New look at tourniquets

[boingo]

There is a big difference between losing fingers or a hand and a leg. Although I agree that not every arterial bleed needs a TQ, I would hate to see an EMT not use one because of concern for complicating the replantation and miss the big picture, keeping the patient from bleeding to death. You should not spend a lot of time trying direct pressure, elevation, pressure points with someone exanguinating in front of you. By the time you come to the conclussion it's not working you are way behind the 8 ball, or by the time it does work its secondary to the low blood pressure and volume, 2 things that might have been avoided with the early appropriate application of a TQ.

 

[Veneficus]

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.

Not just amputations, most GSWs come in by homeboy ambulance service, as well as tree cutter who seem to be able to drink on the job. Chainsaws do the coolest things to femoral arteries, nerves, and veins.

It has been my experience that the most grevious wounds come through the front door, not the EMS entrance.

 

[VentMedic]

There is a big difference between losing fingers or a hand and a leg.

You may not have seen too many amputations since some do come by POV...lucky for them in some cases from what I am now reading on these forums.

Maybe there should be a review in your area on pressure points and direct pressure. Tourniquets have been out of fashion for many years and yet, the majority of patients seemed to have survived. I would hate to see tourniquets replace the training for pressure points and direct pressure.

We just had a patient last week whose arm was torn away at the shoulder. Pressure dressings and the arm was later successfully reattached. The patient even came out of the OR on a nasal cannula. Medicine has made great strides.

You may not care much for your extremities but have you read anything about the suicide rate of those that do lose an arm, leg or even just a few fingers? There are reasons why these patients start intense psychological therapy as soon as they are out of the OR at centers that do replantations or amputations.

 

[Veneficus]

There is a big difference between losing fingers or a hand and a leg. Although I agree that not every arterial bleed needs a TQ, I would hate to see an EMT not use one because of concern for complicating the replantation and miss the big picture, keeping the patient from bleeding to death. You should not spend a lot of time trying direct pressure, elevation, pressure points with someone exanguinating in front of you. By the time you come to the conclussion it's not working you are way behind the 8 ball, or by the time it does work its secondary to the low blood pressure and volume, 2 things that might have been avoided with the early appropriate application of a TQ.

I agree with you in principle, but the problem is that wounds that require a tq in civillian world are not that common and overtreatment by "skill" based providers is a considerable issue. Especially all the wanna be civillian special forces medics.

Consider this thread as an example:
http://www.emtlife.com/showthread.php?t=12235

As well as the earlier hour lecture on civillian vs military trauma perspectives i posted.

Most field providers know so little about trauma that sound clinical decision making is near impossible.

 

[boingo]

You may not have seen too many amputations since some do come by POV...lucky for them in some cases from what I am now reading on these forums.

Maybe there should be a review in your area on pressure points and direct pressure. Tourniquets have been out of fashion for many years and yet, the majority of patients seemed to have survived. I would hate to see tourniquets replace the training for pressure points and direct pressure.

We just had a patient last week whose arm was torn away at the shoulder. Pressure dressings and the arm was later successfully reattached. The patient even came out of the OR on a nasal cannula. Medicine has made great strides.

You may not care much for your extremities but have you read anything about the suicide rate of those that do lose an arm, leg or even just a few fingers? There are reasons why these patients start intense psychological therapy as soon as they are out of the OR at centers that do replantations or amputations.

I can only speak to the evidence out there, and to the wishes of the surgeons who provide our con-ed regarding management of exanguinating extremity injuries. Why you would suggest I don't care about the down stream care of my patients is ridiculous. The evidence is out there. They are relatively safe, easy to use and save lives. That is fact. No one is suggesting a TQ for every injury, amputation or arterial bleed. How much blood are you going to let spill before you resort to a TQ? Not in a hospital, where blood products are available, but in the field. We as a system have researched our own TQ use and found when they have been used they were deemed appropriate and life saving by the trauma surgeons themselves. Not everyone is using piano wire and tree branches.
http://www.jems.com/news_and_articles/articles/jems/3308/the_return_of_the_tourniquets.html

 

[VentMedic]

were deemed appropriate and life saving by the trauma surgeons themselves.

Key words.

They find it is easier to stump an amputation.

How much blood are you going to let spill before you resort to a TQ?

Dramatic.

