The Tourniquet Debate
There is a lot of debate in the use of tourniquets today. This conversation is not just in urban EMS but is creeping into the wilderness EMS as well. Tourniquets are saving lives in the tactical setting, and mass casualty events in the United States. The Question is should it be used as the first line of defense to exsanguination or as a last resort.
Direct Pressure and Pressure Points.
As an EMT instructor, I teach the NHTSA standard curriculum of progressive treatment. That is direct pressure first, pressure points, then tourniquets. According to the American Academy of Orthopedic Surgeons (AAOS) in most cases of external bleeding can be controlled by simply applying direct pressure to the wound. AAOS contends that elevation has no outcome on the process of stopping or slowing the bleeding. That statement alone is causing issues in EMS, however, that is a different topic.
The argument for direct pressure first is the fact that it does allow for blood to get to the tissue distal to the injury, and it allows for t he natural blood clotting process to start. One of the issues that we are facing is the use of hemostatic infused gauze, the protocol is to remove the gauze if the bleeding continues and repack the wound. This process is in direct conflict with the use of traditional dressings where we pack the wound and keeping the saturated dressing in place to promote clotting and not risk the chance of disturbing the clot that has started.
Conflict of Operations:
In urban EMS there are some conflicts of opinion on the proper use of the tourniquet. Just for the record I am on the side of the TCCC and TECCC of early use of the tourniquet and placing the device as high on the wounded extremity. AAOS teaches that you will use the tourniquet as part of the progressive treatment of the patient and keeping the device just above the level of the wound. In my opinion and that of some of my close colleagues in the field of tactical medical operations see that application lacking in the true ability to stop the majority of the blood flow in blast wounds and gunshot wounds. One of the other techniques that is no longer taught and or recommended it the use of pressure points. This is based on 2015 American Heart Association Guidelines: “There continues to be no evidence to support the use of pressure points or elevation of an injury to control external bleeding. The use of pressure points or elevation of an extremity to control external bleeding is not indicated (Class III: No Benefit, LOE C-EO).”
I wanted to take the time to set out some basic tourniquet “rules” that should be followed. These are the current civilian application standards. As stated before In the TCCC and TECC process and application of blast wounds, uncontrolled gunshot wounds, the recommendation is to place the tourniquet at high up on the limb as possible leaving clothing in place. After the bleeding is stopped then expose the wound and assess if the tourniquet can be removed, or placed about 2 to 3 inches proximal (above) to the wound.
Tourniquets have a checkered history and hyperbolic claims continue to muddy the water. Past and current combat experience in the SW Asian theaters has drawn renewed attention to them because injuries to limbs have been a major source of life-threatening bleeding. There, they are being used successfully to control obvious and potentially serious bleeding. In the latter case, they are applied before a proper assessment is possible e.g., multiple casualties, continued live fire. The tourniquets used are relatively cheap and can be life-saving if used properly. As with anything in medicine, nothing works 100% of the time.
In civilian practice, it is relatively rare for death from limb bleeding to occur because properly applied, well-aimed direct pressure failed. Still, tourniquets have their use outside of theater (e.g., mass casualty), so knowing how to use one is important. The relevant questions include what, where and for how long.
1. Choose the one that you like they all have their pros and cons. Learn how to use the tourniquet 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 circumferential pressure. 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 the 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.
A good tourniquet ought to be soft and wide at least 1.5 inches wide and not wider than 3 inches. The most effective size is about 2 inches wide. To be effective, the circumferential pressure needs to be sufficient to stop bleeding. There are of serviceable tourniquets. 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.
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).
To learn more:
To learn more about how to save a life using tourniquets go to wemt.teachable