Thursday, July 23, 2015

Field Medicine: Tourniquets

Tourniquets and how to use them have come a long way from when I was a Boy Scout. They were always passed over a little as a “last resort” treatment. That has changed. We learned a lot of things in Iraq and Afghanistan. We learned that bleeding out was going to be the most common cause of death if we didn’t change our minds about tourniquets. There is some controversy on the use of tourniquets and so what I will give you here is my own opinion. This opinion is from 2 combat medics with several tours under their belts. The other from a combat Doc. Combined these three have 12 tours in combat zones. As with all things, this is only their, and my, opinion. This is not medical advice.
I am not sure that there is a consensus about their use but here is my opinion about tourniquets in remote and hostile environments.
1. Learn how to use one and practice with it.
2. Apply to stop bleeding not controlled by well-aimed direct pressure.
3. Use something wide and firm (but not hard) that can apply pressure evenly all the way around. The pressure should be sufficient to stop bleeding. Make sure that it is in good shape and not a knock-off.
4. Place proximally (upstream) and as close to the wound as possible.
5. Don’t release in the field if the patient is in shock, has an amputated limb, or has a wound site that cannot be monitored for re-bleeding.
6. For a long evacuation, wait an hour before trying to release it. If bleeding starts again, re-secure. Note the time and leave it in place until definitive care is reached or arrives.
7. Under dangerous circumstances, one may be applied before a thorough evaluation is possible. These should be applied to the proximal thigh or arm if there is any question about the location and/or number of wounds. Carefully check the wound when it is safe and feasible. As indicated, leave, reposition, or release it or add a second one proximally.
Remember that this is first aid. You would only do this as a last resort if you don’t have experience with it. As with anything in medicine, nothing works 100% of the time.
The following is directly from these 3 heroic warriors:
“A good tourniquet ought to be soft (but not mushy) and wide. Within limits, wider is better. To be effective, the circumferential pressure needs to be sufficient to stop bleeding. A sphygmomanometer (BP cuff) might be ideal except that they usually will not maintain adequate pressure for a long enough period of time. They and similar devices are also bulky and fragile. The gauges break easily and the fabric, bladder and tubes are vulnerable to sharp objects. Cordage, like a rope or 550 cord (parachute), is not a good choice either because of the potential for direct skin and neurovascular injury.”
There are a variety of more serviceable versions. Two of them, the CAT (combat application tourniquet) and SOFTT (special operations forces tactical tourniquet), have worked reasonably well in combat. They are compact, inexpensive and easily applied, even by the patient. Their advantages are a tradeoff for effectiveness.”
One needs to have enough remaining limb to hold the tourniquet. I have heard intelligent people argue that they should never be applied to forearms and legs (lower). Generally, I disagree and experience would seem to bear that opinion out. They should be applied as close to the wound as possible. When circumstances prevent a proper assessment for location and number of wounds, some recommend using only the proximal arm (upper) and/or thigh as default positions.”
If limb bleeding will not stop, especially with a thigh, another applied in parallel, proximally, may help. Stay off joints. Controlling junctional (e.g., in the groin) bleeding remains problematic.”
How long 1:
People fear tourniquets because prolonged use can lead to neurovascular damage and tissue death. We know that tissue death from impaired circulation can occur in as little as two hours. We also know that tourniquets have been left on for over 16 hours without any notable harm.
Releasing a tourniquet has its own risks and there are circumstances where removal never makes sense. These later would include limb amputation, shock, the inability to monitor the wound or continued bleeding. Intermittently releasing them to temporarily restore circulation has been reported to lead to unrecognized, ongoing blood loss and patient death. On a long evacuation, if the conditions seem otherwise safe, waiting 1 hour before attempting a removal seems like a reasonable time interval. If bleeding starts again, re-secure, note the time and leave it in place.
Improper application is an important cause of failure. They can also fail when they breakdown from environmental exposure or from poor construction (e.g., older version knockoff). Always check your equipment before heading out and replace anything questionable. Practice with any tool before you need it for a real emergency.
There are plenty of good resources online that cover step-by-step application and the identification of knockoffs (e.g., date printed on webbing, red tip on the end of webbing).”
How Long 2:
You want keep the TQ on tight until the medics get there. Recent studies have shown that you can safely leave a TQ applied for up to 6-8hrs. After that time-frame, tissue starts to break down and becomes necrotic or "dead tissue". The problem with that is those dead cells become toxic and can wreak havoc on the rest of the healthy body/cells. So if we loosen up that TQ and allow blood back to that limb; we run the risk of circulating those toxins throughout the body. Not to mention the fact we also run the risk of circulating small blood clots as well. And that is bad.

The debate on releasing it or keeping it tight after 6-8hrs is still ongoing even with high level healthcare providers. Now as a healthcare provider, they can assess the patient taking in consideration their vitals, level of consciousness, environment, ETA to appropriate healthcare facility, the severity of the wound itself, available resources (equipment & personnel), and other factors to determine if loosening or removing the TQ is the best procedure at that time. No matter if that time is before or after that 6-8hr window.

We're not so much worried about "losing the limb" as we are about losing the entire patient.”
Using a tourniquet has saved countless lives but use wisdom in using one. Make sure you know how and then get quality tourniquets. This is what I took from this information. It sounds like this technique is making a comeback and has made a large difference in saving lives. What I like about this is that there is plenty of real experience backing up the use of a tourniquet. I would consider good, quality tourniquets for your bug out bags and first aid kits.
Semper Paratus
Check 6