The case against tourniquets

[thomas konig]

Private security firms are also using them and they are being advertised as 
'when in doubt, apply a tourniquet, as it can be removed later'.  This is 
very worrying.
They are being considered as an easy fix and soldiers like them
Tom


>From: "Thomas Anthony Horan" <thoran at sarah.br>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
>Subject: RE: The case against tourniquets
>Date: Sun, 10 Dec 2006 12:07:40 -0200
>
>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 &amp; 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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