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5 Myths about Tourniquets

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    • 5 Myths about Tourniquets

      Here's an interesting article I thought was worth sharing. I learned most of what I know about Tourniquets back in the '90's and it was a shock to see that the accepted protocols had changed so much.

      I showed this to my RN wife and her response was long the lines of "well duh, how dated was your knowledge?" :D



      This is a dangerous and antiquated approach to trauma. There is an overwhelming amount of substantiated data that dispel this myth. If you're attending a class and that's what you are being told, contact us at Trauma Monkeys ASAP and we will find a course in your area that is teaching the current protocols.
      In combat zone, Tactical Setting, Active
      shooter, dynamic type event a Tourniquet should be the First choice if there is any suspicion that a casualty is bleeding from an extremity. For many years Extremity Hemorrhage was the number one cause of preventable death on the battlefield it has since been surpassed by junctional hemorrhage (armpit, groin, neck).
      Significant improvements in training, coupled with the availability of tourniquets have directly resulted in a marked decrease in mortality. Through education and persistence the military has been able to convince all hands to completely change how they view tourniquets. No easy task considering the how many times we have all been told “only as a last resort”.
      The fact is loss of a limb is extremely rare. The risk of hemorrhage far outweighs the minuscule risk of limb damage. The old "Life over limb” adage applies here. There are many well-documented cases of patients that have had commercial tourniquets in place for greater then eight hours, with no loss of limb. In the cases where their have been a loss of limb(s), they are directly attributable to a gunshot wound, blast injury, shrapnel, fragmentation, high velocity trauma and not as a result of restricted blood flow from tourniquet placement.
      This is Utter Nonsense. Belts make terrible tourniquets; it is extremely difficult if not impossible to completely occlude arterial blood flow using a belt. Utilizing a belt and its buckle will never be tight enough and attempting to tighten the belt with a makeshift windlass is problematic due to it’s rigidity. The makeshift windlass would need to be substantial (i.e. leg of a chair) to have any chance of tightening the belt enough. Belts are readily available and certainly work better then nothing, the point here is to promote commercially made Tourniquets or more suitable makeshift tourniquets (cravat / stick) see our article here on improvised Tourniquets.
      Using what you have on hand in extremis is not only acceptable its commendable. There are no shortages of great stories of people doing self-aid or acting as a first responder, I prefer First Care Provider, more on this in future posts). Read more about Brian Ludmer, the schoolteacher shot in the calf in the LAX shooting. Ludmer crawled to a shop, scrambled into a storage room and shut the door. He found a sweatshirt and tied it around his leg to slow the bleeding. Key phrase there “Slow the bleeding”, that’s what makeshift tourniquets do, commercially made tourniquets STOP the bleeding. Hospitals, EMS agencies, Fire Departments, and anyone in the business of saving lives is negligent if they are not equipped with commercially made Tourniquets.
      This is what the city of Boston had on standby and utilized in the aftermath of the bombing. It’s surgical tubing, and a pair of hemostats to secure the tubing after wrapping it circumferentially around an extremity. It’s important to note that 100% of these were found to be ineffective tourniquets and had to be converted to a commercial tourniquet. That's not to say they did not slow the bleeding and contribute to the high survival rate. Please do not think this is a criticism of those brave folks that responded and undoubtedly saved countless lives.
      Boston has since purchased commercial tourniquets and discontinued the tubing policy. When someone is bleeding significantly from an extremity it is hardly the time for arts and crafts. If you are in the business of saving lives then make it your business to have the gear you need to do so.
      Commercial Tourniquets just like any other piece of gear all have advantages and disadvantages, strengths and weakness, pros and cons. They all have subtle nuances and general rules of thumb regarding their use. I’m often asked what tourniquet I recommend, and my answer is always the question “recommend for who, when, and where?” The Tourniquet that works well for a Marine on his body armor, may not be the best choice for someone doing undercover work. The tourniquet I carry on SWAT missions to treat a wounded Police Officer would be a poor choice in a school shooting with expected pediatric patients. The tourniquet I would use in a controlled emergency room setting would be difficult to use in a low light stressful environment.
      Tourniquets come in all different shapes, sizes, colors, and accomplish the job in a myriad of ways. As with any other job, task, or mission the sensible answer is to choose the right tool for the job. Please visit our YouTube channel and other Blog posts for an extensive review of the common commercially made tourniquets and as always feel free to email or leave a comment below.


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      J Trauma Acute Care Surg. 2014 Sep;77(3):501-3
      Boston marathon bombings: an after-action review.
      Boston Trauma Center Chiefs’ Collaborative.
      Collaborators: Millham FH, Burke P, Gates J, Gupta A, Mooney D, Rabinovici R, Yaffe MB, Velmahos GC.
      Aid by First Responders
      “Another unusual feature of the Boston Marathon bombing was the proximity of a generously staffed medical resuscitation tent in immediate proximity to the blast zones. Injured patients were able to receive immediate care from nurses, physicians, paramedics, emergency medical teams, Boston Police, and National Guardsmen, some of whom had experience in the management of blast victims in war. The early and liberal use of tourniquets on bleeding extremities, possibly reflecting knowledge gained in combat,7,8 may have contributed to patient outcomes. However, not all tourniquets were applied effectively. Several makeshift field tourniquets such as belts or other articles of clothing did not control bleeding sufficiently. Proper tourniquet technique, such as frequent tightening and occasional double tourniquet application on large extremities, were not used. Training for first responders should address this critical need.”
      “(1) Effective use of tourniquets as first aid should be part of the national first aid curriculum. (2) Military tourniquets should be stocked in all emergency vehicles in sufficient quantity to deal with multiple trauma patients.”

