Remove Bystander-Applied Tourniquet?

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Jason0130

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So I've used this forum many times as a reference when I had questions, but I finally registered to ask a question to which I've not found a great answer. Something I've found a few times, three times in my whole 2 years as a medic, is tourniquets on a patient that have been applied by a bystander when it is clear to me that a tourniquet was entirely unnecessary. The most recent example was a patient who got slashed in the anterior tibial region with an ice skate. It was an impressive looking laceration, but no big deal and though it probably looked like a lot of bleeding to the bystander who applied the tourniquet, it wasn't. So probably 10-15 minutes after the tourniquet was applied I confirmed there was a good pedal pulse and capillary refill and cut it off. That's what happened the previous 2 times as well; ineffective tourniquet and we just cut it off.

However, what if the tourniquet is effective (no distal circulation) and yet clearly unnecessary? I know we've advanced beyond thinking a tourniquet means the limb will be amputated, but it's still not a good thing to leave in place if it isn't needed. If you cut it off would you first infuse isotonic fluids and treat it like a crush injury? This is something I'll likely have to address with our medical director to get a good answer for what I would do, but wanted to see if anyone else has addressed this and has ideas before I do. Tourniquet use is becoming more and more common in basic first aid classes, active shooter training, you name it so this is something I'm sure I'll encounter again.

Thanks,

Jason
 
one of the reasons its becoming more popular is that it has been found to be more beneficial than harmful. When i wen through medic school 7 years ago so many people were scared to use them and there was ALOT of poor information out there. Well the war overseas has cleared alot of that up for us, now we want the general public and first responders to be overzealous with it. Much like chest compressions in a person with a questionable pulse we tell people to just do it. If it is ineffective than why remove it? It looks bad on your chart if you remove a tourniquet even if you document the pulses. leaving it on isn't causing any harm if they have cap refill and pulses. i believe it is just good judgment to leave it on and defer to the receiving doctor. What are you helping when you remove it?

now if it is an effective one it depends because even the smallest of LACS and puncture wounds can cause very significant and continuous bleeding. So do you know if its because the wound isnt that bad or because the tourniquet is working? and again this looks bad on your chart if you were to remove this.

Crush syndrome, rhabdo, hyperkalemia, lactic acid buildup all takes time and what we do in the field (bicarb, fluids, calcium) mitigates it but does not fully fix the problem. plus overzealous use of this treatment does have the potential to be harmful.

so to sum up my advice would be to not mess with it and to not make removing one a habbit.
 
Well you hit on my concerns with leaving it on. You figure 10 minutes before people even call 911 in some cases, 10 minutes until we get there, 10 minutes on scene and a 10 minute drive to the hospital, the duration of time a tourniquet will be in place adds up. Our protocols don't authorize NaHCO3 or Ca++ for crush syndrome, just normal saline, but it seems to me like any other case of crush syndrome, provided you know it isn't needed, and the cases I'm talking about were strictly capillary bleeding and large but ultimately superficial cuts that got stitched up in the ER and patient walked out. I have seen my share of lacerations and these were not even in the "direct pressure" neighborhood--nothing a dressing and gentle coban wrap couldn't handle. However, you do make a good point, in that a tourniquet is an example of a crush that we are able to leave in place and move our patient, unlike a car, bookshelf etc. so the urgency to remove it maybe isn't there.

Thanks for the reply, and yes I agree that if there's any doubt a tourniquet shouldn't be messed with.
 
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Unless it has been on there for an extended period of time, I'd just remove it. I've brought in a patient with a tourniquet that I had placed an hour earlier and the doctor just popped it off to get a look at the bleeding without a second thought (she immediately regretted it due to all the arterial bleeding, not the acidosis).
That said, it would probably be best to call med control if it has been more than a few minutes.
 
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Looking over our protocols, which were just updated this week, even a crush injury/compression syndrome we are not meant to infuse fluids unless we suspect the limb's been compressed for over an hour (it also DOES now authorize the IV bicarb as well in that case). I recall in medic school they taught us to treat as compression syndrome if it was compressed more than 20 minutes, so hopefully that change indicates this is less of an immediate concern these days. I work in a city so I probably wouldn't see any patient wearing a tourniquet that long. I'm probably overthinking it.
 
If it was truly "unnecessary," I would remove it and describe why you did it in your PCR. You don't typically have to worry about crush injury with TQ application until it's been on for a long period of time.

If you do remove it, it should go without saying that you should be ready to reapply a TQ if bleeding becomes uncontrolled.
 
Are we talking about a makeshift tq made of a belt or something? Or a true tq out of a cravat and windlass or commercial device?

Sent from my SM-N920P using Tapatalk
 
long term is 8-12 hours now; not 30 - 60 minutes.
If a wound is no longer bleeding and you take off a tourniquet; and it starts bleeding then you have the problem of having to put a new one back on
 
Take it off.
Try putting a tourniquet on your own arm and you will realize how incredibly painful they are.
Ask yourself, why would you do something that is both unnecessary and harmful (i.e., zero blood flow to the tissues!)?
Don't worry about the mythical crush syndrome. This develops long term, i.e. someone trapped under a collapsed building for hours/days.
 
zzyzx said:
Ask yourself, why would you do something that is both unnecessary and harmful
Click to expand...

This x10.

I like the TECC guidelines approach to tourniquet removal:

"Reassess all tourniquets that were applied during previous phases of care. Consider exposing the injury and determining if a tourniquet is needed" and "If a tourniquet is not needed, use other techniques to control bleeding and remove the tourniquet."

If you don't need it, take it off - nothing wrong with applying it to do something else (control bleeding while you manage the airway, say, in the XABC model), but once it's not needed, take it off.
 
I've ran around training environments with a TQ on an arm and a leg for upwards of an hour. It's fairly miserable, but just paradise the pain and compartmentalize it out of your working space. (In other words, embrace the suck and keep doing your job.)

Commercial models are fairly easy to loosen a little to check for bleeding and severity, and immediately re-tighten if needed. Improvised, lord only knows. Could be good, could be bad. Tactically, TQs get thrown on quickly. Probably with a modest rate of over-application. Which is good, because not getting TQd when you need it, kills you. Getting TQd when you don't need it helps stop the bleeding and is otherwise just annoying.

I'm probably going to assess the actual injury, and that frequently includes upsetting EMTs by checking out what's under the bandaging and not just taking their word that "its a bad and deep laceration."

Usual caveats apply. Number of patients, resources (personnel, material, transport, etc...), distance to receiving facility and it's capabilities, mechanism... (i.e.; MCI with inadequate resources and providers, shooting with high velocity rounds, I'm not likely to mess with the proximal femur TQ., chainsaw to the humerus... not messing with it, shark bite taking the leg off,...)
 
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