Do you really think EMT(P)s are that stupid that they will not try to stop the bleeding by the other means also taught?

 

[Veneficus]

They find it is easier to stump an amputation.

I don't think that is a fair statement

 

[VentMedic]

I don't think that is a fair statement

Fair? To who, the patient or the surgeon?

How many trauma surgeons are willing to spend 16 hours in the OR reattaching a limb? And then be ready to go back at a moment's notice for a decrease in flow? If there is a microsurgery center nearby or inhouse, then maybe the trauma surgeon will refer. Usually the trauma surgeons will just tell the patient it is better to lose it now and let the grieving begin. In the year 2009, microsurgeons have made great progress in saving extremities that just 20 years ago only had a so-so chance.

 

[Veneficus]

Fair? To who, the patient or the surgeon?

How many trauma surgeons are willing to spend 16 hours in the OR reattaching a limb? And then be ready to go back at a moment's notice for a decrease in flow? If there is a microsurgery center nearby or inhouse, then maybe the trauma surgeon will refer. Usually the trauma surgeons will just tell the patient it is better to lose it now and let the grieving begin. In the year 2009, microsurgeons have made great progress in saving extremities that just 20 years ago only had a so-so chance.

Not fair to the critical care surgeons.

It is not their job to reattach the limb, but it is the job to do everything possible to give the best chance for the limb to be reattached by another surgeon. With the exception of the most distal part of the finger tips, all of the critical care/trauma surgeons I have met make some very admirable efforts to make reattachment a possibility.

Sure there are probably some old school docs out there, but I would not call quick amputation the norm anymore.

 

[VentMedic]

Not fair to the critical care surgeons.

It is not their job to reattach the limb, but it is the job to do everything possible to give the best chance for the limb to be reattached by another surgeon. With the exception of the most distal part of the finger tips, all of the critical care/trauma surgeons I have met make some very admirable efforts to make reattachment a possibility.

Sure there are probably some old school docs out there, but I would not call quick amputation the norm anymore.

Critical care surgeons?

That would really depend on where you are. Northern CA and South Florida are lucky to have replantation centers with excellent reputations. However, it is well known that if an amputation gets taken to a certain trauma center, the limb will not be reattached. Period. They don't refer outside their facilty. If the patient can make it him/herself to the hospital with the microsurgeons, the limb may be saved. That hospital is unfortunately not a trauma center but occasionally the paramedics will break protocol and bring a traumatic amputation to the more "appropriate" hospital. The hospitals in the distant regions have received education from the microsurgeons and are willing to work with them to get the patient transferred.

BTW, the trauma center that does not do reattachments is a teaching facility for the new trauma surgeons. They are busy and will take the shortest route to close a case. That means no microsurgery. They just want to get the patient into an ICU as quickly as possible.

 

[boingo]

Key words.

They find it is easier to stump an amputation.



Dramatic.

Do you really think EMT(P)s are that stupid that they will not try to stop the bleeding by the other means also taught?

No, you do. Please enlighten us to as when it becomes no longer appropriate for manual pressure and one should transition to a TQ. What are your criteria, and where is the evidence supporting it? I'm glad to see you have equal distain for trauma surgeons, however it clearly isn't for a lack or their education. To each their own, I will continue to treat patients according to the most recent EBM and with the reccomendations of the surgical faculty here, and let others tx based on anecdotal evidence, fear, and concern of downstream microvascular trauma.

 

[VentMedic]

No, you do. Please enlighten us to as when it becomes no longer appropriate for manual pressure and one should transition to a TQ. What are your criteria, and where is the evidence supporting it?.

Do you realize that tourniquets have not been seen around very much for over 20 years? It took another war for people to remember their existence. I may see at least two amputations or mangled extremities per shift in our ED, some of which I fly in myself with my partner from distant hospitals...without a tourniquet. Believe it or not they don't all bleed to death.

I'm glad to see you have equal distain for trauma surgeons, however it clearly isn't for a lack or their education.

Do you work in a hospital setting? Have you even been part of physician turf wars? I have the utmost respect for trauma surgeons except when there should be a another specialist involved and these surgeons do not want to relinquish control of the patient.

To each their own, I will continue to treat patients according to the most recent EBM and with the reccomendations of the surgical faculty here, and let others tx based on anecdotal evidence, fear, and concern of downstream microvascular trauma.

