Tourniquets

LucidResq

LucidResq

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Before I even begin: yes I know they're bad and are very very very rarely necessary.

So I'm curious, anyone need to use one before? What were the circumstances? What did you use? What was the result?
 
YEs & No .. The use of the tourniquets is being studied more and more.. they are used quite frequently in the military at this time. Of course their injuries is much different than civilian types, but we will have to see...

I will encourage those that use them more than I do speak up...

R/r 911
 
Only once did I see one used. It was a traumatic amputation of a leg. A druggie crossed the center line and hit a guy on a motorcyle taking his leg. There was only a small amount of femur left below the hip joint (about 3 inches) His buddy, who was riding with him used his belt to cinch off the injury. There was no leg to save at that point and with the threat of bleeding out through the femoral artery, it was an appropriate action for his buddy to take with no EMS on scene and about a 15 minute response time to the location of the accident.

We left it in place as we were more concerned with getting the pt loaded and into the ER. Pt ended up getting a total of 5 units of blood before being Med-evaced to the trauma center in Seattle. He lived. Driver of the car that hit him is still in jail.
 
haven't personally used one, we just started carrying them in our trauma packs in the trucks, and just recently one of our medics used one. suicidal person that hit his radial artery and they couldn't stop it by the usual means so they put tourniquet on. they said it worked great.
 
I've used them quite a bit. They work and should be thought of sooner than later. Applying direct pressure, pressure dressing, elevation, pressure points are all fine and well, but it wastes a whole lot of time that you might not have. If I have a vascular injury that isn't controlled with a pressure dressing, it gets a tq, no questions asked. During transport it can be re-evaluated and d/c'd if warranted.
 
Just a few weeks ago, I heard an amazing lecture by a doctor (who also happens to be our MD) about tourniquets. Essentially his point is that in an urban environment, where you are never more then 5 miles from a L1 trama center (Boston), and transport times are very short, tourniquets are an amazing resource for sever bleeding. The reality that the time between application of pressure and assesment by an MD (trauma surgeon) is never more then 20-30 min, and in that time, the benefits outweigh the risks in terms of limb loss. With that said, we still dont carry conventional ones on the ambulances.
 
I've used them quite a bit. They work and should be thought of sooner than later. Applying direct pressure, pressure dressing, elevation, pressure points are all fine and well, but it wastes a whole lot of time that you might not have. If I have a vascular injury that isn't controlled with a pressure dressing, it gets a tq, no questions asked. During transport it can be re-evaluated and d/c'd if warranted.
Click to expand...

Really? If someone is bleeding out badly and they have other life threatening injuries, then I can see that.. but if a major bleed is present and that's the only major injury and you have fire/rescue on scene as long as your partner, and BLS (if you are ALS), or the other way around then I don't think a tq should be applied sooner than later.
 
boingo said:
I've used them quite a bit. They work and should be thought of sooner than later. Applying direct pressure, pressure dressing, elevation, pressure points are all fine and well, but it wastes a whole lot of time that you might not have. If I have a vascular injury that isn't controlled with a pressure dressing, it gets a tq, no questions asked. During transport it can be re-evaluated and d/c'd if warranted.
Click to expand...

While I haven't used one, we were always taught that once a tourniquet is applied, it should be left on and not d/c'd in the field.
 
should be left on, because once it's on yeah the bleeding stops, but that also demonstrates the problem with it. there are other blood vessels there, the tourniquet cuts off blood flow to the rest of the extremity and the tissues start breaking down and dying, releasing the toxins in there. yes, this may take a little time to develop, but all the more reason to get the pt. to the ER quickly.
 
I've used one once in a train accident severed leg at the knee. remember to always document the time though (some patients don't like the forhead sharpie so be nice about it) and never use them in a snake bite but rather loose enough to get a finger under not to restrict venous flow just the flow of lymph.
 
Actually, I use one every time I start an IV.

Oh! No, I've never used one. Very rare is a circumstance when they're necessary. And as a last resort thing, and prolonged use will necessitate amputation, well, as said, rare circumstances. But with the little space they take up, it's always best to have one. Just in case.
 
The last resort mentality has caused many a death. The resistance to utilize a tourniquet early is based on old thinking and EMS myth, much like not giving high flow o2 to the COPD pt. The research is out there. TQ's are applied for hours during surgery all the time, without the need to lop of limbs.
 
but then again, they are in the hospital and have all the fancy meds to take care of the toxins that set in from compartment syndrome
 
boingo said:
The last resort mentality has caused many a death. The resistance to utilize a tourniquet early is based on old thinking and EMS myth, much like not giving high flow o2 to the COPD pt. The research is out there. TQ's are applied for hours during surgery all the time, without the need to lop of limbs.
Click to expand...

