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Prehospital Emergency CarePublication details, including instructions for authors and subscription information:http://www.informaworld.com/smpp/title~content=t713698281

Tourniquets: A Review of Current Use with Proposalsfor Expanded Prehospital UseGerard S. Doyle a; Peter P. Taillac aba Division of Emergency Medicine, Department of Medicine, University of Utah, SaltLake City, Utahb Division of Emergency Medicine, Department of Surgery, University of Utah, SaltLake City, Utah

Online Publication Date: 01 April 2008

To cite this Article: Doyle, Gerard S. and Taillac, Peter P. (2008) 'Tourniquets: AReview of Current Use with Proposals for Expanded Prehospital Use', PrehospitalEmergency Care, 12:2, 241 256

To link to this article: DOI: 10.1080/10903120801907570URL: http://dx.doi.org/10.1080/10903120801907570

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COLLECTIVE REVIEWS

TOURNIQUETS: A REVIEW OF CURRENT USE WITH PROPOSALS FOR EXPANDED

PREHOSPITAL USE

Gerard S. Doyle, MD, MPH, Peter P. Taillac, MD

ABSTRACT

The use of arterial tourniquets in prehospital emergencycare has been fraught with controversy and superstition formany years despite the potential utility of these tools. This

review examines this controversy in the context of the historyof the tourniquet as well as its recent use in surgery andmodern battlefield casualty care. Safe prehospital tourniquetuse is widespread in the military and is based on soundphysiologic data and clinical experience from the surgicaluse of tourniquets. The physiologic, pathophysiologic, andclinical underpinnings of safe tourniquet use are reviewedhere, along with a discussion of alternatives to tourniquets.Prehospital settings in which tourniquets are useful includetactical emergency medical services (EMS) and other law en-forcementenvironmentsas wellas disaster and masscasualtyincidents. Beyond this, we present arguments for tourniquetuse in more routine EMS settings, in which it may be

Received April 18, 2007, from the Division of Emergency Medicine,Department of Medicine (GSD, PPT) and the Division of EmergencyMedicine, Department of Surgery, Universityof Utah, Salt Lake City,Utah (PPT). Revision received August 22, 2007; accepted for publica-tion September 4, 2007.

Dr Gerard S. Doyle, along with Dr. Peter P. Taillac, developed theconcept for this paper. Both authors are members of the Universityof Utah Division of Emergency Medicine. Each author performedreviews of the relevant literature. Dr. Doyle wrote the first draft ofthe paper, whichwas then revised by Dr. Taillacacting independently.Finally, the two edited and revised the paper collaboratively.

The authors wish to acknowledge Dr. David Fosnocht, MD, for hisassistance in manuscript review and editing.

None of the contributors had financial supportfor manuscript devel-opment or any financial arrangement that might represent a conflictof interest. Dr. Taillacis Medical Director of the West ValleyCity, Utah,Fire Department.

As of August 1, 2007, Dr. Doyle has relocated to the University ofWisconsin Division of Emergency Medicine.

Address correspondence and reprint requests to: Gerard S.Doyle, MD, MPH, Division of Emergency Medicine, Depart-ment of Medicine, University of Wisconsin Hospital F2/204 CSC,600 Highland Avenue, Madison, WI 53792. e-mail: [email protected]

doi: 10.1080/10903120801907570

beneficial but has heretofore been considered inappropriate.Protocols that foster safe, effective prehospital tourniquet usein these settings arethen presented. Finally, we discuss futuredirections in which tourniquet research and other initiativeswill further enhance the safe, rational use of this poten-

tially life-saving tool. Key words: tourniquet; hemorrhage;emergency medical services; disasters; hemostasis

PREHOSPITAL EMERGENCY CARE 2008;12:241256

INTRODUCTION

Arterial tourniquets have a long and checkered history.Since their introduction, probably in ancient Romantimes, their basic configuration has changed little to thisday. They have been called both life saving and an in-strument of the [D]evil that sometimes saves a life.1

Tourniquets have undergone a dramatic resurgence in

popularity in the past decade, owing primarily to anemphasis on rapid hemostasis on the battlefield duringrecent wars.

Traditionally, tourniquet use has been ruled by thedictum primum non nocere orfirst,donoharm.Tourni-quets have been thought to be dangerous in the handsof prehospital care providers and have usually beenseen as a technique of last resort for the emergencymedical technician (EMT). This is the result of anecdo-tal experience from past wars when tourniquets wereplaced (sometimes unnecessarily) and left in place forextended periods, resulting in limb ischemia, muscleand nerve injury, gangrene, and amputations. How-ever, recent experience with tourniquets in the handsof well-trained military medics, from both the UnitedStates and other countries, has resulted in renewed en-thusiasm for the instrument in military emergencycare.Lives are being saved on modern battlefields as a re-sult of appropriate tourniquet use combined withrapidevacuation of casualties to definitive care. The parallelsto modern emergency medical services (EMS) systemsare obvious, and it is time to reconsider the tourniquetasavaluableandpotentiallylifesavingtoolforthemod-ern civilian EMT.

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242 PREHOSPITAL EMERGENCY CARE APRIL / J UNE 2008 VOLUME 12 / NUMBER 2

Tourniquets, like all medical therapies, have cer-tain dangers inherent in their use. These potentiallimitations and complications must be addressed priorto increased utilization in civilian EMS. Recent posi-tive military experience with this instrument shouldnot lead to irrational, unfettered tourniquet use. Rather,protocol-driven use by well-trained civilian EMTs

wouldaddavaluableweapontothearmamentariumofprehospital emergency providers, as they address dif-ficult problems in controlling extremity hemorrhage.

Recent terrorist activities have served to emphasizethe utility of the tourniquet in disaster settings. Dis-asters, whether man-induced or natural, may result inlarge numbers of bleeding individuals. Early in suchan incident, a few rescue personnel may be required totriage and institute care for a large number of victims.There may not be enough providers to, for example,hold direct pressure on a heavily bleeding wound forlong periods. In these circumstances, early utilization ofa tourniquet by protocol may be appropriate. Indeed,

a primary tourniquet approach, or tourniquet first,may save lives by allowing the EMT to rapidly stopextremity hemorrhage, move on to other victims, andreturn later to reassess and possibly remove the tourni-quet under circumstances that are more stable. Thisis the model that is proving life saving in military fielduse in Iraq and Afghanistan, and should be consideredfor civilian EMT use as well.

We present a review of the medical literature focusingon the history, physiology, and complications of tourni-quets, their current use, and alternatives to tourniquetsfor control of bleeding. We then discuss the use oftourniquets in civilian EMS care. Next, we show why

EMTs should be facile in the safe use of these tools dur-ing situations not well addressed by current protocols.Finally, we argue that civilian EMS as well as law en-forcement agencies should adopt expanded indicationsfor tourniquet use under specific protocols.

