Civilian EMS Should Consider Tourniquets

 

 
 
 

Gregory C. Risk, MD, MPH, FACEP | James J. Augustine, MD, FACEP | From the March 2012 Issue | Saturday, February 25, 2012


Recent military experience has overwhelmingly favored the efficacy of prehospital tourniquets. Their safety has been verified in routine use of tourniquets in the operating room and battlefield for the control of severe extremity hemorrhage.

Civilian EMS providers and emergency physicians are increasingly using tourniquets for situations in which a premium is placed on rapid and definitive control of extremity hemorrhage. This article reviews the history and use of tourniquets in the U.S. military and the applications for emergency providers in non-combat situations.

Case
A worker became trapped in a mobile trash compactor. A sharp edge of the grasping tool dug a jagged hole in his lower right thigh, and his lower leg was trapped in the machine. In an attempt to save his life, the man made his belt into a makeshift tourniquet and placed it on his upper leg.

He was alone at the top of the machine, and a ladder was extended up to access him. A single provider could work at the top. The view into the machine was difficult.

The patient was holding the belt tightly to maintain control of the bleeding, but he was getting lightheaded because of pain and his blood loss. The EMT had access into the machine with only one hand and was able to replace the patient’s belt with a commercial tourniquet. The remainder of the rescue crew was working to reverse the machine and free the patient’s leg.

The patient, whose pant leg was cut away to ensure a smooth skin surface, was advised of the plan to replace his belt with a commercial tourniquet—although his level of consciousness was fading.

The tourniquet was wrapped around the man’s upper thigh, strapped in place and tightened to the point that his bleeding stopped. The belt was removed, and the EMT then focused on assisting in extricating the leg.

Bleeding was controlled with the tourniquet; the patient was given an intramuscular injection of morphine to reduce pain, and his mangled leg was carefully removed as the machine’s grasping mechanism was placed in a reverse direction. The extrication was completed in 20 minutes. The patient was removed, transported to a local hospital and transferred to the regional trauma center—all with the tourniquet still in place.

Trauma Care & the Military
The use of tourniquets for hemorrhage control has undergone a complete reassessment within the U.S. military as part of a larger revolution in tactical combat casualty care (TCCC).

The unfortunate reality is that a large number of advances in trauma care over the past century have been the result of blood spilled in conflict. The incorporation of these advances, especially since World War II, has markedly improved the care of the severely injured trauma patient in the U.S. Some of these improvements and treatment modalities are being adopted slowly, given the experience gained in the preceding 10 years of war.

Tourniquets have a long and storied history, but concerns and unfortunate dogmas persist, despite the known benefits of the proper use and application of this simple, easy-to-apply, effective and inexpensive device. The return of these devices to civilian EMS is slow and needs to be accelerated to ensure that hemorrhage that cannot be controlled by traditional pressure and compression techniques can be stopped by tourniquet application.

The availability and use of tourniquets can be of critical importance in rural settings, where agricultural accidents or equipment injuries to limbs are more prevalent, as are prolonged extrication and transport times. The frequent need to transfer patients from rural hospitals to higher levels of care further emphasizes the need to obtain control of extremity hemorrhage.

History of Tourniquets
The first recorded use of similar medical devices dates to the Greeks.(1) The first use of a medical device with a windlass similar to modern tourniquets was described in 1593.(2) The first recorded recommendation for issuing a tourniquet-like device to each soldier occurred during the U.S. Civil War by Samuel Gross in 1862.(3)

Unfortunately, many of the criticisms of tourniquet use arose during this conflict, often as the result of poor training or delays in transport to field hospitals, which frequently took days to effect. Given these delays, the rudimentary surgical training, wound contamination and lack of antibiotics resulted in frequent limb amputation that would subsequently be attributed to the use of tourniquets.

World War I saw similar outcomes and attitudes develop. Again, evacuation systems from the battlefield were poor to nonexistent; lack of significant surgical advances resulted in large numbers of amputations to extremity injuries.