      A Tourniquet is the one piece of gear you should never leave behind, it's saved countless lives and if you don't have one when you need it, you're in trouble. We strongly advise you have tourniquets in your home, your vehicle, your first-aid kits, bug-out bags, workshop and anywhere else disaster could strike. Don't let your spouse try to stop the bleeding with a towel or an arts & crafts tourniquet. We would love for you to buy one from us to help offset the cost of the site but what's most important is that you get one somewhere.
      >>>Advertise here! Affordable rates and no long term contracts. Send a PM for more details!<<<
    • I've had a look at some of the underlying studies. They seem to be predicated on prompt (2-hour) evacuation (which is fairly likely on a modern battlefield or in an urban setting). In those situations, the old adage of "a limb or a life" is less meaningful, because a tourniquet doesn't do its damage that quickly. (It was based on battlefield injuries in the World Wars, where evacuation to definitive care could only rarely be done that fast.

      In cases where rescue will be delayed (>4 hours), it becomes a much more grisly call, with few good options. Certainly a tourniquet should not be used on a wound where direct pressure is effective, because of not only the possible damage to the limb, but also the risk of rhabdomyolysis and renal failure when the limb is reperfused. Tourniquet release after prolonged application requires the services of an ICU and must not be done in the field, even if the alternative will be amputation. By the same token, if definitive care will be available within an hour or so, it's probably best to let the Emergency Department release the tourniquet. On the other hand, tourniquet release within an hour of application is exceedingly unlikely to result in reperfusion injury and should be done routinely if evacuation will be delayed and it becomes possible because the situation has stabilized in other ways. (For example, additional rescue help becomes available, or a limb is freed from entrapment, or a patient has been partially evacuated to a situation where direct pressure becomes safe to apply.)

      In a backcountry setting with a PLB or a mobile phone signal available to summon aid, prompt helicopter rescue may well be possible. Moreover, much of our hiking is in the "front country", so this article is definitely food for thought.

      My understanding is that in the civilian setting, tourniquets are still considered to be reserved for a few specific situations.
      • High-hazard settings. This mostly means industrial environments such as mines, construction sites, oil fields, farms and fishing vessels, where blast injuries or traumatic amputations are woefully common. (It might also apply to wilderness settings, where difficulty and danger of rescue change the tradeoffs.) Long-line helicopter evacuation, where it may be impossible to maintain direct pressure during the hoist, would be another indication for a termporary application of a tourniquet.
      • Multiple casualties. If sufficient rescuers are not available to treat all wounds with direct compression, then tourniquets may be necessary to save lives.
      • Multiple sites of injury. A single casualty presenting with life-threatening bleeding in multiple limbs, or multiple sites of bleeding on the same limb, may similarly require tourniquets for adequate management. This may be because of a shortage of rescuers, or because the rescuers cannot operate simultaneously without interfering with one another.
      • Entrapment: A crushed limb, or a limb that cannot be extricated and subjected to direct pressure, may need a tourniquet to treat.
      • Traumatic amputation. The limb is likely already lost. (although with prompt surgery, replantation can be successful!) A tourniquet is appropriate. A tourniquet is also often also appropriate for gunshots, deep knife wounds, or blast injuries.
      What's particularly interesting here is the finding that improvised field tourniquets have such poor efficacy compared with purpose-designed ones.

      It's obviously waaaay past time for me to refresh my WFA training. Thanks for sharing this.
      I'm not lost. I know where I am. I'm right here.
    • Dan76 wrote:

      SarcasmTheElf wrote:

      Tuckahoe wrote:

      #1 best place to apply a tourniquet is at the neck... Tight... Really really tight!
      :whistling: :evil: :thumbup:
      Did you have a previous career as a marriage councilor?gif.005.gif
      If so, most likely it was short-lived.

      I wouldn't be a good marriage councilor... I probably would be only a minute into an interview before I'd ask, "why are the two if you such selfish a$$holes?"
      Of course I talk to myself... sometimes I need expert advice.
    • Tuckahoe wrote:

      Dan76 wrote:

      SarcasmTheElf wrote:

      Tuckahoe wrote:

      #1 best place to apply a tourniquet is at the neck... Tight... Really really tight!
      :whistling: :evil: :thumbup:
      Did you have a previous career as a marriage councilor?gif.005.gif
      If so, most likely it was short-lived.
      I wouldn't be a good marriage councilor... I probably would be only a minute into an interview before I'd ask, "why are the two if you such selfish a$$holes?"
      Neither would I..particularly if children were involved.

      Lest we forget.....

      SSgt Ray Rangel - USAF
      SrA Elizabeth Loncki - USAF
      PFC Adam Harris - USA
      MSgt Eden Pearl - USMC
    • Tuckahoe wrote:

      Dan76 wrote:

      SarcasmTheElf wrote:

      Tuckahoe wrote:

      #1 best place to apply a tourniquet is at the neck... Tight... Really really tight!
      :whistling: :evil: :thumbup:
      Did you have a previous career as a marriage councilor?gif.005.gif
      If so, most likely it was short-lived.
      I wouldn't be a good marriage councilor... I probably would be only a minute into an interview before I'd ask, "why are the two if you such selfish a$$holes?"
      That would be a good question for two considering marriage. I have never been married. Maybe I am self-aware.
      I am human and I need to be loved - just like everybody else does