What the last guy said. Plus, giving 02 to a COPD patient for the little amount of time I'm with the patient isn't going to do any harm. However, having an arterial TQ on during that same duration of time can have some serious, serious effects. I'm not saying TQ's shouldn't be used at all, but I'm saying it should be a last resort. And when trying all other things first takes 60 seconds max, is it really so unreasonable to try them first?
 
boingo said:
The last resort mentality has caused many a death. The resistance to utilize a tourniquet early is based on old thinking and EMS myth, much like not giving high flow o2 to the COPD pt. The research is out there. TQ's are applied for hours during surgery all the time, without the need to lop of limbs.
Click to expand...

One cannot think "combat medicine" in civilian medicine. There is a great difference in types of injuries and as well standards of care. If your patient did so happen to develop rhabdomyolysis because of your care or another potential injury you will be held accountable. TQ's and usage has not as of yet been recognized as beneficial in most injuries the common laymen receives, as much less measures has been to be as effective.

A lot of measures in the military setting maybe great for those type of injuries as well as "those type of patients" (18-30 year old perfect healthy males) but may not be good for the common laymen.

Again, not that I do not agree that some changes will occur or even needs to be radically changed. We will have to see how much and what occurs. Alike Vietnam where MAST was used and was to shown to be useful, only later to find out that it was erroneous.

Yes the research is out there.. but again that is research, not the standard of care. One has to be careful not confusing the two. Research is always conflicting as well. Dependent upon which has been proven and then placed into some form of national curriculum or standardized course it will become a routine treatment.

R/r911
 
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The main problem is myoglobin is released into the bloodstrean in such high concentrations, that it can be toxic when filtered through the kidneys.

Myoglobin is released when muscle tissue is damaged, this could cause severe renal problems including failure.

However if the alternitive is death, I would use the tourniquet. I try a bp cuff, pump it up till the bleeding stops
 
I personally haven't used one, and haven't heard of anyone locally using one either. However, we have a protocol that was new January of this year that allows their use as a last resort for stopping/controlling bleeding. I don't have my protocols handy at the moment, and can't recall off the top of my head the specifics of the protocol though. If anyone is interested in more details about it though, I can look it up and post the info.
 
Cauterization?;)
 
TQ as system gauge, and some comments to posts above

1. "Release of myoglobin" is essentially (not precisely) rhabdomyolysis in the case of total compartmentalization (i.e., nothing in or out). You also can release a shock of hypoperfused blood, clots, lactic acid, maybe reproducing microbes and their exotoxins, maybe a fat embolus, etc etc; however, "TK shock" is not going to be a factor for the vast, vast majority of urban and suburban incidents because your TK will NOT be on that long (if documented!). Crushing entrapments with prolonged extrication are another matter, but thankfully pretty darned rare.
2. Originally TK's were done because aid was so far off (WWII, Korean War away from landing zones). Later Korean War, and Viet Nam War, with transport times in hours thanks to heliciopters and shorter distance from FEBA to definitive aid, dictated that TK's were not necessary for many of the wounds they saw brought in because of the time element. Also many of the TK's were improvised, causing their own damage. Now that aid is moving even closer to battle injury sites (NO FEBA in assymetric fighting), TK's if they do not cause crushing or shearing damage are OK because they can be taken off in time. (Taliban et al answer that with shots to the crotch and head, but that's another story). Remember, however, this is MILITARY medicine, takes a few years to filter down.
3. Blanket rules are rules, but they are aimed at the lowest common denominator and the worst scenario. First-aiders need to apply TK when needed and leave it on because their "victim" will plead for its removal or loosening due to pain and fear; the victim will die if the TK is loosened, or removed, due to ex-sang. I think higher level practitioners need to balance time-to-help versus time to shock/death, but get the rules changed first, do the homework and cite it, don't just start making your own rules.
4. A good pressure dressing, backed up by a BP cuff say or done with a whole role of MEDIRIP (Coban), with a pressure pad over the proximal pressure point, will stop many bleeders...and co-incidentally stop all distal circulation....
5. A loose TK will occlude all returning veins including patent ones, causing most arterial inflow to cross-circ out the only outlet...the opened blood vessel and onto your ambulance floor...rather than some of it perfusing other parts of the limb and returning via the patent veins to the heart. (Hence the use of little TK's in phlebotomy). That TK has to be working 100%, or use the other measures.

TK or TQ is a systems gauge because it's use is based upon time ('til hospital versus exsanguination); is EMS close enough to definitve help, and is EMS still caught up in unflexible blanket rules, or able to accomodate higher levels of care and of the art of eval and tx?
 
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