History

Development and Early Uses2

The tourniquet arose from the need of battlefield sur-geons to control bleeding during surgical amputations,with use being dated as far back as ancient Rome. Am-

brose Pare (ca. 15101590) is credited withbeingthe firstto use the word tourniquet, as well as being among thefirst to record a recommendation for operative use of atourniquet. He also performed the first-known modifi-cation on the tourniquet: A screw was placed over themain vessel of an extremity and tightened with a cir-cumferential strap in place. Around the 17th century,William Fabry and Etienne Morel both used a windlass,wherein a stick is used to twist and thus further tightena constricting band. Many modern designs feature awindlass to allow easy adjustment of tension.

Lister and Esmarch used tourniquets starting in themiddle 19th century to introduce bloodless surgery.

Technological advances led Cushing to abandon priortourniquet designs and introduce a pneumatic tourni-quet in 1904. This device made tourniquet applicationand removal easier, and pressure was more evenly ap-plied to the limb than with prior versions. By the mid-dle of the 20th century, use of tourniquets in extremitysurgery to allow operation in a dry field was consid-

ered routine.

The Tourniquet in First-Aid

For many generations, tourniquet use in first aid hasbeen controversial. Tourniquets have long been placedin first-aid kits, yet many surgeons who use them en-thusiastically in operations have agreed with the tenetthat there is no place for the tourniquet as a first-aidmeasure.2 Civilians were felt to be unable to use theinstrument safely or effectively, and there has been pre-vious military experience of harm done by inappro-priate tourniquet use on bleeding limbs.3 The most re-

cent American Heart Association and American RedCross First Aid manuals reflect this philosophy. Whilerecognizing the pivotal role of hemorrhage control,the 2005 First Aid Guidelines of the National FirstAid Science Advisory Board recommends only directpressure and compression dressings (using an elas-tic bandage) to stop bleeding before EMS providersarrive.4

Military Considerations

The tourniquet has a rich historical tradition in militarymedicine, in contrast to civilian EMS use. Tourniquetswere issued in Civil War surgical sets,5 and the failure

to apply one to a wounded Confederate Army generalmay have affected the outcome of that war and thusthe course of U.S. history.6 Paradoxically, it is perhapsfrom the same war that initial ambivalence to tourni-quets arose: Prolonged time from tourniquet placementto definitive care often resulted in severe ischemic com-plications. This caused some surgeons of the day to ar-gue that it was safer to allow continued bleeding thanuse a tourniquet to stop it.7

Tourniquets havelong beenstandardissue in militarymedics kits, yet there has been reluctance to use themin all but the direst of circumstances. In the 1960s, therewere even efforts to have them removed from medicalkits and deleted from the training curricula of militarymedics.2

Mabry describes a cycle wherein the tourniquet isinitially welcomed by the military but soon falls outof favor due to perceived misuse, while many whomight have been saved die of potentially controllablehemorrhage.7 This cycle was repeated until analysisof mortality data from the Vietnam conflict led to re-newed interest in the use of the tourniquet. This anal-ysis suggested that a sizeable proportion of combatfatalities could have been averted by use of a tourni-quet. In one report, it was estimated that 105 (38%) of


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Doyle and Taillac TOURNIQUETS: REVIEW AND PROPOSALS 243

277 soldiers who died from extremity artery bleedingmight have been saved by proper, timely tourniquetapplication.8

Recent experience has reinforced this trend towardmore liberal military usage of tourniquets.911 Mod-ern combat results in high rates of extremity trauma.This fact, combined with the recognition that many

who died of combat-inflicted wounds might have sur-vived if a tourniquet had been used to arrest exsan-guinations, forms the rationale for use of a tourniquetunder modern combat conditions.12 Sebesta, who hasdetailed his experiences as a surgeon in an Army Com-

bat Support Hospital (CSH), states tourniquets are anessential therapy based on recent experience in Iraq.9

This rationale is further reinforced by the circum-stances under which much of the prehospital careis provided during a military conflict: Hostile action

by adversaries, unfavorable environmental conditions,frequently prolonged transport to advanced care, aus-terelogistics,andmultiplecasualtieswithlimitedtriage

and treatment manpower all support the expedient useof tourniquets on the battlefield. It is to be noted thatthese conditions are occasionally, if infrequently, expe-rienced in civilian EMS settings as well.

The U.S. Army and Marine Corps both now issuetourniquets to individual soldiers and marines in theirIndividual First Aid Kits (IFAK) and train them in theirproper use.13,14 The Army prehospital trauma life sup-port (PHTLS) mnemonic is now MARCH (Massive

bleeding, Airway, Respirations, Circulation, and HeadInjury) rather than ABC (Airway, Breathing, and Cir-culation), recognizing that massive hemorrhage on the

battlefield is theprimary treatable threatto survival and

must be quickly arrested.9

Still, despite these changes, more than 50% of thedeaths from isolated extremity hemorrhage were po-tentially preventable by correct tourniquet application,according to one report from the Iraq conflict.11 It isnot known how many patients with multisystem in-

juries had tourniquets placed nor if this interventionimproved or worsened outcome.15 Further reviews of

battlefield tourniquet use will better document theseresults.

Civilian EMS Usage

There has been a movement toward liberalization oftourniquetuseincivilianEMSsystems,butthisremainscontroversial. Most systems still employ the tourni-quet as a technique of last resort, using protocols thatrecommend direct pressure, pressure dressings, pres-sure points, elevation, and cold application as primarytreatments for severe extremity hemorrhage. Of these,only direct pressure can be supported based on avail-able evidence.4 The most recent National Associationfor EMS Physicians (NAEMSP) consensus statementon wound care for delayed or prolonged transport

recommends the use of tourniquets only in cases ofamputation.16

Despite extensive experience with tourniquets in themilitary medical services of the United States and othercountries, recent civilian EMS teaching has not fullyaccepted this potentially life-saving instrument.17 In-deed, many EMS systems do not allow their crews to

carry tourniquets. Unfortunately, this can lead to cir-cumstances in which a tourniquet is required and mayhave to be improvised. Improvised tourniquets are lesslikely to be effective10 and may be more prone to neu-rovascular complications.

The positive experience with tourniquets on the bat-tlefield holds promise for civilian EMS trauma care:Modernmilitary protocols fortourniquet usecould eas-ily be incorporated into civilian EMS systems.