This is exactly what we are afraid of with EMS. Some will take an article to heart and fail to see it as another option and not a new "gold standard". Some will now want to do tourniquets because they can and applying pressure dressings will no longer "cool".

Where do you get "fear"? Do what is best for the patient and not your own ego. That is why there are options. Unfortunately when some can not think for themselves they fail to see that or must have recipes for each step written for them. For some, having a choice is "fear".

I do care about the damage I could do to a patient be it a botched intubation, infiltrated IV or microvasular damage. I would like to see patients keep their extremities as I also consider that part of my "save". If I can get both the patient and their limbs safely to the hospital with all having the best chance of making it, I believe I have provided good care. I am doing this based on experience and education, not a recipe or ego.

Did you even bother to read the links I posted which are also evidence based? The hospitals I work for are part of that evidence based research.

 

[Ridryder911]

I believe what we are missing is that we are automatically "lumping" all injuries as "war type" and truthfully they are not. Civilian type injuries are not usually the same as seen with implosions and shrapnel. Yet, we are attempting to make a standard of care. Yes, there is research but are they always in comparison to civilian type amputations?

I too have worked several amputations. Never have I had to place a tk on one. In fact over 32 years now, I have applied only 2 tk on near amputations. Yes, even in Level 1 TC to large amount of extremity wounds.. Sorry, let's use some common sense. Let us compare injuries and those that can be treating them as well.

I am for changes when appropriate; but let's not do a knee jerk reflex. Especially, when there are so many sponsored studies by companies that will profit by the outcomes.

R/r 911

 

[boingo]

I'm really not looking for a pissing match. The fact is, we have utilized tourniquets for a very long time, way before this war or the last. They are standard of care here, based on good evidence. There are studies showing deaths that would have been prevented by the rapid use of a tourniquet. I am concerned about damage, microvascular or otherwise, but I can assure you that if a replantation needs to take place it will be much more successful in a well perfused, stable patient as opposed to the one that is coagulopathic and hypothermic because adequate hemostasis wasn't achieved in a timely fashion. The surgeons who provide our guideance are senior faculty at world renown medical schools and staff of high volume trauma centers. I can assure you they aren't prone to "knee jerk" reaction. I'm not interested in your intra specialty turf wars, you are a respiratory therapist, not a surgeon. I'm sure regardless of surgical specialty the surgeon is better educated and experienced on the subject at hand. The needs of the vascular surgeon may need to play second fiddle to the needs of the patient as a whole. Is a tq always necessary? No. But one shouldn't delay using one at the cost of a patients life. We collect data on all our TQ patients and have found NO neurovascular sequelae secondary to their use. I agree with you 95 % of the time, but I don't see us agreeing on this issue. I respect your stance on the matter.

 

[boingo]

I believe what we are missing is that we are automatically "lumping" all injuries as "war type" and truthfully they are not. Civilian type injuries are not usually the same as seen with implosions and shrapnel. Yet, we are attempting to make a standard of care. Yes, there is research but are they always in comparison to civilian type amputations?

I too have worked several amputations. Never have I had to place a tk on one. In fact over 32 years now, I have applied only 2 tk on near amputations. Yes, even in Level 1 TC to large amount of extremity wounds.. Sorry, let's use some common sense. Let us compare injuries and those that can be treating them as well.

I am for changes when appropriate; but let's not do a knee jerk reflex. Especially, when there are so many sponsored studies by companies that will profit by the outcomes.

R/r 911

[/I]

I'm not sure where the thread about TQ's became about amputations, but I don't think that was the OP's original intent. I stated earlier in the thread that my experience with TQ use was almost excluively in penetrating trauma, in the civilian environment, so when I speak of my experience, and the data collected on TQ by my agency, I speak only of the civilian experience. I don't advocate TQ for all injuries, however they are a valuable tool when needed. There are agencies around the U.S. that don't even carry them. Maybe someone should start a poll.

 

[Veneficus]

[/I]

I'm not sure where the thread about TQ's became about amputations, but I don't think that was the OP's original intent. I stated earlier in the thread that my experience with TQ use was almost excluively in penetrating trauma, in the civilian environment, so when I speak of my experience, and the data collected on TQ by my agency, I speak only of the civilian experience. I don't advocate TQ for all injuries, however they are a valuable tool when needed. There are agencies around the U.S. that don't even carry them. Maybe someone should start a poll.

