Tourniquet (extremity)
Background
- Tourniquets have been used in military dating back to the Roman army although the term was not coined until 1718.
- In the US military, tourniquets were issued to soldiers from the time of the American Civil War up till World War I. However, tourniquets fell out of favor during World War II.
- During WWI four recommendations regarding the use of tourniquets were given. 1) Never cover a tourniquet 2) Write that a tourniquet was applied on the medical tag 3) If conscious tell the service member to verbally inform medical providers that a tourniquet was applied 4) Leave a tourniquet in place for up to 6 hours only
- During the Vietnam conflict, 2500 US casualties were noted to have perished because of hemorrhaging from an extremity wound alone that is no other significant injuries were noted on the casualty.
- Based on experience from use over the last decade, tourniquets have been shown to be safe and life-saving. The reason tourniquets fell out of favor with the US military was due to poor patient transport out of no man's land in WWI which lead to ischemic complications.
- Extremity hemorrhage is the most frequent cause of preventable battlefield deaths thus early control of severe hemorrhage is critical.
- Tourniquets are a proven effective means of controlling extremity hemorrhage
- Damage to extremity is rare if tourniquet is left on for < 2 hours (recall that TQ are frequently used in surgeries which last several hours). This risk of damage to the limb is considered acceptably small rather than having the casualty expire due to exsanguination.
Indications
- Severe extremity hemorrhage not able to be rapidly controlled by other means
Contraindications
- None
Properties of a Good Tourniquet
- When tightened should eliminate arterial blood flow completely as evidenced by Doppler Ultrasound
- Capable of being easily released and re-applied
- Capable of being applied to self on handed
- Application time should be around 60 seconds
- Application should be simple and require minimal familiarization
- Able to be used in dark, cold, hot, wet, sandy, muddy, icy environments equally well
- No assembly required, no batteries needed
- Shelf life for 10 years or longer
- Width of tourniquet should be > 1"
- Size should be such that it can fit circumferentially around the thigh of 95% of service members (26.7 cm)
- Weight should be < 8 oz. (250 g)
Application of Tourniquet
- Apply directly to skin 2-3 inches above wound
- Remove clothing ensuring TQ is not obscured and remains in full view
- Tighten until bleeding is controlled and distal pulse is eliminated
- Document time of placement on medical tag -- consider writing time of placement on patient with indelible marker
- If bleeding is not controlled and distal pulse not eliminated with first TQ - use a second one just proximal to the first one. Increasing the tourniquet WIDTH with a second TQ controls bleeding more effectively and reduces complications versus over-tightening initial TQ.
- Place tourniquet on BEFORE onset of shock as mortality is very high if casualty already in shock before tourniquet applied
- Consider pain medication after TQ is placed
Precautions
- Do Not place directly over joint such as knee or elbow
- Do Not place over impaled object
- Do Not periodically loosen TQ -- there is no benefit only harm from additional blood loss
- Observe for bleeding as patient is resuscitated and blood pressure increases
- Do Not Remove TQ if:
- The casualty will arrive at a medical treatment facility within 2 hours after time of application
- The extremity distal to the tourniquet has been traumatically amputated
- The casualty is in shock
- The tourniquet has been on for more than 6 hours
Proper Removal at Medical Treatment Facility
- Place pressure dressing over wound
- Loosen TQ slowly observe for bleeding
- If bleeding controlled then leave TQ loosely in place in case of recurrent bleeding
- If bleeding is not controlled without the TQ then re-tighten it