The case against tourniquets

[Bjorn, Pret]

Karim,
Of course you're correct.  This is a milieu-specific intervention, not
unlike adult intraosseous access.  
On the battlefield -- especially in a theater where the weapon of choice
is the roadside mine -- a pocketful of tourniquets makes all kinds of
sense: victims outnumber rescuers, mangled extremities outnumber
victims, the scene is hostile, and the prehospital system is the most
mobile and sophisticated ever constructed by man.
In these unique circumstances, tourniquets aren't merely a means of
treating a wound; they're one element of a swift and systematic
evacuation from hell to hospital, unparalleled in other civilian EMS.
As much as we're learning from our experiences in Iraq and Afghanistan,
it's important to keep our lessons in context.  Most trauma providers of
the world get their uncontrolled extremity hemorrhages one by one, in
comparatively placid environs.  And most of us work in systems where
tourniquets risk staying cinched for regrettable lengths of time.
It's alarming that I've received two separate product flyers for
prehospital tourniquets in the past month.  We've got to stop this
insanity.
Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Karim Brohi
Sent: Sunday, December 10, 2006 8:55 AM
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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