I'm thinking about tourniquets...
Trauma is the leading cause of death in the USA of people between the ages of 1 and 46 years old with some 192,000 people dying each year – that's just in the USA
Bleeding accounts for 30 – 40% of those deaths with many of those people suffering major blood vessel injuries. A large proportion of those people will bleed out before reaching hospital or before the arrival of trained EMS personnel.
The same stats are closely mirrored in most other developed countries, including the UK, Europe and Australasia.
The use of tourniquets has been the subject of a lot of debate within the medical community and whilst it is accepted that tourniquets have saved a great many lives on the battlefield, there are still no consistent guidelines advocating their use in the civilian ems and first aid responder settings, despite the American College of Surgeons strong recommendations in 2014 –
“We recommend the use of tourniquets in the prehospital setting for the control of significant extremity haemorrhage if direct pressure is ineffective or impractical”.
The guidelines stated that “the panel believes that tourniquets used to treat severe extremity haemorrhage have a clear survival benefit, demonstrated by a large and consistent effect size across several studies.”
Medical practices fall in and out of favour, and like many others, the use of tourniquets has too.
The traditionally taught method of stopping bleeding is to apply direct pressure, elevate the wound and the use of sustained pressure on pressure points.
While this works in a great many wounding situations, there are times when the fast and aggressive use of a tourniquet is necessary to stem the flow of blood from an injured limb to save a life.
Bleeding out is usually very quick!
In the civilian medical community, tourniquet use has been viewed as a method of last resort, mostly due to the often touted severe clinical outcomes like muscle death, nerve damage and amputated limbs.
Unfortunately, much of the research supporting these arguments is old, flawed and badly documented, but over the last decade or so there have been some well-researched studies that support the use of tourniquets in the non-military setting and mostly dismiss the adverse effects when they are used correctly.
Tourniquets are nothing new, although the speedy development of them in recent years has been due mostly to their effectiveness in the treatment of arm and leg wounds sustained on the battlefield.
Historically, the first tourniquets were used during the 4th Century BC – also on the battlefield – Alexander the Great's army would use them to stop the bleeding of soldiers who were wounded in battle.
The Romans also used them, not only to stop bleeding but used them to help when the amputation of limbs had to take place.
Trauma surgeons were around even then!
It wasn’t until 1718 that any further real progress took place with the invention of a screw type tourniquet, by the french surgeon, Jean-Louis Platt.
Fast forward another hundred years or so to 1873, when a rubber bandage tourniquet was developed by Friedrich Von Eschmarch.
There have been further developments since then, but up until recently, these were concerned more for in hospital use, especially during bone surgery. These types of a tourniquet are known as surgical tourniquets, and they assist by preventing blood flow to the area of the limb the surgeon is operating on.
As a result, operations can be performed with better precision, safety and speed.
The development of tourniquets for battlefield use has sped up recently, as their effectiveness in treating traumatic arm and leg wounds suffered by soldiers on the battlefields of Iraq and Afghanistan is well proven.
Like in many wars, there is a vast amount of injury, with lots of follow-up care. Modern medicine is usually well documented, and consequently, a significant amount of data is available for medical researchers.
Research at a military hospital In Iraq used 862 tourniquets on 499 injured personnel including civilians.
The tourniquets were applied before evacuation to the hospital by a range of people including medics, bystanders and the injured themselves.
The survival rate was 87% with complications that could be attributed to the tourniquets of less than 2% (1)
A study at the Memorial Herman Hospital In Houston Texas evaluated the treatment with tourniquets of 105 civilians, with 82 of those patients arriving at the trauma centre with tourniquets already applied before arrival – 14 had tourniquets placed after arrival at the ED.
The study concluded that there were no complications attributed to the use of tourniquets and deemed them safe to use in civilians with arm and leg trauma, to arrest bleeding.(2)
Both of these studies used commercially made Tourniquets
Following terrorist and mass casualty events including the Boston Marathon Bombing in 2013, the Harvard Consensus presented a call to action that no one should die from uncontrolled bleeding and advocated for providing first aid kits to all EMS, Police and any concerned citizens.
These kits, which include haemostatic dressings, tourniquets and gloves, are recommended to be placed similarly to the provision of Defibrillators, readily available in public places.
The Hartford Consensus – The Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events was founded by the American College of Surgeons (ACS).
The committee met twice in 2013, making specific recommendations and issuing a call to action. The deliberations of the committee have become known as the Hartford Consensus.
A third meeting was convened on April 14 2015. This Hartford Consensus III meeting, focused on implementation strategies for effective bleeding control
There has been much debate and confusion on the best place to apply a tourniquet.
A lot of the suggestions put forwards are based on worries about nerve and tissue damage below where the tourniquet is applied, and so often conflicting guidelines are advocated.
Similarly, the use of tourniquets is often only supported in specific scenarios like high hazard settings, industrial accidents, multiple casualty and active shooter incidents.
While these are all situations where there will be increased risk of catastrophic bleeding, personally, I don’t give a stuff where it's happening – if someone is bleeding out, you need to be aggressive at stopping it, as soon as it is safe to do so
The argument for placing the tourniquet close to and above the wound suggests that placing it there will somehow protect the limb above the wound from damage caused by the tourniquet.
