Tourniquets - Back in Fashion

I just got back from Afghaniland and yea the CATs are sweet, but the plastic bends and snaps when tightened to much. As for the Swat-ts, the metal pieces are much better but at the same time, it takes far to long to apply. There are new Swats coming out called Swat-W or swat Wide. Can be used much quicker and more effectively.

Also CATs are better used not double looping. Going through one loop allows the ability to tight the TQ much tighter as well as much quicker. I can promise that you can put it on completely effectively in under 10 seconds. As for anyone who says that it wont be secure. Well your supposed to tape it anyways so yea. We used them in this fashion and they worked amazingly. Just try not to use it more then once lol.

We used to carry 2 for each limb and a couple backups. But that was due to a possible MASCAL situation so that applies differently lol

Im a huge supporter of TQs, and sometimes you need those hands to do other things other then holding direct pressure.
 
The BC Ambulance service is slowly making a move to rolling them out. The plan is to have the TQs in our cars but not in our kits.

The logic behind it is conventional direct pressure should always be the first line of defence to control haemorrhage, and if the bleed is severe and not able to be controlled with direct pressure, putting the TQs in the car will help instil that these patients ultimately require a trauma surgeon and to not delay transport.
 
SOFTT-W is a good TQ. People who have blowout kits are dorky, but I'd be happy to save them first.
 
cprted said:
The BC Ambulance service is slowly making a move to rolling them out. The plan is to have the TQs in our cars but not in our kits.

The logic behind it is conventional direct pressure should always be the first line of defence to control haemorrhage, and if the bleed is severe and not able to be controlled with direct pressure, putting the TQs in the car will help instil that these patients ultimately require a trauma surgeon and to not delay transport.
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When I did my EMR with the JIBC I asked my instructor if they carried tourniquets on their rigs and I was honestly surprised when she said no. Good to hear they're getting them though.
 
We used two CATs on a patient a few weeks back and damn near broke the plastic windlass. I wound up making one out of a cravat and a penlight that worked better and didn't break.
 
I'm glad we're shifting away from the ARC's "don't use a tq or your arm will fall off" mindset. Patients have lost a lot more blood than they should have due to a rescuers reluctance to apply a tourniquet. We carry 2 CATs on every rig, and although they don't get used a lot, they are a godsend when they're needed.
 
TransportJockey said:
We used two CATs on a patient a few weeks back and damn near broke the plastic windlass. I wound up making one out of a cravat and a penlight that worked better and didn't break.
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May I ask, were you using the old style cat or the new ones with the reinforced windlass?
 
When I get to work I'll have to check. We use an orange CAT that we get from boundtree... but since I don't do ordering I'm not sure the exact one we get
 
Or you could consider a second TQ to spread the pressure if tighten the first one became a problem.
 
Handsome Robb said:
We carry the SWAT-T. Used it more than a few times. My favorite part is if you don't need it as a TQ it makes an awesome pressure bandage to free up hands.

I'll try to find the source but a military helicopter pilot went down and had a TQ on his "cyclic" arm for like 16+ hours before he was rescued and delivered to a surgical center. Took ~ two years but he's flying again with no deficits in that arm.

Does anyone carry junctional TQs?
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Haven't seen any other than in a training video.
 
TKs are great tools. Direct pressure, as stated before, doesn't always work. DP is good for slowing a bleed down while placing a TK. QCK and Celox do work well in areas that are not amenable to a TK. And of course, this is all dependent in the environment you find yourself in. Tactical, non tactical, etc.
 
Does anyone have a decent source for advantages/disadvantages to using a hemostatic agent versus a tourniquet for extremity bleeds?
 
I'm curious about pediatric TQs. In reference to the marathon bombing in Boston, you never know when and where that could happen, and to whom... with a pediatric casualty, would you just apply direct pressure? Is it okay to slap on a regular CAT (or whatever) and just be mindful of the pressure you're applying? Are there any pediatric TQs...if so, do they work well?
 
I wouldn't be averse to a tourniquet in a pediatric. Just be mindful of the amount of pressure you're applying- apply enough to stop the bleeding and you should be fine. The only issue I could think of is if the pediatric's extremity would be too skinny for the tourniquet to be applied appropriately. In that case, there are of course other methods to control bleeding. Pressure points should be easy enough to tamponade on a pedi while you manage the wound.
 
So how about The Abdominal Aortic Tourniquet? Looks very interesting
 
Expensive, large, and potential complications. But it can also save previously unsalvagable patients...