Physiology, Complications, and Safe Useof Tourniquets

PhysiologyArterial tourniquets work by compressing muscle andother tissues surrounding extremity arteries that, inturn, collapse the lumina of these arteries and therebyarrest flow distal to the tourniquet. The tension or forceneeded in order for a tourniquet to compress the arteryis dependent on the size of the extremity as well asthe width of the tourniquet. In general, larger circum-ference of an extremity correlates with higher requiredtension.18 Wider tourniquets typically are more effec-tive at stopping arterial flow at a given tension thannarrow tourniquets.19

Complications

Tourniquet use, which is well accepted as a techniquefor bloodless extremity surgery, has been associatedwith local and systemic complications (see Table 1).

TABLE 1. Potential Complications of Use of Tourniquetsa

Local Systemic

Postoperative swelling andstiffness

Increased central venous pressure

Delay in recovery ofmuscle power

Arterial hypertension

Compression neuropraxia Cardiorespiratory

decompensationWound hematoma Cerebral infarctionWound infection Alterations in acid-base balanceDirect vascular injury RhabdomyolysisBone and soft-tissue

necrosisDeep venous thrombosis

Compartment syndrome Tourniquet painSystemic inflammatory response

syndromeb

Fibrinolysisc

Complications of operative tourniquetsthat have been reported in the surgicalliterature are presented here.a Ref. 20.b Ref. 31.c Ref. 32.


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Early surgical use of tourniquets led to the recognitionthat improper tourniquet design or prolonged tourni-quet application (longer than 1.5 to two hours) couldlead to muscle, nerve, and vascular injuries, resultingin a syndrome known as tourniquet palsy or tourniquetparalysis. Additionally, irreversible ischemic damage tolimbs is known to occur in cases where a tourniquet

had been left in place for longer than six hours; ampu-tation of the limb above the level of the tourniquet wasrecommended in these circumstances and still remainsa surgical dictum.2

Tourniquet time (i.e., the total time during which ar-terial flow beyond the instrument can be safely inter-rupted)isanissueofcontroversy.Evidencefromanimalstudies shows that even minutes of tourniquet use willlead to changes in muscle and nerve physiology as wellas systemic effects. These studies demonstrated that af-ter one hour, there was no evidence of muscle damage,while two hours of ischemia led to elevated levels of

both lactic acid and CPK, suggesting muscle damage

was occurring.21Most surgical guidelines recommend, and clinical

studies support, no more than 6090 minutes of op-erative tourniquet time in order to safely use this tech-nique. Two hours of tourniquet time is a useful guide-line for an upper limit.20 Patients with advanced age,vascular diseases, and traumatic injuries are at higherrisk for complications, including nerve and muscle in-

jury. Nerve injuries have been reported after only 30minutes of tourniquet time. Muscle, especially that di-rectly under the tourniquet, has shown damage afterone hour, though actual myonecrosis seems to occuronly after three hours.22 Post-tourniquet syndrome (com-

prising weakness, paresthesias, pallor, and stiffness) iscommon but seems to resolve after about three weeks.23

Recent military experience supports the safety ofthese short tourniquet times in prehospital patients.911

Chambers et al. reported limb salvage in 11 of 14 (79%)of patients witharterial injuries despite total tourniquettimes averaging two hours.24

All known complications of tourniquets seem toworsenwith prolonged tourniquet time.Unfortunately,tradition has held that tourniquets, once placed, should

be left on until removed by a physician. This tenet likelyarose from the recognition that repetitively looseningand retightening a tourniquet exacerbates blood loss.While such reperfusion intervals are controversialand discussed in more detail below, our proposed pro-tocol (and current military doctrine) allows for reevalu-ation of the need for, and possible removal of, a tourni-quet by EMTs prior to reaching the hospital.

Tourniquet use may also result in venous compli-cations, including worsened venous bleeding and ve-nous thromboembolism (VTE). One major criticism oftourniquets is that, if not properly applied, tourniquetscan actually increase bleeding by occluding venousreturn while not completely arresting arterial inflow.

Thrombosis could occur due to venous stasis duringtourniquet use. Subsequent embolization of the clot(s)to the pulmonary circulation could then occur, either

before or after tourniquet removal. The role of tourni-quets in inducing venous thrombosis and pulmonaryembolism is notclear. VTEhas been reported to increasewith tourniquet use in surgery; however, others have

suggested that this complication is a result of surgeryitself, not merely of tourniquet use.2527

Elasticor compression dressings can be similarly crit-icized, as both may increase bleeding and promote ve-nous stasis and VTE. A further drawback is that ifplaced too zealously, they can become an unrecognizedarterial tourniquet.

Compartment syndrome has been a reported com-plication of tourniquet use. In most cases, this is feltto result from the injury necessitating tourniquet use,rather than the tourniquet itself, except in prolongedtourniquet-induced ischemia (more than three hours)or excessively high tourniquet pressures.23

Systemic acid-base changes may result from releaseof a tourniquet in place for an extended period oftime. Limb ischemia results in lactic acidosis of tissuesdistal to the tourniquet. After release of the tourni-quet, reperfusion of the extremity carries this acidand free radicals into the central circulation, a syn-drome labeled ischemia-perfusion injury. Hyperkalemiaand systemic acidosis may result in cardiac arrhyth-mias, among other problems. Clinical experience onthe systemic metabolic effects of tourniquet release isinconsistent, and may vary with anesthetic technique.One study showed no such results after one to threehours of tourniquet time in a sample of elderly ortho-

pedicsurgery patients,28 whileasecondshowedthatar-terial pH, PaO2, PaCO2, lactate, and potassium changedsignificantly after tourniquet release.29

Hypertension and increased central venous pressurefollowing operative tourniquet application are well-documented, but may be related to surgical practice:elevation and compression of the extremity to create a

bloodless field results in autotransfusion of extremityblood into the central circulation.30 Such an event is notlikely to occur with field use of the tourniquet.

Other systemic changes, such as creation of a sys-temic inflammatory response and increased fibrinolyticactivity, seem to be transient and are not known to beclinically significant.31,32

Pain from tourniquet use is a major concern. Somehave stated that tourniquets can cause excruciat-ing pain33 despite proper application. In one report,however, awake, nonanesthetized volunteers who hadtourniquets placed and inflated to 100 mmHg abovetheir systolic blood pressure tolerated the instrumentsfor 25 minutes on their forearms and 18 minutes onthe upper arm.34 It is not clear if a lower pressure,sufficient only to arrest bleeding, would be toleratedlonger. Lower extremities, perhaps due to increased


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circumference, have higher average times of pain tol-erance, around 30 minutes.35 It is clear, however, thatmost awake patients on whom a tourniquet is used willrequire medication for pain control.36

Safe Prehospital Use

Safe prehospital tourniquet use depends on a numberof factors. Underlying all safe prehospital tourniquetuse are conservative and specific protocols definingindications, application and removal techniques, andapplication times. As always, regular training in proto-cols for prehospital providers is crucial. The outline ofsafe, effective protocols for prehospital tourniquet usecan be extrapolated from both widespread surgical useand recent military experience.

