There aren’t too many topics in EMS that give rise to more hysteria than using tourniquets for bleeding control. I think that the reason for this is that much of what we is outdated. The information seems to be outdated.
As a matter of fact, a search of various websites, some of them official training sites of various agencies, shows a wide variety of instructions.
The Sixth edition of the PHTLS text book states, “A tourniquet is used only after all other efforts have failed and in some combat situations.”
From ArmyStudyGuide.com comes this advice.
“Mark the casualty’s forehead, if possible, with a “T” to indicate a tourniquet has been applied. If necessary, use the casualty’s blood to make this mark.”
and
“(9) Seek medical aid.”
Sound advice!
And this caution,
“CAUTION: DO NOT LOOSEN OR RELEASE THE TOURNIQUET ONCE IT HAS BEEN APPLIED BECAUSE IT COULD ENHANCE THE PROBABILITY OF SHOCK.”
On the other hand, ehow advises us
“Write “TK” on the injured person’s forehead in pen, along with the time of application.”
I’d advise a felt tip, if possible.
“Get the injured person to a hospital as quickly as possible. If a hospital is more than an hour away, check the bleeding every 10 minutes by slowly loosening the tourniquet to see if clotting has stopped the bleeding. If so, clean and bandage the wound (see “How to Clean a Wound During First Aid” and “How to Bandage a Wound During First Aid”). If not, retighten the tourniquet and check again in 10 minutes.”
And then there’s this advice from Brookside Associates.
To be effective in saving a life, the decision to apply a tourniquet needs to be made very quickly (within seconds, not minutes), and the application needs to be equally fast (within seconds, not minutes).
Which is actually very good advice.
So, we should either apply the tourniquet immediately or after we’ve tried everything else. We should loosen it after 10 minutes or not loosen it at all. We should mark it with a T or a TK with pen, blood or possibly spray paint.
That’s in the US, other countries have different protocols totally. The authoratative Wikipedia tells us that it is the tool of first resort in France, but never to be used in Australia.
Some of what we think we know dates back to World War I. Or earlier. Before World War II, it was routinely days before wounded soldiers were treated for serious wounds. Putting a tourniquet on a limb back then meant almost certain loss of the limb, if not the life. Starting in World War II and continuing to the current day, the trend has been to get soldiers to surgical care more quickly. Hours in World War II became minutes in Korea and Vietnam due to the introduction of helicopters to the battlefield. With these improvements a lot of the rationale for not using tourniquets has been obviated, but in civilian EMS it seems that the old ideas still persist.
Here are a couple of things to think about though. A deep wound to an artery such as the brachial or femoral can be rapidly fatal. If you try a number of techniques to control the bleeding before applying a tourniquet there’s a good chance the patient will bleed out. Which as we know isn’t good. Until someone comes up with an oxygen carrying IV fluid for use in the field, we don’t have anyway to replace that lost blood.
If you have a patient with several serious injuries how much sense does it make to tie up an EMT doing direct pressure? Can you afford to do that?
Surgeons in Operating Rooms (different environment, I know) routinely put tourniquets on patient so they can perform surgery. If four or six hours of no blood flow don’t cause harm, is it reasonable to think that ten minutes will?
Does it make sense to bring a well packaged patient, with pressure dressings on various wounds, if the patient continues to bleed?
I’m not advocating anyone go outside their protocols, heaven forefend. I AM advocating that EMT instructors stop teaching outdated information, EMTs think critically about skills they are taught, and that medical directors and surgeons reconsider their system protocols.
I’ve been lucky to work for several years in an area where an influential trauma surgeon not only championed EMS, but considered medics and EMTs as thinking clinicians, not mere robots who should blindly follow orders. Nor did he blindly follow conventional thinking. Or allow us to.
Based on his experience as a military surgeon he knew that we could apply tourniquets properly and that they save lives. So, tourniquets are protocol in our system and we are encouraged to use them when appropriate. Over the years I’ve seen numerous instances where the timely application of a tourniquet has allowed a patient to walk out of the hospital, limbs intact.
Which is what we’re all about, right?
Comments?
That is what we are all about.I know of at least one case where a medic did not apply direct pressure to stop the bleeding, did not apply a tourniquet, but did attempt to start an IV. After all, he is a medic. If he doesn’t do ALS stuff, he has brought dishonor on his job title, or something like that.Anyway, he was not successful at starting the IV. He was not successful in arriving at the hospital with a living patient. He thinks the two are connected, as in: if only I could have been able to fill the patient up with saline, everything would have been alright.Maybe Bob Marley’s Three Little Birds should be the official IV song for EMS. Then we don’t have to mess around with those nasty, but sometimes very effective tourniquets.I have found that trauma surgeons are much more accepting of tourniquets than ED doctors.
I think you should only put a tourniquet on someone when their are bleeding. Otherwise it is a bad thing.
A good point mr. pamola. You will make a fine nurse yourself someday because your mind is right.
“You will make a fine nurse yourself someday because your mind is right.”LMFAO. (f stands for fat, not f’ing, because that’s how i roll, pregnant style…or something)
I’m an ambulance officer in Australia, and if I couldn’t stop the bleeding any other way I’d be using a tourniquet. And I’d like to think that it wouldn’t take me vary long to get to that point, just a matter of seconds if the bleed is severe enough and using the pressure points didn’t slow it down.
From the same book: P. 181 no research on whether elevation works, pressure points not studied. Therefore if direct pressure or pressure dressing don’t work don’t use above, rather tourniquet “is a reasonable step” tourniquets are not only “safe but lifesaving” I have not had such a situation come up and it could be considered a protocol deviation, but I’d not have a problem using a tourniquet.
Anonymous, maybe I should have put “authoratative” in quotes when I referred to Wikipedia. It’s not, since the articles aren’t vetted. Is there a provision in your protocols for the use of tourniquets?
My protocols just say to control life threatening haemorrhage. We don’t carry torniquets (except to cannulate), so I’d have to improvise. It would then most likely go to a case review by experienced paramedics, but I don’t think there would be a problem if I’d tried other methods first.If you wanted to look at protocols very similar to mine, Victoria’s are available at http://www.mas.vic.gov.au/media/docs/index.htmI don’t work in Victoria, but my protocols are very similar. In the authority to practice matrix the QAP level is closest to what I can do, with some small changes in procedures/skills and drugs carried.
I’m a medic in the 101st ABN DIV, and Army medics are now taught that the first line of defense in a combat injury is a tourniquet. The number one preventable cause (note preventable not overall) of deaths in combat is extremity hemmorage. Properly applying a tourniquet has saved many lives in combat, and now there is actually a widespread movement heading towards the use of tourniquets in a lot of major medical circles.If you really want some information check out the AMEDD website http://www.amedd.army.mil or the Army medic training site at http://www.cs.amedd.army.mil