The case against tourniquets

[Forrest Robleto]

I attended a conference where the presenter a military doctor talked about
how expendable limbs were in terms of saving lives.  I was a little
uncomfortable with his bravado.


On 12/10/06, Karim Brohi <karim at trauma.org> wrote:
>
> 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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-- 
V/R

Forrest Robleto
R House Health & Safety
www.RHouseTraining.com
FRobleto at RhouseTraining.com
609-792-9047