The case against tourniquets

[Thomas Anthony Horan]

karim, 
this is an excellent editorial, it needs to be published, will it be?
Tom 

> ----------
> From: 	trauma-list-bounces at trauma.org[SMTP:trauma-list-bounces at trauma.org] on behalf of Karim Brohi[SMTP:karim at trauma.org]
> Reply To: 	Trauma & Critical Care mailing list
> Sent: 	domingo, 10 de dezembro de 2006 11:55
> To: 	trauma-list at trauma.org
> Subject: 	The case against tourniquets
> 
> 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
> 
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