The fundamental factors relating to safe tourniquetuse are: tourniquet design, placement location, tourni-quet tightness, and tourniquet time.

In terms of tourniquet design, it is well known that

wider tourniquets with rounded, rather than sharp,edges are best in terms of limiting damage to under-lying structures. The tourniquet should be made ofa uniform, smooth material, as those with wire rein-forcements are known to predispose to direct vascu-lar injury due to unequal application of pressure un-der the wires.37As a pneumatic tourniquet, a bloodpressure cuff is theoretically ideal, as it provides uni-form pressure over a wide area. Its practical use, how-ever, is somewhat limited by its size and weight, aswell as its inability to maintain high pressures for pro-longed periods. It is also difficult to apply securelyto a short residual stump in the case of a traumatic

amputation.Most operative manuals recommend tourniquet

placement on the thickest portion of the limb in order tomaximize the tissue through which pressure is exertedand minimize the pressure require to stop arterial flowand thus the risk to underlying skin, muscle, nerves,and vessels. This may also limit the pain associatedwith tourniquet use, though some studies contradictthis.33,38

EMS providers, however, have traditionally beentrained to place the tourniquet just above the injury,while avoiding placement over a joint.39 This more dis-tal placement recommendation probably arises fromconcerns about the need for an amputation after defini-tive care is reached. The goal is to preserve as muchlimb length as possible. However, with proper tourni-quet design and limited tourniquet time, a more prox-imal placement of the largest portion of the extremityis preferred because of speed of application, minimiza-tion of pressure injury to underlying tissues, and thepossibility that multiple distal bleeding sites exist.

When applying a tourniquet, the lowest effectivepressure should be used in order to minimize subse-quent ischemic complications: A tourniquet must be

tightened only to the pressure required to arrest hem-orrhage.

There is no rationale forusing an occlusive tourniquetas a high-pressure dressing by placing it directly over awound dressing, as it will not effectively stem arterialinflow to the wound in this location. Used nonocclu-sively, however, a tourniquet could effectively be used

to augment a pressure dressing and hold it tightly inplace, as suggested in a recent review of tourniquetuse.40

Some have attempted to prolong tourniquet time byuse of reperfusionintervals. Although taughtin somepopular wilderness first-aid manuals,41,42 these inter-vals are not practical in prehospital scenarios. Thesehave been shown clinically to reduce complicationsonly if perfusion is restored for 30 minutes or more.43

Therefore, to be effective at reducing ischemic compli-cations, they would likely also allow slow exsanguina-tion. An interesting suggestion designed to lessen in-

jury to tissues directly under the device is to use two

adjacent tourniquets, alternately employing one thenthe other.44

All tourniquet usage must be well documented, thencommunicated on transfer of care. This minimizes thelikelihood that a tourniquet will be overlooked bysubsequent care providers and inadvertently left onfor a prolonged period. Time of application must berecorded, either on the triage tag or physically writtenon the skin of the victim. The forehead is suggested asa prominent location. Triage cards should clearly an-notate that a victim is wearing a tourniquet and thetime of placement, as does the current DD Form 1380 Field Medical Card. One early advocate of the tourni-

quet recommended that casualties who are consciousbe instructed to tell everyone with whom they comeinto contact that they have a tourniquet in place.45 Forthe same reason, tourniquets should never be covered.There is evidence that cooling the extremity distal tothe tourniquet may reduce complications.46 A blanketplaced over a tourniquet may be doubly dangerous,

both warming the ischemic extremity and obscuringthe tourniquet. The extremity is probably best left un-covered, except in temperatures where there is risk ofdirect cold injury. If available, a brightly colored markermay be placed at the tourniquet location as well.

The tourniquet should ideally be manufactured forits purpose. Improvised tourniquets will tend to ap-ply pressure unevenly and often have sharp edges, in-creasing the risk of underlying tissue injury. Examplesof suboptimal improvised tourniquets include beltsand similar straps, which can entrap skin and directlycause injury. Cravats (i.e., triangular bandages) or elas-

tic dressings (i.e., ACER

bandages) can bunch whentwisted with a windlass.47 Although these improvisedoptions are frequently taught in first-aid manuals, theyshould be avoided unless no other options are availableto arrest hemorrhage.


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Finally, and most critically, tourniquet time must beminimized. In most cases, this will mean transportingthe patient expeditiously to a higher level of care. In-forming the transportation officer at a mass casualtyevent of tourniqueted patients may allow these pa-tients to have higher priority for transport to hospital.In our protocol, no patient with a tourniquet will re-

ceive a triage code less acute than yellow. In addition,specific protocols can be utilized to remove tourniquetsthat, upon reassessment at a later time, may no longer

be needed to control bleeding.

Alternatives to the Tourniquet

Pressure Dressings

Pressure dressings are adequate to stop most cases ofhemorrhage, whether it occurs from the extremities orother parts of the body. One commercially available

bandage already in use by the military for this purpose

is the Israeli dressing. Other compression dressingscan be improvised with large amounts of gauze and anelastic bandage that is wrapped around the woundedlimb, as described in a recent PHTLS manual.39 These

bandages work on the principle of providing compres-sion to reduce the flow of blood through damaged ves-sels (primarily capillaries and veins) while providinga scaffold on which blood can clot. As mentionedpreviously, a carefully placed tourniquet could also

be utilized to tightly compress a bandage and act asa pressure dressing, but only if it is not so tight asto occlude arterial inflow or to increase distal venous

bleeding.

Experience with pressure dressings shows that theywork well in trained hands, stopping all moderate

bleeding and most profuse bleeding (81%), accord-ing to one study. A tourniquet was required to stop onecase with profuse bleeding.48

A major drawback of this type of dressing is thatthey take time and often more than one set of handsto apply properly. They must also be reassessed fre-quently to ensure that bleeding has, in fact, been ar-rested, which requires access to the site of the dressingas well as a light source. It is foreseeable that circum-stances may arise in which one or both of these are notavailable, and time and personnel are needed to per-form these assessments. In contrast, once placed andtightened to arrest bleeding, modern tourniquets arehighlyunlikely to lose effectiveness. Afterresuscitation,however, they may require retightening if the victims

blood pressure increases sufficiently to allow distalflow.36

Self-application of an adequate pressure dressing canbe extremely difficult, if not impossible, and is cer-tainly time-consuming. Modern tourniquets, includingthe model preferred by the military, have been specifi-cally designed for one-handed self-pplication. The goal

is rapid self-application in order to allow the victim tocontinue the mission, if physically able to do so.

Finally, pressure dressings may be difficult or impos-sible to secure to limbs that have sustained partial orcomplete amputation.

