Tourniquet with Femur Fracture

[VFlutter]

Had an interesting flight recently and wanted to get some feedback.

Mid 30's y/o Male who was unrestrained driver of single vehicle roll over with ejection. Upon arrival of EMS patient was outside of vehicle in cardiac arrest with a obvious femur fracture. Femur was displaced, medially rotated and had mild protrusion through posterior thigh. ACLS to the nearest hospital and patient had ROSC in route. When we arrived patient was shocky and getting 2 units of blood. The open wound on the posterior thigh initially had external hemorrhage but was now controlled. Also some how still had a weak pedal pulse. Too mangled to attempt traction. So we pack up and head to the Level 1 trauma center where patient quickly received a REBOA and 6 more units of blood. Upon arrival the trauma surgeon asked why we did not tourniquet the leg and honestly the thought didn't cross my mind. The only option would be to place it high in the inguinal fold which from what I understand is not the most effective.

Anyone have any experience with this? Is anyone using Junctional Tourniquets for this type of injury? Aside from the military. I can see how a junctional tourniquet may have been beneficial however not sure a traditional CAT tourniquet would actually occluded the femoral in that position.

 

[MonkeyArrow]

Was the wound still bleeding? If bleeding was controlled, there doesn't seem to be a need to TQ it. Especially with an open fracture, I would think you would see if there was any bleeding or not externally. I guess theoretically, internal bleeding could be a concern, but the leg would swell up and turn itself into a compartment syndrome, auto-tourniquet, and coagulate eventually.

 

[VFlutter]

Nope, minimal external bleeding. Definitely internal bleeding, thigh was significantly swollen and tight.

 

[hometownmedic5]

I probably would have tried to place a cat as high up the thigh as possible, all the while saying "this is bs and won't work".

I don't have a JET device, but that probably would have done the trick, or at least been better that a CAT

 

[EpiEMS]

Reminds me of a question I never got a good answer to...if you have penetrating trauma to the femur that results in a fracture of the midshaft femur in addition to profuse bleeding, do we tourniquet then traction splint? Or do we not even bother with the splint?

 

[TXmed]

Good story, good question. I never would have thought of placing nor would i think it would work enough to matter.

 

[Carlos Danger]

Good story, good question. I never would have thought of placing nor would i think it would work enough to matter.

This ^^

 

[VFlutter]

I agree that I do not think it would have made a difference but I am curious if a junctional tourniquet would have helped. The SAM JTs look interesting. Basically a cross between a pelvic binder and Femostop.

 

[MackTheKnife]

If it wasn't uncontrolled hemorrhage, no tourniquet. Junctional? Used for amputations, yes?

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[VFlutter]

If it wasn't uncontrolled hemorrhage, no tourniquet. Junctional? Used for amputations, yes?

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Uncontrolled external hemorrhage, No. Does not mean there was not severe internal hemorrhaging. Yes Junctional tourniquets are commonly used for amputations. But what’s the difference between hemorrhage from traumatic amputation vs traumatic fracture. Bleeding is bleeding.

 

[MackTheKnife]

Question is, would a JT have been appropriate if there was severe hemorrhage?

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[TXmed]

Well just examine where the JET or CAT would restrict flow and the artery you figured the bleeding was coming from.

 

[RocketMedic]

I'd reckon this would be a great time for the JETT or another abdominal wedge tourniquet, or manual compression of the descending aorta with a burly manly man if possible.

 

[Akulahawk]

The proper time to have placed that TK would have been upon initial find. Once the bleeding was controlled (via external direct pressure and internal compartment syndrome...) then placing a TK won't be significantly more effective than what has already happened. Bleeding is bleeding but you don't want to blow off clots so... treat that guy like any other major trauma victim, keep him (relatively) dry and get him to a trauma surgeon quickly.

If all you have is a CAT, just hope that you can crank down on that CAT enough to at least SLOW down blood flow to make other measures more effective in stopping the leak distal to the CAT.

I'm actually more worried about internal hemorrhage anyway with that guy...

 

[johnrsemt]

You don't put traction splints on a leg with an open fracture, but no problems with a tourniquet.

 

[Akulahawk]

You don't put traction splints on a leg with an open fracture, but no problems with a tourniquet.

Each has their own indications and contraindications.

 

[jwk]

Not sure a tourniquet of any type would be much use in this type of fracture. Much of the blood supply to the femur comes from vessels proximal to where you could any type of tourniquet. I do a ton of surgery for proximal and mid-shaft femoral fractures and have never seen a tourniquet used. Distal femoral fractures and below, all the time. Granted, a high proximal tourniquet would be right across the surgical field, so somewhat impractical. But as a couple others indicated, I'd be more worried about bleeding elsewhere, and the tourniquet would be of little, if any, benefit.

 

[MackTheKnife]

You don't put traction splints on a leg with an open fracture, but no problems with a tourniquet.

Yes, you do.

 

[EpiEMS]

You don't put traction splints on a leg with an open fracture

Can you justify this? I don't see any reason not to. Applying traction to realign the fracture seems like a reasonable measure to reduce hemorrhage, (potentially) restore distal circulation, and reduce pain.

And let's be real - if you are worried about contaminated bones bringing in dirt and debris and bacteria...any reasonable surgeon is going to hit the patient with rounds of IV antibiotics. (Of course, I don't mean to be callous about inducing further wound contamination, I just don't think open fractures can't be traction splinted...heck, think about the original use of the Thomas Splint. Alternatively, look at the use of traction splints on GSWs & IED injuries in Iraq and Afghanistan, after all, those patients have lots in the way of contamination but prehospital providers still traction splint.)

 

[VFlutter]

The Trauma center did end up placing him in traction. Personally, I wasn't going to attempt it with that significant of a fracture unless the leg was pulseless.