Page 61 - Journal of Special Operations Medicine - Summer 2015

arrival of EMS, cardiopulmonary resuscitation was commercial tourniquet failure was due to improper
in progress by firefighters on scene. A tourniquet was placement. However, when the misplaced tourniquet
placed by our EMS personnel and achieved hemostasis, was replaced with a properly placed one, external hem-
however, the patient never regained spontaneous circu- orrhage was controlled. The proper use of these agents
lation and expired in the field. produces good outcomes, as seen in experimental studies
that showed 100% effectiveness in human volunteers.
16
A CAT should be placed 2–3 inches above the wound
Discussion
location and tightened to occlude arterial blood flow.
Tourniquets have a long and complicated history. The Furthermore, the tourniquet should not be removed un-
use of tourniquets dates back to 1517, when bandages til the patient arrives at an ED or OR. QuikClot Com-
were used proximal to wounds to help control bleed- bat Gauze should be placed on or in the wound and held
ing. However, over time, the fact that most major exter- with direct pressure for 3 minutes. It should also not be
8
nal hemorrhage can be controlled with direct pressure, removed until arrival at an ED or OR. The majority of
as well as the increased recognition of the morbidity as- external hemorrhages can and will be controlled by ap-
sociated with tourniquets, led to decreased use. Some of plying a stepwise approach (Figure 3 ).
17
the major morbidity results of tourniquet use, includ-
ing permanent nerve, muscle, vascular, and soft tissue Figure 3 Protocol for prehospital external hemorrhage
control.
injury, significant pain, and improper application of
improvised, ineffective tourniquets, led to emergency
medical authorities discouraging their use. 9,10

The key to the re-emergence of tourniquet use has been
the development of commercial tourniquets and train-
ing for providers in their appropriate use, leading to a
decrease in the morbidity and mortality associated with
historical tourniquet use. Military experience has shown
tourniquets and hemostatic agents to be safe and effec-
tive, significantly decreasing mortality from extremity
hemorrhage. Currently, all military personnel in the-
11
ater, not just the unit medics, carry tourniquets and/or
hemostatic agents and are trained to use these prod-
ucts. From the largest military experience database
11
present, which included 499 combat individuals, Kragh
et al. found that tourniquet use was strongly associated
with survival when shock was absent. The use of tourni- The recent Hartford Consensus conference has encour-
quets on the battlefield contributed to improved hemor- aged wider civilian use of tourniquets for management
rhage control and survival. Tourniquet use caused no of hemorrhage in active shooter situations. Junctional
18
loss of limbs, and morbidity attributable to the tourni- zones, such as the groin, axilla, neck, and perineum,
quet was minor. 12 present a particular problem to medical personnel
when trying to control the hemorrhaging wound and
In the UK Armed Forces, QuikClot Combat Gauze is issued are clearly inappropriate for tourniquets. Bulger et al.
4
to military medical technicians for use on external injuries recommended the use of topical hemostatic agents, in
when conventional gauze field dressings have failed. Simi- combination with direct pressure, for the control of sig-
13
larly, a study from the Israeli Defense Force highlighted the nificant hemorrhage in the prehospital setting, in ana-
importance and effectiveness of QuikClot Combat Gauze tomic areas where tourniquets cannot be applied and
in the prehospital treatment of combat casualties. While where sustained direct pressure alone is ineffective or
14
previous-generation products by QuikClot have had side impractical. 17
effects, including partial-thickness burns due to a conse-
quential exothermic reaction from product activation, Based on the military’s success with tourniquets and
the third generation product is heat free. Furthermore, hemostatic bandages, our prehospital personnel began
15
its mechanism of action has improved, as it is a kaolin using tourniquets and hemostatic gauze as adjuncts for
(clay) impregnated bandage that enhances clotting and hemorrhage control. To date, this study is the first re-
platelet function, as well as absorbance. port of their use in the civilian population, which clearly
differs significantly from the military population. The
As seen in this study, all three improvised tourni- mean age of the Active Duty Force is 28.7 years and
quets (belts) were unsuccessful. Furthermore, the one 85.4% of this population is male, compared with
19

Prehospital Hemostatic Bandage, Tourniquet Use in Civilian Trauma Care 51