The case against tourniquets

[Ronald Gross]

Karim,

I couldn't agree with you more!  While the use in battlefield
conditions MUST be tempered with the possibility that the tourniquet
will be improperly applied, the blast injuries and tactical conditions
combined make the use of the tourniquet in a combat setting acceptable
but less than optimal.  Use in the civilian world is absolutely not!

Just my 2 cents.
Ron

>>> "Karim Brohi" <karim at trauma.org> 12/10/2006 8:55 AM >>>
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

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

Confidentiality Notice

This e-mail message, including any attachments, is for the sole use of
the intended recipient(s) and may contain confidential or proprietary
information which is legally privileged.  Any unauthorized review, use,
disclosure, or distribution is prohibited.  If you are not the intended
recipient, please promptly contact the sender by reply e-mail and
destroy all copies of the original message.