The case against tourniquets

[Karim Brohi]

Recently, the US and UK military have "rediscovered" tourniquets.  Their use
has been published in meetings around the world and is now spreading to
civilian practice.  ATLS and other groups have spent years campaigning to
remove tourniquets from civilian practice, for good reasons, and now they
are back - with not a shred of evidence to support this reversion.

Maybe we need reminding of why tourniquets were abandoned in civilian
practice - so here's a case from a couple of weeks ago.  A young man is
brought to another hospital after a multiple stabbing incident.  Most are
superficial but he has arterial haemorrhage from a wound in the distal
medial thigh.  A tourniquet is placed in the upper thigh and he is
transferred to us.  On arrival he is taken straight to the operating room
for revascularisation but total time with the tourniquet is 2.5 hours.

The popliteal artery injury is small and only requires direct suture repair.
However the distal limb shows signs of swelling and a 4-compartment lower
leg fasciotomy is performed.  The patient is transferred to the ward but
despite the early fasciotomy has a large rise in his Creatine Kinase and
develops renal impairment.  Further he has a complete foot drop from
ischemic injury which may or may not recover.

The patient's haemorrhage would have been easily controllable by pressure
either at the site of injury or by digital pressure over the common femoral
artery at the femoral head.  2.5 hours is not a particularly long ischemic
time and there was no associated vein injury.  Venous congestion,
fasciotomy, ischemia to calf and thigh misculature, ischemic nerve damage
and renal failure were all contributed to, or arguably entirely the result
of tourniquet use.

The military operate under entirely different conditions.  A second pair of
hands to provide manual pressure may not be available and hence a
self-applied tourniquet may indeed be life-saving.  These are blast injuries
and often control haemorrhage from distal amputation.  But they may well not
be limb saving - indeed the amputation rate is twice that of previous wars.
(Yes more lives are being saved and yes there is improved torso armour etc
etc).   Further anecdotal UK experience suggests that soldiers are often
applying them with too little force and therefore causing venous obstruction
and increasing blood loss from the limb.  Watching 3 marines walking down
the street in San Diego with one leg between them was sobering.

And for all the talk of not having a second pair of hands, there is a wealth
of evidence from landmine victims that non-medical, in fact uneducated
villagers in remote, rural settings can control haemorrhage with digital
pressure and transport victims long distances for medical therapy (using
donkeys, not CCAT military transports) - and villagers can teach other
villagers to do it). The Tromsoe Mine Victim Resource Centre
(http://www.traumacare.no/) has been doing this in Cambodia, Afghanistan,
North Iraq, Burma and Afghanistan for years.  Read what they have to say
about tourniquets and the cases and images of increased haemorrhage
following their use.

To use a military term, we are suffering from severe mission creep as
tourniquets seep back into civilian practice.  Their use was banned for a
reason, which we are in danger of forgetting - and relearning.  The military
have their own reasons for using them, but we need to see real data about
their effectiveness for limb salvage.  For the military, tourniquet use
should be a last resort, in the knowledge that morbidity, disability and
amputation are increased with their use. They should not be advocated in
civilian practice at all.

Karim