Tourniquet use has once again become ubiquitous for controlling massive hemorrhage. Research has shown that prompt and proper use of a tourniquet prior to the onset of shock can help prevent death. Some of the “myths” surrounding tourniquet use, such as “the patient will lose their limb,” or “there will be permanent damage as a result of tourniquet use,” have been disproven or minimized.
There are many different devices that are being marketed and sold as tourniquets, and there are a lot of factors to consider when selecting a device, such as width, durability, size (for easy storage and fitting around an extremity) and safety closures to ensure the tourniquet is prematurely released.
Tourniquets are a fast and effective tool to stop major extremity bleeding when used properly. There are some risks associated with tourniquets, mainly from improper use, lack of training or prolonged tourniquet times. Guidelines developed by the Committee for Tactical Emergency Casualty Care (C-TECC) exist to aid in assuring that providers use tourniquets correctly and lessen the chance of complications. These guidelines are based on existing evidence, best practices and military recommendations and experiences. C-TECC takes into account the differences in civilian populations and operating parameters in the guidelines, and doesn’t recommend or endorse a particular device.
Agencies should consult tourniquet studies and their medical directors prior to selecting any device, and not necessarily rely on recommendations or endorsements of devices used by the military. Studies have shown that improvised tourniquets are ineffective in 40% of applications. C-TECC recommends a commercially produced tourniquet as the first choice.
Proper placement of tourniquets depends on the operational situation facing the provider. If in a direct threat environment (hot zone) where there is imminent danger to the provider or patient, the tourniquet should be placed high on the extremity over the clothes.
In an indirect threat environment (warm zone) or during non-high-threat situations, the tourniquet should be placed directly against the skin several inches above the wound, but not over a joint. If the provider can’t easily determine the extent of damage, the tourniquet should be placed high on the extremity.
It’s important for providers to use direct pressure and/or pressure points to help control the bleeding while placing and tightening a tourniquet. A proper tourniquet should result in not only visible control of bleeding, but also the loss of a distal pulse in the extremity. If one tourniquet is not enough to control the bleeding, a second tourniquet should be added next to the first device.
Once a tourniquet is in place, the subsequent goal is to reduce chances of neurovascular damage to the extremity by de-escalating or downgrading the tourniquet. Research shows that there’s a minimal chance of damage, which can be transient or permanent, when using tourniquets. Perfusion intervals, or loosening the tourniquet in 15–20 minute intervals, isn’t recommended and doesn’t reduce the chance of complications. Research also shows the chances of complications increase if a tourniquet is left in place for more than two hours.