New look at tourniquets

mycrofft

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We were all trained at some time and level to consider TK's like the Devil's pretty sister. The nature of wounds in the current conflicts and the relocation of battlefield 2nd and 3rd echelon care (some degree of surgery) very close to the scene of battle has, as wars do, forced us to rethink this valuable tool.
If you have used them, especially in Iraq/Afghan, please share the current official and unofficial protocols. If you have used them elsewhere, chime in. Please note if you speak from first, second, or no-hand (sorry!) experience.
 
Gotta go see some felons, so... here's a pebble.

First hand: never had to. Used pressure, pressure points, elevation. These are not combat experience.
Second hand: Saw a couple amateur TK's come to the ER while stateside. Not necessary in either case and one was made of wire (eek). Neither was tight enough to actually stop the arterial flow to the legs they were on.
THIRD HAND:A coworker described an incident where a drunk has his neck cut with a bottle, another drunk whipped off his belt to use as a tourniquet, and the wide belt acted as an occlusive pressure device for the few minutes it took LE and parameds to arrive (not tightened very much).
 
1st hand, any extremity arterial hemmorhage with shock, or any penetrating injury that has resulted in exanguinating hemmorhage get a TQ. The trauma staff at our medical direction hospital feels that they are effective, do not require extra hands to provide manual compression of pressure points or elevation, cause little to any harm, are removed in short order in the OR under general anesthesia and save lives. There have been cases where they were not used because there was no active bleeding only to result in severe hemmorhage during resus as volume is being restored, therefore theyy are the tx of choice in patients who have lost significant volume and present in a hypoperfused state, regardless of active bleeding or not. This is the protocol as dictated by the surgical staff here.

As for the TQ itself, it is a length of surgical tubing, double wrapped and pulled tight, secured with hemostats. There is discussion of going to a commercially made TQ such as the CAT, however as things are today, its is the former.
 
We use them in our protocols. Any extreme extremity bleeds get a TK. We use the one made by NArescue. They are fast and work well. Why wait and use pressure, that may stop the bleeding after a while. But, your pt loses a liter of blood in the process. Put a TK on and stop it right away.

We also use them in remote rescue and have had them on for up to 7 hours, with no ill effects.

This is one thing that has been changed due to evidence based medicine, not old myths!
 
First hand of using a bp cuff as a TQ on multiple occasions only in the civillian world.

I think that it is the advancement of vascular surgery that makes tqs more valuable now. Knowledge of metabolism, surgical procedure, and rehab is exponentially larger than it was when the first EMS treatments were devised.

(in the terms that they will not automatically result in loss of a limb)

Perhaps we were just afraid of the potential consequences and complications of tq use early on and the myth has been carried on? Wouldn't be the first time it has happened.

Also the advancements in trauma systems makes this a more usuable tool.

All of the literature coming out of recent conflicts demonstrate it can be beneficial. Probably just like Novo7 for trauma, it's value depends on who you are giving it to.

http://www.hemostasiscme.org/Activities/TraumaManagement/ActivityHome.asp?

this is a really good lecture on the subject, though it is a bit older.
 
Thanx for this thread. I, like a lot of people were hit early with the thoughts we "NEVER us them usless you have no other choice. 1 hour at most and the patient will lose the limb anyway!"

I've never had to use them myself because I have never encountered a bleeder I couldn't stop by other means or get tx fast enough to have teh ER deal with it. Then again, the 2 sets of protocols I have worked under in my short time both went by the "DON'T USE THEM" mentality. It's interesting that other protocls not only allow them, but encourage them as a "first line defence". Maybe I'll keep one closer at hand then before... without breaking my obviously barbaric protocols. :blush:

Someone said in a recent thread that elevevation is not considered usefull by National Reg standards. Does anyone elses protocols still mention it?
 
Haven't used a tourniquet as of yet in the field but I haven't had a viable patient with a bleed that would warrant a tourniquet yet either.

Our protocols still mention elevation, and as far as I know it's still the second step according to the national standard curriculum. Maybe somebody can prove me wrong but until then I'd keep keep practicing elevation.
 
In our first aid kits that we get issued, there is a CAT (combat application tourniquet), which can be applied on oneself. They are awful simple to put on - I call them army-proof. They have been in use for some time now, and they're starting to be advertised in civilian publications. Most of the military first aid courses still go by the direct pressure/elevation/pressure point/tourniquet flowchart, although in extremity amputations, I've seen people go straight for the TK.

CAT: http://www.combattourniquet.com/tourniquet-videos.php
 
The Army is moving away from direct pressure on any wound that has more than a small amount of blood especially in situations were there is still combat going on so the fight can continue.

My platoon's medic in Iraq said the Army didn't start worrying about TQ time on until close to the 10-12 hour mark now.
 
I dont have any experiences one way or another, but i did have a question. my instructor was telling us that they took out elevation and pressure points here, so now we just got straight from direct pressure to tk. does anyone else know anything about this?
 
My service recently introduced a new protocol for tourniquet use. We are using military-style tactical TK's. Haven't had to use it yet, but I'm sure the opportunity will present itself sooner or later. A few of my coworkers that have had a chance to use it had positive opinions.
 
I'm sensing some subthreads here

For starters...MIDE, the military triage, where minimals get first tx to get them back on the line during combat. The other is, what are the long term outcomes of these ten hour TK patients? Wherein it's ok to TK people in a mass cas (HMVEE versus IED) and every case is life versus limb and you need to be taking tactical actions, but doing this to Granny whose lawnmower ran over her foot may not yield the best outcome.

We were taught that the majority of TK's coming in during Nam were unnecessary. This might reflect different mech of injury (Nam was mostly frags, Iraq seems to be high-powered slugs and explosive impingement).
Either way, I hope laypersons don't start applying half-cocked tourniquets on everything.
 
