Page 31 - Journal of Special Operations Medicine - Spring 2015

Common themes of modern combat publications il­ Recommendations for Conversion of
lustrate that early tourniquet use prevents limb exsan­ Tourniquet to Hemostatic or Pressure Dressing
guination and saves lives, that nonindicated tourniquet The 2013 TCCC guidelines stated that after tourniquet
placement is common (even when CUF is included as placement, reassessment is recommended during the
an indication), and that morbidity is uncommon when TFC and TACEVAC phases of care and that conversion
tourniquet use is relatively brief. Ineffective tourniquet to hemorrhage control with a hemostatic or pressure
use remains common, and in one process improvement dressing should be attempted if evacuation is antici­
project published in 2012, 83% of limbs treated with a pated to be longer than 2 hours. 35
tourniquet had palpable distal pulses and 74% did not
have a major vascular injury; concurrently, no major The Ranger Medic Handbook (4th edition) describes
37
vascular injury presented without a tourniquet. This a tourniquet conversion procedure with four indications
3
experience further supports that a certain amount of for conversion: bleeding is controlled, hemostatic dress­
overtreatment—placement of tourniquets later deemed ing is effective, evacuation is prolonged, or the user is
unnecessary—may be needed to achieve a zero miss relocating the tourniquet distally. If any indication is
rate for exsanguination; however, additional emphasis present, then the tourniquet is loosened and the wound
should be given to training on tourniquet indications assessed for bleeding. 37
and early conversion to hemostatic or pressure dressing
in the field. Additional published guidelines for tourniquet conver­
sion include the report of a 2003 Army expert panel
Indications for Tourniquet Use that recommended tourniquet conversion to hemostatic
TCCC guidelines specify that tourniquets should be ap­ or pressure dressing if the casualty is not in shock and
plied for life­threatening external hemorrhage that is an­ conversion can be monitored regularly for rebleeding;
atomically amenable to tourniquet application, the only the panel recommended not to loosen the tourniquet if
medical intervention recommended during CUF. Due there is an amputation or arterial injury or if the tourni­
35
to tactical priorities during the CUF phase that override quet has been in place for over 6 hours. 38
those of routine, nontactical medical care, the capacity
for assessment and treatment is limited and tourniquets Doyle and Taillac published a similar tourniquet re­
36
may be placed aggressively to prevent exsanguination. moval algorithm intended for civilian emergency medi­
cal services: In the absence of circulatory shock, unstable
Other published indications for tourniquet use include clinical situation, or limited personnel/resources prevent­
situational indications such as mass casualty events and ing placement of a pressure dressing or monitoring for
total darkness, or when the patient also requires an air­ rebleeding, tourniquets may be considered for removal.
way or breathing intervention. Anatomic indications For an amputated extremity, leave the tourniquet on.
include arterial hemorrhage and traumatic amputation Otherwise, apply a pressure dressing and loosen the
above the wrist or ankle. 31,33,36 tourniquet. If significant rebleeding occurs, retighten the
tourniquet until arrival at a higher level of care. 36
The CoTCCC recommends tourniquet placement for
life­threatening hemorrhage (to include suspected life­ Periodic loosening of tourniquets for the purpose of reper­
threatening hemorrhage not fully assessed during CUF), fusing the limb has resulted in incremental exsanguination
in multiple casualty situations, when multiple injuries and has no role on the battlefield, as described by Wolff
require interventions in a single casualty, and for all ma­ and Adkins in 1945 and re­emphasized by Walters and
jor amputation injuries. Mabry in 2005. 24,38 Additionally, periodic reperfusion of
the ischemic limb may increase the amount of damage to
In a prospective observational survey of 728 casualties the limb by worsening of the ischemia­reperfusion injury. 39
with 953 limb injuries, indications for tourniquet place­
ment were categorized by amount of hemorrhage, ana­ Three criteria for tourniquet conversion to a hemostatic
tomic indications, and situational indications. Of these, or pressure dressing were selected for inclusion in this
51% had major hemorrhage and 49% had minor hem­ 2014 update to the TCCC guidelines: The casualty is not
orrhage. The most common anatomic indications for in shock, it is possible to monitor the wound closely for
tourniquet placement were open fracture (27%), trau­ bleeding, and the tourniquet is not being used to control
matic amputation (26%), soft­tissue wounds (20%), bleeding from an amputated extremity. All three criteria
and vascular injuries (17%). The most common situa­ must be met before considering tourniquet conversion.
tional indication for tourniquet placement was bleeding
from multiple sites (61%); it was stated that CUF and Complications of Tourniquet Use
other situational indications for tourniquet placement A thorough understanding of the risks of tourniquet use
were under­reported in this survey. has led to process improvements that have allowed for
33

TCCC Limb Tourniquet Guidelines Change 14-02 21