In short, pressure dressings are excellent instrumentsto control most causes of hemorrhage, but are not eas-

ily adaptable to circumstances in which there are lim-itations on time and personnel, after amputation, orwhen self-application is required. In these scenarios, atourniquet is much more easily and effectively used.

Topical Hemostatic Agents

Topical hemostatic agents were developed in responseto the recognition that uncontrolled hemorrhage isthe major source of preventable mortality in com-

bat settings. Several have been deployed with U.S.forces in recent combat actions around the world49 andtheir successes and shortfalls reported in the medical

literature.5052Although they may be useful adjuncts, these agents

do not have the same simplicity and effectivenessof pressure dressings or tourniquets. Experience inanimal models has shown that many agents sim-ply do not work quickly or well enough to stop

brisk bleeding.51 HemCon is a gauze dressing impreg-nated with chitosan (extracted from shrimp shells)that assists in clotting. Although this dressing wasfelt to work well for hemostasis on war-woundedin Iraq, the majority of these were venous bleeds.52

Another agent, QuikClot, was shown to cause burnsand other soft-tissue complications in nearby tissuewhen used in its initially marketed powder form.51

A newer formulation reportedly does not have thiscomplication.

Small, deeply penetrating wounds like thoseproduced by missiles are also problematic for topicalhemostatic agents, which must either be trimmed orotherwise altered and placed in wounds in direct con-tact with bleeding sites to ensure hemostasis. In thecase of the HemCon dressing, even large cavitationalwounds required that the dressing be placed under di-rect vision, directly on the bleeding site, for the dressingto be most effective.51 Finally, it should be noted that,

with the exception of QuikClot, these are expensive,perishable agents. These issues all limit these agents tobeing useful adjuncts, rather than primary treatments,for extremity hemorrhage in disaster and other EMSsettings.50

Systemic Hemostatic Agents

Hemostatic agents that improve coagulation, espe-cially in hypothermic, coagulopathic, and acidotic mul-titrauma patients, have been in development and


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preliminary use in the recent past. Factor VIIa con-centrate, for example, has been extensively used bysurgical teams in Afghanistan and Iraq with favorableresults.9,53

Little, if any, specific prehospital use of these agentshas been reported.54 In most cases, these agents have

been used in patients with cavitary or visceral rather

than external hemorrhage, and their applicability inextremity injuries is not known. In addition, currentagents are prohibitively expensive for routine EMS anddisaster use.

Recommendations for Tourniquet Use inCivilian EMS Systems

Tactical EMS and Police Officers

Tactical EMS (TEMS) providers, usually paramedics,support special weapons and tactics (SWAT) or spe-cial operations teams found in many civilian law en-

forcement agencies, from the municipal to the federallevel. Most of these personnel come from a backgroundof civilian EMS agencies and are steeped in the tradi-tion of tourniquet avoidance. Current trends in law en-forcement, particularly as they impact on SWAT oper-ations, demand that we reevaluate the appropriatenessof applying typical civilian EMS practices to law en-forcement and TEMS environments. Civilian firearms-related incidents are becoming more and more like mil-itary operations.

Military-style weapons with large, high-velocity bul-lets have proliferated in recent years as weapons ofchoice among gangs, narcotics traffickers, and terror-

ist groups. No longer can law enforcement officers as-sume that they can easily outgun the suspects theyare charged with apprehending.

Coincident with the change in the nature of theseweapons is a change in the wounds and injuries result-ing from their use. Like todays military, police officerstypically wear body armor as a means of mitigatingsome of the increased risk they now face from heavilyarmed suspects. While helping reduce risk of death orgrave injury from torso wounds, these vests have notreduced the burden of extremity injury as a potentialcause of death in urban conflicts.55

In 1997, a pair of heavily armed bank robbers wear-ing body armor held Los Angeles police at bay until

being fatally wounded. One responding officer shot inthe thigh reportedly lost an estimated 40% of his totalvolume of blood, lost consciousness, and nearly died.Had he had access to a tourniquet, he might have beenable to stop the bleedinghimself and perhaps even con-tinue to support the mission at hand.

The weapons used by police in responding to vio-lent criminals could also create circumstances in whichthe tourniquet may prove beneficial. A medical exam-iner stated one suspect in the event described above

died due to thigh wounds that caused exsanguination.Civilian EMS personnel were unable or unwilling toenter the scene.56 The suspects family sued the city ofLos Angeles for this notorious inattention. Applica-tionof a tourniquetunder these circumstances, perhapseven one given to the victim with instructions on howto place it, may have saved the life of this person.57

Beyond firearms, the use of explosives by terroristsand other elements is blurring the distinctions betweenmilitary conflict and civilian crime. ATF and FBI statis-tics show that, even before the Oklahoma City bomb-ings and 9/11 made terrorism more of a concern in theUnited States, there were large numbers of bombingsfor criminal and entertainment purposes.58,59

The traditional civilian model of trauma care ex-emplified by the golden hour concept will bluralong with these changes. Deaths from military-styleweapons and explosives conform to a different distri-

bution of time of death when compared with the moretypical civilian trauma experience. Most deaths occur

very early, prior to hospital care. Many of these aredue to exsanguination60 and extremity hemorrhage isthe leading cause of death in potentially salvageablevictims.12

These considerations all argue fortraining andequip-ping police officers for tourniquet use on themselvesor others, much as the military has done for its front-line troops. While widespread tourniquet availabilityamong lay providers may make some uneasy, wenote that individual soldiers have been able to usethe instrument successfully on themselves or woundedcolleagues.15 In addition, there is justification for allow-ing trained police officers to use tourniquets on civil-

ian victims, as part of basic first aid. There is alreadywidespread experience with police personnel deliver-ing first-responder care, including cardiac care via theuse of AEDs. Police officers have also been trained toperform triage at mass casualty incidents.61 Initial con-cerns about acceptance of these roles by police officers62

have not been borne out.63

Disaster Situations/Mass Casualty Triage

Isolated extremity injury causing exsanguination alsooccurs in civilian EMS practice. Preventable deathsdue to failure of prehospital personnel and hospitalproviders to stop limb hemorrhage have been reported.In one study, 57% of those dying in metropolitan Hous-ton due to isolated penetrating extremity trauma had

bleeding sites amenable to tourniquet therapy.64

The events of 9/11/2001 showed that global terror-ism can now be a local occurrence. With terrorismcome weapons of mass effect. While biological (suchas anthrax), chemical, and nuclear/radiologic weaponthreats have received great focus, attacks using con-ventional weapons such as explosives and firearms still


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prevail as the most common type of terrorist attacksin modern history.65

Casualty data and mortality trends from civil unrest,especially bombings, have bolstered the arguments foruse of tourniquets in prehospital care: penetrating ex-tremity injuries occur in about half of the severelyinjured.66 This increase in extremity trauma is not lim-

ited to adults: Pediatric victims of violence also havehigher rates of penetrating extremity injury than dochild victims of non-terror-related injuries.67

Explosives, via primary, secondary and tertiary blasteffects, induce amputations, partial amputations, andpenetrating wounds of the extremities in bystanders.Recent experiences in Lebanon,68 Palestine,69 Israel,65

Kosovo,70 Bali,71 Madrid,72 London,73 and other set-tings have shown that there can be large numbers ofvictims with complex injuries, including mangled ex-tremities, amputations, partial amputations, and mis-sile injuries, in addition to head, spine, and visceralinjuries.

