The case against tourniquets

[oded private]

DR. Brohi,

During my time as a senior instructor in the IDF military medical school, 
the debate around the use of tourniqutes had always been a great source of 
work for me. A combination of tradition, myths and sometimes even lack of 
proper knowledge led to the glorification of the tourniqute. The leading pro 
was "so what if it cuases ischemic damage... it's better then have the 
pateint exshanguinate" The other was, that now adays wounded soldiers got to 
the hospital within relatively short times.  Yes, there are circumstances 
where tourniquets are appropriate in the military setting. However, the use 
has long gone past these circumstances. When the war in lebanon took place 
last summer, and it took hours to get to the hospital, many medics used 
tourniqutes for wounds that did not require. Moreover, they didn't let them 
off when tactical circumstanes such as a fire fight were no longer an issue. 
Many legs were lost. Telling everyone "I told you" would'nt have had much 
impact now...

Here is Israel, a small state were everyone has to do a mandatory army 
service and military medicine is closely related with the EMS, the use of 
tourniqutes is widely spread. Today I practice EM instruction, mostly for 
lay rescurer. The first things that pops to these guys' head when they hear 
the word "hemorrhage" is "tourniquet". It's a matter of culture here, 
nothing less.

Along side with the glorification of the tourniqutes, there is very very 
little awareness to the negative implications. Paradoxial increase of venous 
bleeding is a term not understood or known by many medics. The fact the 
tourniquets may not be effective for bleeding from an intra-osseous vessel  
is also understated, and ischemic damage is thought to only happen in 
historic wars.
Moreover, explaining a lay rescurer in a first aid class that the pain 
suffered by a pateint when you apply a tourniquet for more than 30 sec. will 
have implications on their ability to manage the pateint is nearly 
impossible, since he (the rescurer) sees it as "either I hurt you or you 
bleed to death. What's your choice?".
Not to mention that many (if not most) of them can't aplly it corectly, and 
thier use of will likely to result in an increase of venous bleeding.

>From: "Karim Brohi" <karim at trauma.org>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: <trauma-list at trauma.org>
>Subject: The case against tourniquets
>Date: Sun, 10 Dec 2006 13:55:21 -0000
>
>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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