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A Critical Shut-Off Valve

AAOS-Illo-of-BP-Cuff-1

Recently, I was presenting a lecture in which I stated that all BLS and ALS personnel should carry and use modern-day, easy-to-apply, wide-banded tourniquets for significant extremity injuries where hemorrhage can't be controlled by direct pressure measures.

I cited the case of Kevin Sterne, a student shot twice in the leg during the 2007 Virginia Tech massacre. Sterne, using hemorrhage control techniques he learned as an Eagle Scout, tied an electrical cord around his thigh as a makeshift tourniquet soon after being injured. The EMS crew that cared for him replaced the cord with a state-of-the-art tourniquet, and the surgeon who treated him noted that the early tourniquet application saved his life.

During the question-and-answer period at the end of my lecture, several attendees anxiously waved their hands like kindergartners in need of a trip to the bathroom. They all wanted to say the same thing. But, A.J., our state doesn't permit us to apply tourniquets!

It's a comment I'd heard in other states, and I gave them the same answer. ˙That's nonsense. Every single soldier in the Iraq and Afghanistan war theatre is not only carrying a tourniquet, but is trained to apply it to themselves with one hand. If your state EMS agency or medical director is forbidding you from applying a tourniquet, are they also saying you can no longer take blood pressures?Ó

I could see puzzled looks in many eyes and finished my train of thought. ˙When you inflate a BP cuff to a point at which it occludes venous and arterial blood flow, in effect, you're applying a tourniquet.Ó

There was a hush over the audience as my message sunk in. I then told them to look under ˙tourniquetÓ in old (and new) AAOS textbooks and they'd see BP cuffs being applied as tourniquets.

I don't know who planted the seed to stop the use of tourniquets in the field, but it's time to change back to what makes medical sense and was acceptable practice until about five years ago. The same concerns and misconceptions seem to crop up whenever you talk about tourniquets: 1) Manual pressure should suffice to control hemorrhage; 2) The availability of trauma centers should stop patients from exsanguination before they reach definitive care; and 3) Tourniquets lead to increased rates of amputation, ischemic complication and neurologic dysfunction.

SoJEMS intends to lead the charge for change, beginning with this month's article ˙The Return of Tourniquets,Ó p. 44 . The article points out that, in seven years of tourniquet use by Boston EMS, there have been no untoward effects from their use.

Also, in the October issue,JEMS will present additional footnoted articles on the science behind tourniquet use in a special supplement on trauma care and the lessons we've learned from military conflicts.

The results of the Boston study and the military's significant use of tourniquets in Afghanistan and Iraq present strong evidence that tourniquets can be properly applied in the prehospital setting and that they can control potentially fatal bleeding from significant extremity injuries. Also, tourniquets left in place fewer than three hours aren't associated with neurovascular complications.

Although it's true that ischemic and neurological complications can occur if a tourniquet is used improperly, the Boston results showed no neurologic compromise occurring specifically from tourniquet use, with mean tourniquet times averaging 75 minutes (with a range of 37-167 minutes). Further, all of the patients with lower-extremity gunshot or stab wounds retained complete neurologic function post-operatively.

Today's short scene and transit times and rapid movement of patients into an operating room for definitive care mean tourniquet application times can easily be limited to fewer than three hours. Within this timeframe, ischemia and reperfusion shouldn't lead to irreversible muscle-cell damage or prolonged systemic inflammatory response.

The Boston research team also compared their successfully managed cases with those from another study, with injuries similar to those in Boston. Based on the comparison, they concluded some patients in the other study who didn't have the benefit of tourniquet application likely died because of inadequate hemorrhage control. That's unacceptable based on what we know in 2008.

A tourniquet is a critical shut-off valve that all EMS providers should be able to use in an extreme emergency. State EMS agencies need to take the lead in promptly re-evaluating tourniquet use in their states and allowing their use for penetrating extremity injuries that can't be controlled with direct pressure.

With basic use criteria similar to those used in Boston, proper training, rapid transport of patients, availability of trauma centers, today's well-designed tourniquets and mandatory case follow-up, there's no reason tourniquets shouldn't be used to safely and effectively control life-threatening bleeding from penetrating and other massive extremity injuries. JEMS

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