It has been noted that these types of events com-bine the severe mechanisms of injury typically asso-ciated with military combat with the short intervalsfrom injury to rapid transport and definitive treatment,which are more characteristic of the civilian traumaexperience.74 Under these circumstances, many vic-tims need only very simple interventions from EMSproviders: The use of tourniquets for brief periods tolimit blood loss and expedite transport would be a ra-tional, and possibly life-saving, intervention.

Control of bleeding is beneficial to patient survival.75

Indeed, even in those who survive despite massivehemorrhage, reducing blood loss and thereby preserv-

ing vital oxygen-carrying capacity will lessen compli-cations, such as the adult respiratorydistress syndromeand multisystem organ failure. A tourniquet that com-pletely arrests hemorrhage before resuscitation willmaximize preservation of red blood cells.

A triage officer or EMScrew responding to mass casu-alty event must be able to act quickly with simple inter-ventions in order to maximize victim survival. Takingthe time (and personnel) to apply pressure dressingscould impair the smooth implementation of triage al-gorithms in mass casualty situations. As an example,the most recent PHTLS handbook recommends 1015minutes of direct digital pressure to stop bleeding.39

Clearly, this will be impractical or impossible in manydisaster situations. In addition to penetrating extrem-ity injuries, head and torso injuries may also demandimmediate stabilization. Multiple serious injuries maketime-consuming hemorrhage control measures an un-affordable luxury.

In these circumstances, EMS personnel must have ac-cess to, and training with, arterial tourniquets. A pro-tocol that allows tourniquets to be used as a first, ratherthan last, resort is imperative. Placing a tourniquet ona bleeding extremity, noting the time of placement, and

moving on to the next victim will allow providers toimmediately stop bleeding that would otherwise con-tribute to hemorrhagic shock and may even cause fa-tality. Advanced Trauma Life Support (ATLS) trainingnow acknowledges the need to stop obvious external

bleeding during the primary survey.76

Once all victims have been triaged, or more help has

arrived, prehospital personnel can return to those vic-tims who have tourniquets in place. Wounds can then

be reassessed and tourniquets possibly removed andreplaced with pressure dressings. Although this ap-proach seems to violate the traditional teaching thata tourniquet placed in the field must be left on until thevictim reaches a hospital, there are circumstances inwhich this approach is reasonable, for example, if de-layed or prolonged transport is anticipated.Algorithmshave been developed for primary tourniquet placementand reevaluation with conversion to nontourniquet-

based hemostasis10,77 and successfully used in 76% ofcases.10

Tourniquets are simple devices. Nonmedical safetypersonnel as well as lay people (such as walkingwounded) can be quickly trained to apply these de-vices safely and effectively. Victims themselves couldeven effectively use some types of tourniquets ontheir own wounded extremities.78 Data from Canadianstudies show that most commercial tourniquet mod-els can be applied effectively in under 3040 seconds.79

Providers canbe easily taughtto quicklyand effectivelyapply tourniquets. Life-support courses have beenchanging to simplify techniques for responders.Tourni-quetsshouldbetaughtasanadjuncttostandardhemor-rhage control techniques. Pressure points and elevation

are commonly taught to lay persons. These techniquesare arguably no simpler than tourniquet applicationand, unlike tourniquets, are of unproven benefit.4

Routine EMS Usage

Tourniquets can also be useful in cases involving sin-gle patients, but only if EMS providers have access toappropriate protocols, training, and equipment. Theymust have familiarity with the indications and tech-niques for the use of tourniquets in order to avoid aninappropriate (and historically based) fear of these in-struments. Tourniquets are naturally compatible witha scoop and run approach to trauma care in whichsimple, rapid, and potentially life-saving interventionsare combined with expeditious transport to definitivecare.

The use of a tourniquet to control extremity bleedingmaximizes the ability of EMS providers to resuscitatea hypotensive patient by stopping the leak. Ongo-ing extremity bleeding will hinder adequate resusci-tation. Intravenous (IV) fluid infusions will simply di-lute valuable oxygen-carrying hemoglobin and clottingfactors.63,80


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A tourniquet first approach to the single, multiplyinjuredpatient allows the provider to immediately stopobvious extremity bleeding, allowing attention to bethen turned to more time-consuming airway or breath-ing priorities. After these are attended to, attention can

be directed to the bleeding extremity, with possible ex-change of the tourniquet for a pressure dressing.

Transportation of prehospital patients is also facili-tated by placement of tourniquets. Personnel do nothave to maintain digital pressure or frequently checkand reinforce dressings. This frees the provider to paymore attention to maintenance of vital signs, to obtainIV access, or to complete a secondary survey en route tothe hospital. In austere circumstances such as wilder-ness settings, disasters, or hostile-fire situations, thisadvantage is made even more significant as providersare freed to perform other roles or to care for multiplepatients.

We also know that field-improvised tourniquetsmay not be as safe as commercially manufactured

tourniquets (bandage/windlass combinations canbunch into a constricting band47) and are frequentlyineffective.10 It is better to have equipment, specificallydesigned for the task of controlling catastrophic bleed-inginthehandsofpersonnelwell-trainedinitsusethanto ask them to fabricate crude devices under stressfuland possibly physically threatening circumstances.

Protocols for Prehospital Tourniquet Usefor Severe Extremity Hemorrhage

Indications

Table 2 presents proposed indications for prehospitaltourniquet use, including routine EMS use in nondis-aster settings. The goal of tourniquet use as presentedhere is to allow prehospital personnel to safely, rapidly,and effectively stop extremity hemorrhage, thus free-

TABLE 2. Indications for Tourniquet Use in EemergencyMedical Services (EMS) and other Prehospital Settings

Amputation

Failure to stop bleeding with pressure dressing(s)Injury does not allow control of bleeding with pressure dressing(s)

Significanta extremity hemorrhage in the face of any or all of:Need for airway managementNeed for breathing supportCirculatory shockNeed for other emergent interventions or assessmentBleeding from multiple locations

Impaled foreign body with ongoing extremity bleedingUnder fire or other dangerous situation for responding caregiversTotal darkness or other adverse environmental factorsMass casualty eventb

Proposed indications for tourniquet use in EMS.a Significant as defined by the EMS providers on scene.b Anyeventwherethenumbercasualtiesand/ortheseverityofinjuriesexceedthe ability of EMS personnel to provide optimal initial care all casualties.

ing the rescuer to triage and treat other patients orrapidly address other emergent issues on a solitary pa-tient. These principles are relevant to both mass casu-alty situations and the care of a single patient. Theyare intended to maximize the rescuers efficiency andenhance the safety of both patient and rescuer duringtriage and treatment.

