now you have no hands to remain in the fight, or someone else has to, which removes another person from the fight. TKs in a tactical environment are very simple, and effective, however I'm not so convinced that their use in civi EMS outweighs their potential misuse, with some apparently very few exceptions.