The case against tourniquets

Mon Dec 11 23:56:54 GMT 2006

I see first hand, all too often, attitude along the lines of "just throw a tourniquet on it, regardless of the tactical situation".  Luckily, I have not yet seen this attitude put into practice.

Many paraproffesionals don't grasp the concept of "failure of direct pressure and pressure points", and "last resort".  This, along with when to remove tourniquets, are definately concepts that need to be better emphasized with pre-hospital caregivers.  

I will agree that there are very rare, if any, circumstances that justify the use of tourniquets in civilian life (even more rare than in Military service).  One of these could possibly be a mass-casualty situation, when victims outnumber caregivers.  Not having the ability, for the sake of other patients, to apply direct pressure would count as "failure of direct pressure".  (although even then, it could be argued that bystanders, when available, can be put to use)

Ultimately, this all boils down to TRAINING.  Those who know, share.  Be the change you wish to see in the world.  If you hear about cases of EMT's misusing or overusing tourniquets, volunteer to teach the next local PHTLS class.  If you see this firsthand, correct it.  Take advantage of the occasional lull in your ED to share some knowledge with your Techs/EMT's/Medical Assistants.  My thanks to Dr. Brohi and my friend "private" for sharing their knowledge.  I will most definately print your testimonies out and share them with my Corpsmen.  

HM3 Shaw

> ----- Original Message -----
> From: "oded private" <tangentcarrot at hotmail.com>
> To: trauma-list at trauma.org
> Subject: RE: The case against tourniquets
> Date: Sun, 10 Dec 2006 16:22:16 +0200
> 
> 
> 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 & 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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