Mass Casualty and Disasters

Inthemilitaryenvironment,useoftourniquetsduringamass casualty event is well established and adaptationof this use to civilian disaster care is natural.

Figure 1 shows an algorithm advocating that respon-dersstoppotentiallymassivebleedingfirst:thisiseasilyand safely accomplished witha tourniquet. The promptarrest of major extremity hemorrhage minimizes bloodloss while allowing the triage provider to move rapidlyto assess other patients. With multiple casualties, theremay not be the time or manpower to applyan adequatepressure dressing.

After completing triage and other emergent proce-dures such as airway stabilization, medics would then

be free to reassess the need for the tourniquet in pa-tients on whom it was previously applied. Allowingproviders to reassess wounds for ongoing tourniquetneed under calmer circumstances maximizes the safetyand effectiveness of this tool. Tourniquet reassessmentand removal algorithms are presented below.

Finally, in order to minimize tourniquet times, werecommend that no patient with a tourniquet in placeshould have a triage code less acute then yellow and

FIGURE 1. Proposed algorithm for mass casualty tourniquet use.Triage teams should apply tourniquets to patients with bleeding ex-tremity wound(s) and continue with START or similar triage pro-tocols. They also mark or label the casualty to alert others to thetourniquet.


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Routine EMS Tourniquet Use Algorithm

Significant Extremity Bleedingwith need for other interventions?

Yes: No:

Apply tourniquet tobleeding limb(s) onproximal segment

Transport 30 min expected?

Yes: No:

Leave onand transport

Reassessfor removal

FIGURE 2. Proposed algorithm for routine EMS tourniquetuse. Bleed-ingin patientswithindications listedin Table 2 isarrested bya tourni-quet placed primarily. If time, clinical situation,and personnel allow,a pressure dressing could be tried first.

that they have priority fortransport. Thepresence of thetourniquetand the time that thetourniquetwas appliedshould be prominently marked on each patient.

Routine EMS Use and Law Enforcement

ConsiderationsTypical protocols for tourniquet application in EMSstringently limit the use of this device. In most sim-ple single-patient extremity hemorrhage encounters,a tourniquet will not be required; standard pressuredressings will suffice. However, in cases of amputation,severe hemorrhage,multiple patients, or singlepatientswith extremity hemorrhage combined with airway or

breathing emergencies, a tourniquet must be availableand providers must be well trained in its use. Figure 2shows a proposed algorithm for safe and rational rou-tine tourniquet use within a civilian EMS systems.

EMS providers are charged with providing sophis-ticated care in their daily jobs: airway interventions,vascular access, medication administration, defibrilla-tion, and the like. Expecting them to be able to de-cide whether or not to apply a tourniquet is certainlywithin their scope of training and practice. Allowingthem to reassess and remove tourniquets and mon-itor for further bleeding is also simply a matter ofcommon sense, involving only simple protocols andtraining.

Control of bleeding is especiallyimportantin patientswith multisystem trauma who need multiple interven-

tionsand immediate transport. Rapidcontrol of extrem-ity bleeding with a tourniquet facilitates other inter-ventions and allows rapid transport to definitive carewhile minimizing blood loss. In multiply injured pa-tients, we suggest allowing providers to place a tourni-quet first to stop blood loss immediately, then attendto airway, breathing, or other emergent priorities fol-

lowing the militarys MARCH protocol. After theseare addressed, the medic may then return to see if thetourniquet is still needed. In cases with short transporttimes, well within the known safety margins of tourni-quettime, rapid transport without removal is indicated.When delayed or prolonged transport is anticipated, ef-forts to replace the tourniquet with a pressure dressingshould be undertaken.

We also suggest that law enforcement officers, espe-cially those in high-risk operational settings, be allowedto carry tourniquets and given training on how to usethem on themselves, their teammates, and other vic-tims, in an effort to stop severe extremity hemorrhage

while awaiting EMS arrival.

Reassessment and Removal of Tourniquets

Previous discussions of prehospital tourniquets havetypically recommendedleaving tourniquets on until re-moval by a physician, regardless of the time involved,while some systems have advocated loosening tourni-quets intermittently for brief reperfusion intervals inthe event of prolonged transport. We reject both of theseapproaches. Based on available evidence, safe reassess-ment of tourniquet need and tourniquet removal in thefield can be accomplished with simple, standardizedprotocols and training. Figures 3 and 4 show proposedalgorithms for reassessing the need for and performingthe removal of tourniquets, respectively.

Future Directions

Improved Tourniquet Design

Multiple design features to improve safety and effec-tiveness could be incorporated into tourniquets for usein prehospital and disaster situations. For example,curved tourniquets, which fit the natural conical ta-per of an extremity better than do straight rectangulartourniquets, provide hemostasis at lower pressures andseem to allow longer tourniquet times.20

Padding under a tourniquet with two-layer dress-ings, like stockinette or cast padding, reduces the skindamage these instruments can cause.81 It may be pos-sible to incorporate more padding into nonpneumatictourniquet models and thus reduce the risk of skin in-

jury. Other simple, potentially effective design changeswould includewidening the nylon strap on which mostnew models are based and coloring them brightly tomake them conspicuous.


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Tourniquet Reassessment Algorithm

Patient in circulatory shock?

No Yes

No Yes

No Yes

Leavetourniqueton andtransportpatientto higherlevel ofcare

Unstable clinical situation?

Limited personnel/resources?

Proceed to removal algorithm

FIGURE 3. Steps to be followed to determine ongoing tourniquetneed. The tourniquet should not be removed if the situation is un-stable or there are not personnel or supplies available to place anadequate pressure dressing and monitor the site for rebleeding.

Finally, microelectronics could be incorporated tomaximize both the effectiveness and the safety oftourniquets. Such smart tourniquets might detectflow through arteries beneath them and continu-

Tourniquet Removal Algorithm

Amputated Extremity?

No Yes

No Yes

Leavetourniqueton andtransportpatientto higherlevel ofcare

Apply pressure dressing,* loosentourniquet (leaving it in place)

Significant bleeding from site?

Further significant bleeding?