A prevailing attitude was captured in the following statement published in a British medical manual during the war, “The systematic use of the elastic tourniquet cannot be too severely condemned. The employment of it, except as a temporary measure during an operation, usually indicates that the person using it is quite ignorant both of how to stop bleeding properly and also of the danger to life and limb caused by the tourniquet. If an orderly has applied a tourniquet, it’s the duty of the medical officer who first sees the patient to remove it at once. Then the orderly must examine the limb to ascertain whether there’s any bleeding at all, and if there is, to use proper measures for its arrest.”(4)

In some measure, this statement captures attitudes that persisted for the rest of the 20th century. This stance ignores the fact that only those patients who were reached in a timely fashion and had a tourniquet applied in the field survived to reach a field hospital.
World War II (WWII) saw significant advances in battlefield care and one of the first efforts to study combat casualty care during conflict.

The authors of an article published by the U.S. Army Medical Department looked at a series of several hundred wounded who had tourniquets applied. Their findings were among the first to strongly advocate for the use of tourniquets in extremity trauma and couldn’t find any clinically significant evidence of extremity damage or loss attributable to tourniquet use.(5)

Problems were noted with the then-quoted advice to loosen the tourniquet every 30 minutes to allow for limb perfusion. This was subsequently replaced in most references with a protocol that only a medical officer/physician could remove a tourniquet.(6)

Subsequent studies during the Korean War and Vietnam documented the efficacy of tourniquets and the paucity of limb ischemia or injury associated with their usage. It must be pointed out that the surgical techniques employed in the field and trauma treatment facilities markedly improved after WWII, with more liberal usage of fasciotomies to prevent compartment syndromes, better splints and better vascular techniques for limb salvage.

Most importantly, helicopters made their appearance in Korea and were the main method of casualty evacuation in Vietnam, reducing the time to surgical treatment and nearly eliminating prolonged tourniquet times.(7–9) Most of the tourniquets used during these wars were improvised, and the official U.S. Army tourniquet made of canvas and belt buckle was unable to provide arterial occlusion.

Unfortunately, the experiences gained during these conflicts were lost or forgotten, and dogmas about limb amputation became common again. The teaching in the early 1980s at the U.S. Army’s basic medical specialist course was that tourniquets were to be used only after direct pressure, limb elevation and pressure point application had failed and bleeding continued. Most importantly, the decision to use a tourniquet was a decision to sacrifice the limb to save a life, and that amputation would invariably follow.(10)

The standard military surgical text at the time enforced the following dogma, which equated tourniquet use with inevitable limb amputation persisted.

As an emergency measure, until more effective measures can be instituted, external hemorrhage can often be checked by direct pressure. In most instances, it can be controlled by the application of a firm pressure dressing, which must not, however be so tight that circulation is impeded. Satisfactory control of bleeding by this means may not be immediate, and the medical officer should bear this in mind and should not resort to other less desirable means until pressure obviously has failed. Tourniquets are rarely needed for the control of hemorrhage and should be used only when all other methods fail. A tourniquet properly applied can save life but endanger limb.”(11)

These opinions were repeated in the 1988 revision to the Emergency War Surgery text, and these opinions were prevalent through the past decade of the century.(12)

Turning the Tide
During the 1990s, special operations forces were aggressively using tourniquets. Studies of casualties by the U.S. Army Rangers in Somalia revealed life-saving capabilities and safety of early and aggressive hemorrhage control.(13–14)

This and other studies undertaken by special operations and the U.S. Army Medical Department began to take hold, and the development of the first new commercial tourniquet designs, was undertaken. Eventually, more than 40 new types of commercial tourniquets were developed. Today, two tourniquets are issued to every service member in a combat role. The U.S. military is also evaluating clothing that incorporates tourniquets in each extremity section.

The 2004 edition of the Emergency War Surgery Manual now states, “Use a tourniquet early, rather than allow ongoing blood loss. Substitutes for issued tourniquet include belt, torn cloth, gauze and rope, among others … does not require constant attention; allows first responders to care for others, extends resources.”(15) The concern about limb injury is more measured, noting that, “Application for more than two hours may increase limb loss. Don’t avoid a tourniquet in order to save a limb, and then lose a life! Use of the tourniquet does not always lead to limb loss.”