I agree 100% with you mycrofft. While combat medicine will always be to maintain combat strength the methods used don't carry over to the civilian medicine we practice most. TKs can be extremely effective and life saving when used properly but when not used can cause more harm than good.
 
Here is a literature review of tourniquets from historical to present.

Tourniquets for the control of traumatic hemorrhage: a review of the literature

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2151059

For those of you in California, you may be familiar with the Buncke Clinic in San Francisco which is the birthplace of microsurgery. This is what the microsurgeons prefer from the hospitals they receive patients for replantation of digits and extremities. The hand and digits are particularly sensitive to ischemia. Just about any ED in Northern and Central California will have a copy of their protocols.

http://www.buncke.org/book/ch30/ch30_1.html


Injured Hand or Extremity
Apply saline-moistened sponges to the wound and cover with a sterile, bulky dressing. If extensive bleeding is noted, apply a pressure dressing rather than a tourniquet. Truly uncontrollable bleeding must be treated surgically before transport. Splint and elevate the injured part for comfort.
 
For starters...MIDE, the military triage, where minimals get first tx to get them back on the line during combat. The other is, what are the long term outcomes of these ten hour TK patients? Wherein it's ok to TK people in a mass cas (HMVEE versus IED) and every case is life versus limb and you need to be taking tactical actions, but doing this to Granny whose lawnmower ran over her foot may not yield the best outcome.

We were taught that the majority of TK's coming in during Nam were unnecessary. This might reflect different mech of injury (Nam was mostly frags, Iraq seems to be high-powered slugs and explosive impingement).
Either way, I hope laypersons don't start applying half-cocked tourniquets on everything.

In the link i sent they talk about this. :)

But I think it is a matter of patient condition. A Tq because of the nature of IEDs and high velocity projectiles may be the best treatment for those wounds. Not "uncontrolled" bleeding in general. Most bleeding (90% according to my last ATLS class) can be controlled by direct pressure.

I think EMS needs to get out of the "one size fits all" treatment mode and start analyzing a bit more of what is going on with the pt.
 
I think they have Finally looked at the medicine side of it. That is why they are bringing them back to the forefront of EMS.

I have talk with the vascular surgeon here. He stated that he has no problem with the proper use of tourniquets. He served in Iraq and has seen their use up close. He stated that if they receive care in an appropriate time frame, that no damage to the vascular structures have been noted. He is watching their use in EMS closely, but is happy to see EMS Finally using evidence based medicine, rather then the old myths!
 
I have talk with the vascular surgeon here. He stated that he has no problem with the proper use of tourniquets. He served in Iraq and has seen their use up close. He stated that if they receive care in an appropriate time frame, that no damage to the vascular structures have been noted. He is watching their use in EMS closely, but is happy to see EMS Finally using evidence based medicine, rather then the old myths!

Does the vascular surgeon do replantation?

Again, this is provided the patient is taken right away to the vascular surgeon. Often, it is hours before the patient and their amputated body parts get to a replantation center. If everyone leaves the tourniquet in place, the patient has lost their extremity and will be paying for an expensive transport for cleaning a stump that could have been done at the sending hospital.

Many of those coming from Iraq are now at specialty centers either within the military system or referred clinics/hospitals for prosthetic fitting. Few, if any, have had replantation either due to the extent of damage or lack of microsurgeons that specialize in replantation. Some are coming to the civilian specialized micro and plastic surgeons for massive reconstruction and to even be able to use a prosthetic. In times of war, just saving life and moving the patient to safety are the most important priorities. However, in the U.S., with the availability of hospital care nearby and specialists that can save a limb and a person's occupation, it is worth a try to utilize the method that is least extreme. Using a tourniquet just because you can again may still not be the best alternative especially if it is not always warranted.

This deserves repeating.
I think EMS needs to get out of the "one size fits all" treatment mode and start analyzing a bit more of what is going on with the pt.
 
I think they have Finally looked at the medicine side of it. That is why they are bringing them back to the forefront of EMS.

I have talk with the vascular surgeon here. He stated that he has no problem with the proper use of tourniquets. He served in Iraq and has seen their use up close. He stated that if they receive care in an appropriate time frame, that no damage to the vascular structures have been noted. He is watching their use in EMS closely, but is happy to see EMS Finally using evidence based medicine, rather then the old myths!

I do not disagree with this at all, but what concerns me is that a Tq is not required for every bleed, just like an IV or a heart monitor is not required on every call.

I worry that EMS providers, especially those who do not see a lot of major bleeding will start using it as a first line treatment on any bleeding extremity when pressure would work just fine.

When extrapolating military medicine, I think it is important to look at the cause of the injury, as well as the anatomical structures involved.
 
I agree too. That is why the surgeon stated appropriate use! There are times they are needed. They may be needed as front line, but that is a case by case basis. Most services do not even carry them. So, if you need it, you need to make one.

That is where the evidence is bringing us. To have them back on the trucks, so they are there if needed!
 
Do you know how many amputations come into the ED by POV? Some patients even drive themselves with their amputated body parts. Rarely is a tourniquet used. Even those that have friends who were once in the military attending to them don't use a tourniquet. They often will say they know the difference for chances of saving an extremity in a war zone and in a city in the U.S.

I can see more of a misunderstanding about the use of the tourniquet in EMS due to a lack of education or inexperience. For some it may be the thrill of having a new "skill" or "tool" to try out since many in EMS now were not around when tourniquets were earlier. There are some who may think one 4x4 guaze covered in blood is massive. Those that do see an amputation for the first time will probably be a little overwhelmed initially. Usually complete amputations are the easiest to manage. It is the slicing of an artery length wise that can be difficult to manage depending on location and if pressure points can be used effectively.
 
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