No Yes

Tightentourniquetand begintransportpatientto higherlevel ofcare

FIGURE 4. Algorithm for field tourniquet removal. A pressure dress-ingshouldbeapplied(witha topicalhemostatic agent ifallowed andavailable.) Thetourniquet isloosened butlefton andthe wound mon-itored. If rebleeding occurs, tighten the tourniquet to arrest bleeding.

ously self-adjust tension as the victims blood pres-sure rises or falls, only applying the minimum pres-sure required to stop arterial flow. Other safety fea-tures, such as timers (allowing receiving facilitiesto know the tourniquet time) and alarms (to alertthem to the tourniquets presence), might also beadded.

Tissue Protection

Ischemia and reperfusion injury (IRI) is a known com-plication of prolonged tourniquet use and liberation offree radicals and other compounds after tourniquet re-lease.

Recent work with n-acetylcysteine and precondition-inghasnotyetyieldedsuccess,82butasourunderstand-ing of this process improves, it is foreseeable that pre-hospital personnel will have access to compounds ortechniques that may reduce IRI and further improvethe outcome of tourniqueted limbs.

Research and Registry

Review of current and future uses of tourniquets isneeded to continually improve our tourniquet pro-tocols. Tumor boards, wound and trauma registries,and other prospective cohorts have enhanced medi-cal knowledge about a number of conditions. Similarregistries of tourniquet use should be encouraged andwould be especially easy to initiate using data fromrecent military experience. This will help refine proto-cols, enhancing future safe tourniquet use. Controlledtrials of prehospital tourniquet use are unlikely to be

feasible given ethical and other clinical considerations.Appendix 1 presents a proposed data-collection formfor use in a tourniquet registry.

Pediatrics

There is no reported prehospital experience with use oftourniquets for hemorrhage control in children. As pre-viously noted, pediatric victims of violence often havethe same injury patterns as adults; hence, they may also

benefit from rapid extremity hemorrhage control withtourniquets. Further research to evaluate special con-siderations such as tourniquet size, childhood physi-ology, and other pediatric-specific issues must be per-formed in order to ensure maximum safety and benefitfor all age groups.

Training

Continued safe and effective tourniquet use in the pre-hospital arena will be fostered by adequate trainingof personnel in use of this instrument. Appendix 2presents a suggested outline of a tourniquet use train-ing curriculum.


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CONCLUSION

Traditionally, the risk-benefit calculus involved in theEMS use of tourniquets has been encapsulated in thephrase lose a limb and save a life,5 because thesedevices have the potential to cause ischemic damageto a limb even when applied to stop life-threateninghemorrhage. Some authors, concerned with inappro-priate use of tourniquets as well as reperfusion in-

jury despite appropriate use, recommend prohibition.They state that there is no exclusively clinical rea-son to apply tourniquets, which should not be used ex-cept in the exigent circumstances of military or disastersituations.83

In contrast, Lee, et al. have suggested that thereare rare circumstances when tourniquet use mayindicated.40 However, recent military experience withwidespread tourniquet use by individual soldiers,front-line medics, and combat hospital personnel, com-

bined with almost universal acceptance of tourniquet

use in bloodless extremity surgery, indicates that themaxim of tourniquet as last resort in civilian EMScare is clearly antiquated. Instead, there should be aprominent role for these potentially life-saving devicesin civilian prehospital care. EMS providers must betrained and comfortable with tourniquet use whenextremity bleeding is a threat and standard methodslike direct pressure and elevation are ineffective orimpractical.

Penetrating extremity trauma is an increasingly com-mon occurrence in our communities, whether asso-ciated with accidental injuries, firearm violence, orterrorist-related incidents. Experience and research in-

dicate that life-threatening hemorrhage can be quicklyand reliably arrested by the use of a simple tourni-quet. This device allows limited numbers of providersto rapidly triage and provide hemostasis to multiplepatients. Tourniquets can be self-applied by injured po-lice, fire, or rescue personnel, allowing them to continueduty, if necessary, until safe evacuation and treatmentare available.

Ischemic complications can be avoided by rational,protocol-driven use involving quick initial placementand rapid transport to definitive care, keeping tourni-quet times to a minimum. When conditions allow, atourniquet can be reassessed and replaced with a pres-

sure dressing.

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APPENDIX 1. DATA COLLECTION FORM FOR TOURNIQUET REGISTRY

Tourniquet Registry Data Collection Form

Date of Encounter:

Time of Dispatch: (use 24-hour clock for times) Time of Arrival at Hospital:

Patient Identifier: (Run #, SSN, Med record, etc.)

Patient Sex: M F (circle one) Patient Age years old

Crew Members/Personnel:

Number of Victims on Scene: Mechanism: Blunt Penetrating

Site of Tourniquet Application: (circle; use additional sheets for > 1 tourniquet applied to single victim)

Arm Leg R L

Tourniquet Applied by: Victim Bystander EMS Other:

Measures Used Prior to Tourniquet Use: (circle all that apply)

Direct Pressure Pressure Dressing Pressure Point(s) Hemostatic Agent

Time of Tourniquet Application: Time of Tourniquet Removal:

Tourniquet Removed by: (circle one) EMS (name ) Hospital Personnel

Total Tourniquet Time: (minutes) Transport Time: (minutes)

Protocol Utilized for Tourniquet Placement: (circle one)

Mass Casualty/Disaster TEMS/Law Enforcement Routine EMS

Removal In Field/En Route: (circle one)

Attempted/Successful Attempted/Failed Deferred

Did Patient Require Pain Medications because of Tourniquet Pain? Yes No Unknown

Tourniquet-Related Complications (defined by higher level-of-care/Medical Control) (circle all that apply)

None Ischemic Damage VTE Compartment Syndrome Reperfusion Injury

Other: (explain)

Type(s) of Bleeding Distal to Tourniquet: (as defined by higher level-of-care/Medical Control)(circle all that apply)

Capillary Venous Arterial


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APPENDIX 2. SUGGESTED OUTLINE OF A TOURNIQUET-USE TRAINING CURRICULUM.

Tourniquet Training Curriculum Items:

I. BackgroundHistory of the Tourniquet Controversy

II. Review of Hemorrhage Control

Significance of HemorrhageHemorrhage Control Methods and AlternativesNew trends: Military Use, Hemostatic Agents, etc.

III. Protocols for Tourniquet UseApplication

IndicationsMass Casualty/Disaster SituationsTEMS/Law EnforcementRoutine EMS

TechniquesMonitoring EffectivenessRemoval

IndicationsTechniques

IV. Quality Improvement/Registry Instrument

V. PracticumScenarios for Practice Using ProtocolsSimulations to Practice Applying Tourniquet

SelfPartnersActive Hemorrhage Simulators

from Mabry RL. Use of a hemorrhage simulator to train military medics. Mil Med. 2005 170(11):921925.

doyle pre hospital emergency care june 2008 2

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