Outdated, unsubstantiated fears about tourniquet use need to be put to rest once and for all
Outdated, unsubstantiated fears about tourniquet use need to be put to rest once and for all
Not your grandpa’s tourniquet: Many of the myths and misconceptions surrounding tourniquet use are carryovers from a bygone era, when tourniquets were left on patients for up to 18 hours while they waited for surgery
It is an atypical Saturday in your busy Level One trauma center as, fortunately, the knife and gun club seems to be taking the day off. You’ve just gotten a quick bite to eat when you hear the radio go off. EMS is bringing in a police officer shot in the thigh during a SWAT raid. The report is that he has an entrance wound in the upper mid-thigh with these vital signs: blood pressure 100/60, heart rate 120, respiratory rate 22, and 98% on room air. On the phone, the paramedics indicate that the bleeding is controlled with a tourniquet.
As the 40-year-old patient arrives in the ER, he is mildly diaphoretic, with a pulse of 100 and the same blood pressure reported in the field. As he’s wheeled into the trauma room, you do not see any obvious signs of active bleeding. You start your primary survey, and after establishing an intact airway and breathing, focus on the patient’s circulation.
But then the general surgeon covering trauma arrives and starts to yell at the paramedics about the dangers of putting a tourniquet on the patient, asserting that they may have put the patient in danger of losing his leg. Then the SWAT officer chimes in, stating he was the one who actually placed the tourniquet. He adds that he has just received training in the latest Tactical Combat Casualty Care guidelines, and now all SWAT officers are carrying tourniquets. The surgeon looks confused, and you realize you will need to have a talk with him after the shift.
The Past is Past
In the last several years, the United States military has gathered substantial evidence on the safety benefits of using tourniquets [1,2,3]. However, many physicians still may be hesitant to use this potentially lifesaving device. The chief concern: A tourniquet can induce ischemia in an already at risk extremity, which may lead to an unnecessary amputation [2]. This belief first developed in World War I when evacuation to surgical care took up to 18 hours and was re-enforced in World War II.
Prolonged evacuation times and reliance on improvised tourniquets meant surgeons often saw survivors who may have not needed a tourniquet. Those that died in the field from simple extremity hemorrhage just never made it to the surgeon. In his 2012 article on the history of the tourniquet, John Kragh pointed out that, in several instances in war zone conflicts where the use of the tourniquet was criticized from these conflicts, there was a paucity of evidence to support those positions [2].
This bias, perpetuated in the surgical literature, is perhaps best put into perspective by New Zealand surgeon Douglas Jolly, who succinctly said that “more limbs and lives are lost at the front from the improper use of the tourniquet than are saved by its proper use [4].” Other observers have characterized the tourniquet as “an invention of the Evil One [5].”
The Answer is YES!
So, what’s the current evidence? The most recent studies indicate that the tourniquet is safer than previously described. In 2008, Kragh et al. studied 232 patients with 309 limbs that had tourniquets applied and determined that there were no amputations resulting from tourniquet use [1]. The enhanced safety of the tourniquet is in no doubt due not only to technical advances in their design but also because transport times to surgeons have been greatly reduced. This reduction in transport time is not relegated just to the battlefield, but also affects today’s civilian trauma systems.
Civilian trauma often mimics military trauma. The situation that medics and first responders find themselves in may not allow them to exhaust all other means to get extremity hemorrhage under control before reaching for a tourniquet. Tourniquets installed at the scene do not often remain in place several hours later when the patient can receive surgical care, and there are clearly several situations in which the tourniquet should be a first line agent to treat extremity hemorrhage, including those involving mass casualties, active shooters or limited medical resources [6]. A well-placed tourniquet can eliminate the need for first responders or medics to apply direct pressure to the bleeding and enable them to engage in other important interventions.
The Committee on Tactical Combat Casualty Care (CoTCCC) recommends three different commercially available tourniquets [7]. All the tourniquets were tested by the US Army Institute of Surgical Research to ensure that they would reliably be able to obstruct arterial blood flow. The Combat Application Tourniquet (C-A-T™) has the advantages of being lightweight and therefore can be operated with one hand, allowing someone to place on one’s own upper extremity with the other hand, if needed. The SOF® Tactical Tourniquet is also a commonly used tourniquet on the battlefield. The third tourniquet is the Emergency and Military Tourniquet (EMT™), by Delfi, which instead of using a windlass rod like the C-A-T™ or SOF® TT, works pneumatically.
Care under Fire vs. Tactical Field Care
The CoTCCC guidance for the use of the tourniquet makes a distinction between care under fire and tactical field care [7]. The distinction is based on whether or not the provider and patient are still in immediate danger from being in a hot zone (care under fire). Of course, every EMS provider is taught to consider scene safety and not to put themselves in harm’s way. However, there are circumstances where that is simply unavoidable, such as tactical EMS situations or tactical operations, in which SWAT team members would be required to render aid to themselves or colleagues. Tourniquets in care under fire are installed hastily and usually over clothing.
In the tactical field care phase of treatment, TCCC recommends a slightly different approach:
- First, place the tourniquet two to three inches above the wound, directly on the skin;
- Then, check for a distal pulse and if bleeding persists;
- If so, consider placing another tourniquet side by side and directly above the first or tightening the existing tourniquet.
Epilogue
Let’s get back to our patient and the surgeon. When you discuss the situation, the surgeon points out that the SWAT officer had a femoral artery and vein laceration. He tells you that the vessels were cut obliquely and that he doubted that they would have clotted off quickly on their own. The direct pressure would have been difficult to implement due to the extensive damage to the patient. He hypothesizes that the officer would have bled out within a matter of minutes had he not applied his own tourniquet. The officer told the surgeon in the recovery room that it took the paramedics 20 minutes to get to him after he had applied the tourniquet and asked the surgeon if the tourniquet saved his life. The surgeon smiled and said “maybe.”
For more information, access the TCCC guidelines and educational materials via the Journal of Special Operations Medicine
Stephen A Harper, MD is a Major in the US Army and current Military EMS and Disaster Medicine Fellow.
Robert Mabry, MD, LTC is Director, Military EMS and Disaster Medicine Fellowship and Director, Trauma Care Delivery, Joint Trauma System, at the US Army Institute of Surgical Research.
REFERENCES
1. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008; 64(2 Suppl): S38-49; discussion S49-50.
2. Kragh JF Jr, Swan KG, Mabry RL, Blackbourne LH. Historical review of emergency tourniquet use to stop bleeding. Amer J of Surg. 2012; 203: 242-252.
3. Eastridge BJ, Mabry RL, Sequin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012; 73(6 Suppl 5): S431-437.
4. Jolly DW. Field Surgery in Total War. New York: Paul B. Hoeber, Inc.; 1941:24-25.
5. Blackwood M. Royal Army Medical Corps, 3rd Corps Medical Society. Treatment of wounds from fire trench to field ambulance. 1916. J R Army Med Corps 2001;147:230-235; discussion, 229.
6. Bulger EM, Snyder D, Schoelles K, et al. An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 2014; 18: 163-173
7. United States Army Institute of Surgical Research. Tactical Combat Casualty Care Guidelines, Published 2 June 2014. https://www.jsomonline.org/TCCC.html