Page 93 - Journal of Special Operations Medicine - Fall 2015

Tourniquet Conversion

A Recommended Approach in the Prolonged Field Care Setting

Brendon Drew, DO; David Bird, PA-C, MPAS; Michael Matteucci, MD; Sean Keenan, MD

ABSTRACT

Life-saving interventions take precedence over diagnos- to the conversion of tourniquets before definitive care
tic maneuvers in the Care Under Fire stage of Tactical is reached.
Combat Casualty Care. The immediate threat to life
with an actively hemorrhaging extremity injury is ad- In the Care Under Fire (CUF) phase of the Tactical Com-
dressed with the liberal and proper use of tourniquets. bat Casualty Care (TCCC) guidelines, liberal use of
The emphasis on hemorrhage control has and will con- tourniquets is encouraged on all concerning extremity
tinue to result in the application of tourniquets that may hemorrhages. In this phase of care, the ability of wounded
not be needed past the Care Under Fire stage. As soon as individuals and medical personnel to safely and accu-
tactically allowable, all tourniquets must be reassessed rately complete diagnostic evaluations is nearly impossi-
for conversion. Reassessment of all tourniquets should ble due to the ongoing active enemy threat and incoming
occur as soon as the tactical situation permits, but no fire. Life-saving actions take precedence over diagnostic
more than 2 hours after initial placement. This article maneuvers. As soon as the tactical situation permits, reas-
describes a procedure for qualified and trained medical sessment of all wounds and tourniquets occurs. For com-
personnel to safely convert extremity tourniquets to lo- pressible hemorrhage not amenable to tourniquet use, or
cal wound dressings, using a systematic process in the as an adjunct to tourniquet removal (if evacuation time is
field setting. anticipated to be longer than 2 hours), the use of hemo-
static dressing with direct pressure is indicated. Reassess-
Keywords: prolonged field care; tourniquets; tourniquet ments of the need and quality of the tourniquet should
conversion; Tactical Combat Casualty Care be accomplished at least every 2 hours during this phase,
with the goal of converting the tourniquet to a hemostatic
and pressure dressing as early as possible. 3,4
Introduction
The safety of this recommendation to place a proximal
The use of tourniquets has been controversial through- tourniquet for any significant extremity hemorrhage is re-
out military history. As recently as 2003, literature inforced by the lack of documented cases of permanent
1
has referenced the tourniquet “as an instrument of the tissue damage, permanent vascular injury, or permanent
devil that sometimes saves a life.” Although the au- nerve injury from a properly applied tourniquet (arte-
2
thors of this article described the “balance of risk [as]) rial flow to extremity stopped) in place for less than 2
unclear” with tourniquet use, they acknowledged the hours. Most complications reported in the literature
5–7
effectiveness of tourniquets in selected tactical situa- were the result of improper application. Venous occlusion
tions. Seldom in recent medical history has the medi- without arterial occlusion is a major concern that leads
2
cal pendulum swung more extensively than in the use to continued bleeding, and is beyond the scope of this
7
and utility of tourniquets. Fortunately, comments such paper. In one case-series review of 91 patients, 47% of the
as the quote above are no longer found in the litera- tourniquet applications were classified as “not indicated,”
ture. Research on tourniquet use during the recent a 6.5-cm-wide elastic band was used, and total tourniquet
military conflicts has demonstrated the effectiveness times less than 150 minutes had no documented complica-
of properly applied tourniquets. As combat operations tions. Not only were almost half of the tourniquets placed
8
shift from Iraq and Afghanistan, evacuation times will not clinically indicated, but the type of tourniquet used ex-
become longer and longer due to the immaturity of the erted more mechanical damage on tissue than the TCCC-
medical footprint at the tactical level and the sheer dis- approved tourniquets. The risks of not using a tourniquet
tances that must be traveled, such as in Africa. Future immediately are more relevant than the risks of a properly
tourniquet training must include discussions relating applied tourniquet in the CUF phase of TCCC.

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