Meanwhile, a more systematic approach has occurred. A series of studies have looked at the efficacy of prehospital tourniquets and their safety.(16–18) The conclusions are overwhelmingly in favor of applying tourniquets to control severe extremity hemorrhage. In addition, they highlight the near-total absence of significant complications attributable solely to the use of tourniquets.

Although the studies continue to verify a lack of extremity injury attributable to the use of tourniquets, the ongoing improvement and reduction in transport times to tertiary levels of care further reduces those concerns.

Instances of effective tourniquets being placed for up to 20 hours have been recorded with complete viability of the limb and return to full duty. At times within a deployed environment given multiple casualties, and the presence of a single medic or corpsman at the point of injury, a premium is placed on rapid and definitive control of extremity hemorrhage, and evacuation to higher levels of care by means of transport and by personnel who aren’t dedicated to medical evacuation and treatment.

The temporary application of tourniquets to control significant hemorrhage during early triage operations has also been proven valuable and helped stop the unsubstantiated recommendation that a tourniquet not be released once applied. The reality is that EMS and hospital staff applies and releases tourniquets every day as they inflate and deflate blood pressure cuffs on their patients.

The current Department of Defense TCCC guidelines recommend evaluating extremity injuries after tourniquet application and if possible, releasing the tourniquet and “converting” to a pressure dressing or other method if hemorrhage is controlled and adequate time for thrombus formation has occurred.(19) 

This allows the paramedic to remove the tourniquet during the tactical evacuation phase of TCCC, after triage of patients is complete, or if faced with prolonged care and transport of a patient in excess.

These guidelines are different than the more traditional guidelines that a tourniquet should be only removed by a medical officer once placed. They also represent a further evolution in care of extremity injuries.

From Combat to Civilian EMS
Military injuries have traditionally been different than those seen in the civilian environment. The incidence of explosive injuries has been less common, as have multiple life-threatening extremity injuries in a single patient.

The incidence of catastrophic mass casualties is also less frequent. There are usually adequate resources at the point of injury and the process of evacuation is rarely under the type of duress encountered in combat. This would allow the medical personnel involved to remain with the patient until delivery to a higher level of care and ensure ongoing hemorrhage control.

Each of these points is meant to delineate the differences that would likely mean less civilian EMS use of tourniquets, more rapid transport and shorter times for their usage—hence, less potential for limb ischemia. Therefore, there should be far less hesitancy about using this tool at the appropriate time and for the appropriate patient to obtain rapid hemorrhage control. The limiting factors appear to be appropriate medical direction and protocols, equipment selection and adequate training.

It’s import for providers to be aware that tourniquets are a routine part of the practice of operative care in most hospitals for a variety of everyday surgeries. Orthopedic surgeons frequently use pneumatic tourniquets in operating rooms for several hours. Hand surgeons use smaller devices for surgeries on hands and fingers, with
no complications.

Although these devices are of a different specification, this lends further evidence that when used for less than two hours, concerns about limb ischemia should be nearly completely alleviated. The short time intervals would be typical for EMS transport to emergency departments or associated with transport to an operating suite from an emergency department for extremity injuries seen in civilian practice.

Civilian EMS Adoption
Effective medical leadership should focus on providing solutions for first responders who might face the potentially dire situation of improvising tourniquets when faced with uncontrollable extremity hemorrhage.

Tourniquets are inexpensive, proven devices that should be placed on each emergency response unit and in each first-in bag. Military personnel each carry two tourniquets in case they lose more than one extremity as has been frequently experience in Iraq and Afghanistan after detonation of an improvised explosive device or other weapon.

Protocols should emphasize the rapid control of extremity hemorrhage to prevent shock as expeditiously as possible, allowing transition to pressure dressings or other methods as time and situation allows. It’s incumbent on EMS medical directors and educators to emphasize the relative safety of this technique.

Surgeons at local or regional trauma centers may also be helpful in the decision-making because they’ll likely be the ones who need to remove the device.

Military training techniques will be useful. Personnel rotating through pre-deployment training continually underestimate the skill required to effectively place a tourniquet, which achieves arterial occlusion.

Although there are key differences in the training approach, providers can meet the goal of tourniquet placement with arterial occlusion within 60 seconds only through repetitive and supervised application of selected devices.