If you have Kling, you have a tq

I would say HVLT (high velocity lead therapy) to an extremity is definately a time a tq may help. Trouble is the shooter usually manages to hit center of mass where I work.

 

[boingo]

Yeah, I live in the land of the gang that couldn't shoot straight. Hollywood doesn't help markmanship.

 

[VentMedic]

I'm really not looking for a pissing match. The fact is, we have utilized tourniquets for a very long time, way before this war or the last. They are standard of care here, based on good evidence. There are studies showing deaths that would have been prevented by the rapid use of a tourniquet. I am concerned about damage, microvascular or otherwise, but I can assure you that if a replantation needs to take place it will be much more successful in a well perfused, stable patient as opposed to the one that is coagulopathic and hypothermic because adequate hemostasis wasn't achieved in a timely fashion. The surgeons who provide our guideance are senior faculty at world renown medical schools and staff of high volume trauma centers. I can assure you they aren't prone to "knee jerk" reaction. I'm not interested in your intra specialty turf wars, you are a respiratory therapist, not a surgeon. I'm sure regardless of surgical specialty the surgeon is better educated and experienced on the subject at hand. The needs of the vascular surgeon may need to play second fiddle to the needs of the patient as a whole. Is a tq always necessary? No. But one shouldn't delay using one at the cost of a patients life. We collect data on all our TQ patients and have found NO neurovascular sequelae secondary to their use. I agree with you 95 % of the time, but I don't see us agreeing on this issue. I respect your stance on the matter.

Yes, I am also an RRT which means I must work with many different Physicians (and other professionals) as well as learn their protocols and where they are coming from when it comes to their point of view in medicine. That gives me a broader view of medicine than what I had working just as a Paramedic in EMS. I must have an open mind to a certain extent. I do value the Microsurgeons' opinions on salvaging the extremity over the trauma surgeon since many that now specialize in microsurgery also did a lengthy residency in trauma. They are also the ones that will be trying to save the extremities. Their intimate knowledge and expertise in this field do give them credibility.

Vascular surgeon is yet another specialty and does not qualify as microsurgeons for replantation, so you are correct, they do take a backseat.

How many replantations does your hospital do per week? Arms? Hands? Fingers? Legs? How many replantations have you been personally involved in their care? Played with any leeches lately? What are your resuscitative protocols for your faciltiy? Do you have a replantation prep protocol in place?

Like I said, we fly patients from at least 4 different states to the centers on both coasts and a couple of different countries for replantation. Tourniquets are a very rare item. If your facility has an effective resuscitative plan, stabilization and replantation can be a reality. Having a few big names doesn't always mean a quality facility. The trauma center I mentioned earlier is also well known but they still won't reattach even a finger that would be an everyday procedure for most microsurgeons now in the year 2009.

READ, READ, READ!

 

[VentMedic]

They are standard of care here,

Since my other links probably have not been read, let me post an article from JEMS:

http://www.jems.com/news_and_articles/articles/jems/3308/the_return_of_the_tourniquets.html
The Return of Tourniquets


Notice the title.

Yes, for some penetrating injuries they may be effective. But, with a trauma center around the corner where these studies were done, the TQs were not left in place very long. The studies even admit the flaws involved. Thus, one can not say conclusively for the use civilian TQs based on this research. Again, it should not be the standard of care but rather another tool that can be used if nothing else will work. One must be trained and educated to recognize the difference.

 

[mycrofft]

I'm not hearing a lot of actual disagreement on clinical facts,

and a lot of personal challenges. Keeps things lively.

I think the TK is a valid tool which has sometimes been used improperly, much like the cricothyrotomy ("Crikey! Thyrotomy!", and thanks Dr Metcalf I can't forget that ever!!<_<), it was banished because it was overused and "done wrong". Sort of thinking which would bar people from using scalpels because they're so darned sharp and someone got cut who wasn't trained right...

You folks have brought up some great stuff. I have treated people who underwent reattachments...but that's another thread.
I know a class of wound whoch really needs it and is still hard to do it right...high limb amp with arterial retraction but still bleeding.

Hmmm. Could we generalize and say TK's on arterial bleeding unstopped in five minutes by pressure (or jump to TK if the spurter is above the knee or elbow)?
How about you wilderness folks, Bossy, ResQ, et al?