The current research disputes this and has found that a tiny percentage – less than 3% – of adverse effects from tourniquet use.
The difficulty here also, is that if the wound is to the lower part of the limb, blood vessels are protected by the double bones and the tourniquet can be less efficient when applied here.
Current military guidelines – and to be fair – this is where most of the current user data is coming from – state the tourniquet should be placed as high up the limb as possible.
Put it on high and tighten until bleeding from the wound has stopped.
If it's still bleeding, put another one on next to the original and get that one tightened up too.
The reason here is that the upper limbs are only single bones and the blood vessels are more easily compressed against the bone by the compressed muscle tissue from the use of a tourniquet.
Also, this removes the confusion factor, in what is usually a very stressful situation and does away, temporarily at least, the need to expose the limb to isolate the injury.
It's suggested that tourniquets are applied over bare skin but unless the wound area is already exposed, this causes unnecessary delay and more blood loss.
High and tight, as quick as you can!
When they are correctly applied, there will be a lot of pain where a tourniquet is fitted, and this shouldn’t be seen as a reason to loosen them.
Occasional loosening isn't a good idea either, as in a lot of cases this has led to further bleeding out resulting in death.
Once it's on, leave it on.
Write a “T” and the time of placement on the patient's forehead or cheek and pass on this information to the EMS or other health professionals when they arrive. They will be able to deal with any pain issues then, but this may be low on the list of priorities!
Placing a tourniquet on anyone also means they need immediate evacuation to a hospital – preferably one with a trauma centre.
Currently, there are a number of tourniquets on the market, and you only have to look on eBay and Amazon to be overwhelmed by the variation in price and quality.
Unfortunately there are a great many rip-offs and while some of these look and feel like the real thing, when they need to work, they fail miserably.
The Combat Application Tourniquet (made by North American Rescue Products) is currently in use in the US and other militaries and has been extensively tested in real life. Its been proven to be effective in stopping blood flow in both upper and lower extremity injuries.
At the time of writing the generation 7 is in use and this is recognised by the winding arm being a single thickness and a red tip on the strap. The manufacturers label is also moulded into the plastic.
Its got a single slot routing buckle to pass the strap through which makes it a lot easier to thread through and tighten than previous generations of CAT.
The SOF-T tourniquet by Tac Med Solutions has a 1 1/2 inch widewide strap that is similarly tightened by a metal windlass handle like the CAT. However it has a wide hook and buckle quick connect mechanism that does away with the need to thread a strap.
This can reduce the application time and make it easier to apply under stress.
It has alloy components for strength and durability and is easily applied one handed for self aid situations.
The Mechanical Advantage Tourniquet by Pyng Medical uses a mechanical system protected in a polycarbonate housing.
It has a similar hook and buckle set up like the SOF T but all similarities end there.
The windlass mechanism uses a turnbuckle that tightens the strap and this allows the pressure to be adjusted in smaller increments with blood flow stopped in less than 30 seconds.
The MAT easily applied one handed and and the mechanical advantage system ensures it will not slip or loosen.
Its durable and is designed to operate in extreme conditions – mud, water, sand submersion as well as extreme cold and ice encrustment.
A new kid on the block although at the time of writing isn't for sale just yet. This tourniquet from Thor TQ uses a ratchet mechanism like a ski boot buckle and looks like its one of the easiest to learn and apply.
It also doesn’t depend on fine motor skills to use it.
One handed application, looks robust enough. Importantly it appears to be fast and that really matters over just about eanything else.
Before the development of commercial tourniquets, what did people use and how effective were they?
I’ve seen a great many improvised tourniquets, some put on in a vain attempt to stop bleeding and some for other emergencies like snake bites. These have ranged from fence wire to rope and most things in between.
Most of these have been catastrophic failures although more than a couple have been well applied and successful.
A great many of the tourniquets used following the Boston bombing in 2013 were improvised out of whatever was to hand and applied by EMS and bystanders alike.
These improvised TQs obviously saved a great many lives that may have otherwise perished if not for the quick actions of those responders and others at the scene.
Commercially made tourniquets are much more preferred than improvised – beware of cheap rip offs
Tourniquets are proven in the treatment of catastrophic bleeding from extremity wounds.
Placing the tourniquet high and tight on the effected limb reduces time figuring out where to put it.
If one doesn’t work, apply a second one next to the first.
Write the time applied on the tab on commercial Tourniquets and write a big T on the forehead or cheek of the patient.
Immediate evacuation to hospital
Practice using a tourniquet on yourself and as part of any first aid training scenarios.
Make sure other people you know how to use them.
1 – Battle Casualty With Emergency Tourniquet Use to Stop Limb Bleeding. Kragh, JF 2001
2 – Safety and Appropriateness of Tourniquets in 105 Civilians
Michelle H. Scerbo MD, Jacob P. Mumm MD, Keith Gates MD, Joseph D. Love DO, Charles E. Wade PhD, John B. Holcomb MD & Bryan A. Cotton MD, MPH
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