Military personnel train for both self and buddy application. Civilian training should focus primarily on the latter. Personnel that serve on or support tactical units should train and practice both methods.

Training to apply the tourniquet properly until loss of distal pulse familiarizes the provider with the degree of tension required, which most providers initially underestimate.

Providers also need to grasp the reality that a properly applied tourniquet results in minor discomfort for the patient. This is perhaps best appreciated only after having multiple tourniquets applied to each responder during training.

Several important points need to be emphasized with regard to tourniquet training. The most important is that applying the tourniquet to the appropriate tension to achieve arterial occlusion can weaken the tourniquet. Microscopic tears develop in most commercial tourniquets using the dominant windlass mechanism necessary to achieve mechanical advantage. The package inserts for several tourniquets emphasize that tourniquets used in training shouldn’t then be used for actual treatment due to a much higher failure rate.

Therefore, tourniquets used for training purposes need to be segregated or disposed of so they aren’t included with other emergency supplies. Second, EMS providers should note the timing of tourniquet placement and mark this on the patient in some formalized fashion as part of the training routine. Failure to document this critical treatment needlessly complicates subsequent treatment.

Finally, the proper placement and positioning of tourniquets must be addressed. Recommendations for placement of the tourniquet vary. The prevailing notion is to place the device as distally as possible to salvage as much of the limb for subsequent rehabilitation and use in the event of amputation.

The current recommendations involve placing the tourniquet above the joint at the site of injury. This entails placement above the knee for a lower leg injury and above the elbow for a lower arm injury. The rationale for this is that compression of the artery doesn’t occur through circumferential compression, but through compression of the artery against a long bone. Therefore, the upper portion of each extremity affords the best anatomical possibility because there’s only one bone—either the humerus or femur—and direct pressure on the arteries can be achieved.

The lower portion of each extremity offers more anatomical challenges because there are two bones in each (the radius/ulna in the arm and tibia/fibula in the leg) that may prevent pressure on the artery from achieving adequate compression of the vessels to obtain hemorrhage control.

For injuries involving the upper portion of each limb, the mantra of “high as you can, tight as you can” simplifies the placement. The issue for the upper arm or leg is achieving adequate compression through a large amount of muscle mass in either the mid-thigh or the biceps/triceps muscle complex. Placement above these areas affords the best chances for hemorrhage control of injuries to the upper portions of each extremity.

In larger individuals, experience has shown a single tourniquet on the upper portion of limbs may be inadequate. Current TCCC recommendations advocate for a second tourniquet if necessary. “If a distal pulse remains after tourniquet application, then a second tourniquet must be applied side by side and just above the original tourniquet. This second tourniquet applies pressure over a wider area, and more easily stops the arterial flow.”(20–21)

Case Resolution
The worker was safely transported to the regional trauma center. The tourniquet remained in place until his arrival in that emergency department, where an attempt to release it led to severe hemorrhage. The patient was then taken to the operating room, where his leg was amputated below the knee, and the injuries above the knee were repaired. A prosthesis was fitted for the patient. After several months of rehabilitation, the patient was able to return to work.

Conclusion
A growing body of evidence shows that tourniquet use for severe bleeding from extremity injuries and as an initial triage tool is effective and safe. The challenges presented in controlling life-threatening extremity hemorrhage in the field leave little margin for error. Therefore, adding tourniquet devices and training to the civilian EMS armamentarium should be considered.

By developing tourniquet policies, procedures and protocols, selecting the right equipment and conducting effective training, each EMS system can be better prepared to deliver the life-saving care needed by our hemorrhaging patients. JEMS

Gregory Risk, MD, is an emergency physician who has spent 30 years of service with the U.S. Army. He served as assistant dean at the Joint Special Operations Medical Training Center, Special Warfare Center and Schools. He has multiple deployments to Operation Iraqi Freedom and Operation Enduring Freedom. He’s a clinical assistant professor of emergency medicine at Oklahoma University School of Medicine in Tulsa.

James J. Augustine, MD, is an emergency physician from Atlanta with 30 years of service in EMS. He served as assistant fire chief and medical director for Atlanta Fire Rescue and the District of Columbia Fire EMS Department. He’s the director of clinical operations at EMP Management in Canton, Ohio. He’s a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, Ohio and a member of the JEMS Editorial Board.