This one shows it is equal to REBOA in swine: https://www.ncbi.nlm.nih.gov/pubmed/29661286

Interesting proposition for us in CPR in hemorrhagic arrest validated in a swine model:
https://www.ncbi.nlm.nih.gov/pubmed/28885969

Seems like it would also be efficacious in most non-traumatic arrests as a temporizing measure since it should boost perfusion pressure with a smaller effective systemic circuit to pressurize through compressions.
 
Regional protocols including metro areas now have tourniquets allowed as soon as direct pressure fails.

Relevant section of
Chang, R., Eastridge, B., and Holcomb, J. (2017) Remote Damage Control Resuscitation in Austere Environments

Given the effectiveness of tourniquets in controlling extremity hemorrhage, the 2015 Hartford Consensus emphasized the need for civilian preparedness in responding to mass casualty incidents, a major component of which is rapid hemorrhage control with the appropriate use of tourniquets and hemostatic dressings by professional first responders.74 Emerging data suggest that tourniquet application reduces blood loss and shock75 with a low risk of ischemic limb loss in civilian trauma patients.76,77,78. In a single-center retrospective review of 326 tourniquets placed on 306 patients for extremity injuries, delayed tourniquet placement (in the trauma center) was associated with an increased likelihood of exsanguination (OR 8.5, 95% CI 1.1 – 68.9) compared to prehospital tourniquet placement.77 However, in the austere environment where definitive hemorrhage control is delayed, prolonged tourniquet application could result in detrimental limb ischemia. A study using porcine models found that neuromuscular recovery was well-preserved when tourniquet application was ≤3 hours but significantly diminished at 6 hours.79 Current TCCC guidelines recommend reassessing every 2 hours and to convert the tourniquet to a hemostatic or compression dressing if the following criteria are met: 1) patient is not in shock, 2) limb was not amputated, and 3) it is possible to monitor the wound closely for bleeding.80 Periodic loosening of the tourniquet to reperfuse the limb results in increased blood loss without any benefit (possibly worsening the ischemia-reperfusion injury)81 and should be avoided. Because of the risk of reperfusion syndrome, removal of a tourniquet which has been applied for ≥6 hours should be done only when close monitoring and laboratory capability are available.80
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And relevant section from:

Pikoulis et al (2017). Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting

A prospective study analyzing 428 tourniquets placed on 309 injured limbs showed that early tourniquet use before the onset of shock was associated with a 90% survival rate versus 10% survival if the application was delayed until the casualty was in shock (21).

Retrospective studies have examined the use of prehospital tourniquets in civilian trauma. In a 2007 review of tourniquet use in the prehospital setting, it was found that immediate application of a tourniquet may be justifiable in: (a) life-threatening limb hemorrhage, amputation, or a mangled extremity, (b) life-threatening limb hemorrhage not controlled by simple methods, (c) entrapment of a limb preventing access to a point of hemorrhage, (d) multiple casualties with extremity hemorrhage and inability to perform simple methods of hemorrhage control, or (e) benefits of prevention of death outweigh limb loss from ischemia caused by use of a tourniquet (22).

When studied in the urban emergency medical service (EMS) setting, prehospital tourniquet use appeared to be safe. The Boston EMS experience with prehospital tourniquets reported that 91% (95/98) of cases resulted in successful control of hemorrhage, and they were in place for an average of 14.9 min prior to hospital arrival. Tourniquets were removed in the emergency department in 54.7% (52/95) of cases, and in the operating room in 31.6% (30/95) of cases. Of the 30 tourniquets removed in the operating room 14 did indeed have a documented vascular injury which required repair. A complication rate of 2.1% was reported in that study, showing that effective tourniquet application may be used in the prehospital setting safely (23). Despite this, complications of tourniquet use are well documented including: arterial injury and thrombosis, deep venous thrombosis, and neuronal injury. It has been documented in the literature that up to 65% of tourniquet gauges are inaccurate and inappropriate pressures up to 500 mmHg have been applied to limbs improperly (24). Regardless of these potential complications, the use of tourniquets in the prehospital setting has been shown to be effective and potentially life-saving. Education on proper tourniquet use is a key to the success of this strategy.

Recent initiatives in the United States have aimed at educating citizens to provide bleeding control for those in need. The “Stop the Bleed” campaign encourages citizens to learn how to prevent or slow potentially life-threatening hemorrhage as well as have access to and learn to use bleeding control kits.
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