References
1. LaDran J: The Operations in the Surgery of Mons. LaDran: London, 1749.

2. Mabry RL. Tourniquet use on the battlefield. Mil Med. 2006;171(5):352–356.

3. Gross SD: A Manual of Military Surgery, or, Hints on the Emergencies of Field, Camp and Hospital Practice. J.B. Lippincott: Philadelphia, 1862.

4. Injuries and Diseases of War. U.S. Government Printing Office: Washington, D.C.; 1918.

5. Wolff LH, Adkins TF: Tourniquet problems in war injuries. Bulletin of the U.S. Army Medical Department. 1945, 37:77–84.

6. Walters TJ, Mabry RL. Issues related to the use of tourniquets on the battlefield. Mil Med. 2005,170(9):770–775.

7. Bowers WF, Hughes CW: Surgical Philosophy in Mass Casualty Management. Charles C. Thomas: Springfield, Ill., 1960.

8. Hughes CW. The primary repair of wounds of major arteries: An analysis of experience in Korea in 1953. Ann Surg. 1955;141(3):297–303.

9. Jahnke EJ Jr, Seeley SF. Acute vascular injuries in the Korean War. Ann Surg. 1953;138(2):158–177.

10. Basic Medical Specialist Manual 91B. U.S. Army Medical Department Center and Schools: 1975.

11. Emergency War Surgery, First United States Revision. U.S. Government Printing Office: Washington, D.C.; 1975.

12. Emergency War Surgery, Second U.S. Revision. U.S. Government Printing Office: Washington, D.C., 1988

13. Mabry RL, Holcomb JB, Baker AM, et al. United States Army Rangers in Somalia: An analysis of combat casualties on an urban battlefield. J Trauma. 2000;49(3):515–528.

14. Butler FK, Hagmann J, Butler EG. Tactical combat casualty care in Special Operations. Mil Med. 1996;161(Suppl.):3–16.

15. Burris DG, Fitzharris JB, Holcomb JB, editors, et al.: Emergency War Surgery, 3rd edition. U.S. Department of Defense: Washington, D.C., 2004.

16. Rassmussen TE, Clouse WD, Jenkins DH, et al. Echelons of care and the management of wartime vascular injury: A report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. Perspective Vasc Surg Endovasc Ther. 2006;18(2):91–99.

17. Beekley A, Sebesta J, Blackbourne L, et al.: Pre-hospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes. In 36th Annual Scientific Meeting of the Western Trauma Association, Big Sky, Mt., 2006.

18. Welling DR, Burris DG, Hutton JE, et al. A balanced approach to tourniquet use: Lessons learned and relearned. J Am Coll Surg. 2006;203(1):106–115.

19. Tactical Combat Casualty Care Manual. U.S. Department of Defense: Washington, D.C., 2005.

20. Tactical Combat Casualty Care Handbook No. 10-44. Center for Army Lessons Learned: Ft. Leavenworth, Kansas, May 2010.

21. Winter 11 Training Supplement to the Journal of Special Operations Medicine. USSOCOM medic Certification Program: MacDill Air Force Base, Fla., 2011. 




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Related Topics: Patient Care, Trauma, prehospital use of tourniquets, prehospital tourniquets, military tourniquets, control of severe extremity hemorrhage, commercial tourniquets, Jems Features

 

Gregory C. Risk, MD, MPH, FACEPGregory C. Risk, MD, MPH, FACEP, is an emergency physician who has spent 30 years of service with the U.S. Army. He served as assistant dean at the Joint Special Operations Medical Training Center, Special Warfare Center and Schools. He has multiple deployments to Operation Iraqi Freedom and Operation Enduring Freedom. He’s a clinical assistant professor of emergency medicine at Oklahoma University School of Medicine in Tulsa.

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James J. Augustine, MD, FACEPDr Augustine is a clinical Associate Professor in the Department of Emergency Medicine at Wright State University in Dayton, Ohio. He currently serves a Medical Director role with Departments in Florida and Georgia. He is the author of numerous EMS articles.

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