Page 96 - Journal of Special Operations Medicine - Fall 2015

to tourniquet conversion is the inability to monitor the tourniquet (Plus 1) loosely over the extremity to prevent
patient directly. The inability to observe the casualty additional bleeding from becoming clinically significant.
in the event of rebleeding is a contraindication to con-
version. This includes patients wrapped in blankets or Tourniquets are essential tools in the initial treatment
other hypothermia-prevention materials. Conversion of exsanguinating extremity injuries, but adverse ef-
should not be attempted if the extremity cannot be ob- fects of tourniquet application can result in significant
served for active rebleeding. morbidity. Early conversion to hemostatic agents and/
or standard wound dressings should be attempted by
Conversion should not be attempted on a patient in qualified and trained medical personnel in a controlled
shock. This concern has been documented as far back as and systematic manner to avoid further complications
1945. Wolff and Adkins reported on an alert but tachy- and potentially reduce morbidity.
cardic and hypotensive patient who lost an estimated
100ml of blood during removal of a tourniquet before Disclaimer
a new one could be placed. He showed immediate clini-
cal signs of worsening shock and a systolic blood pres- The views expressed in this article are those of the
sure of 80 mm Hg. With any concern for hemorrhagic author(s) and do not necessarily reflect the official pol-
12
shock, resuscitation must be initiated prior to attempted icy or position of the US Department of the Navy, US
tourniquet conversion. Department of Defense, or the US Government.

Should tourniquets be periodically loosened to give the Disclosure
tissue oxygen and blood? A tourniquet should never be
periodically loosened for this purpose. This results in The authors have nothing to disclose.
“incremental exsanguination.” In other words, the
12
patient is bled to death in short bursts. A tourniquet
should only be loosened during conversion. References
1. Kragh JF, Swan KG, Smith DC, et al. Historical review of
Are there additional reasons that tourniquet conversion emergency tourniquet use to stop bleeding. Am J Surg. 2012;
is important? Independent of hemodynamic and tissue 203:242–252.
preservation considerations, tourniquets are very pain- 2. Navein J, Coupland R, Dunn R. The tourniquet controversy.
J Trauma. 2003;54:S219–S220.
ful when applied. Any intervention that decreases pain 3. MacIntyre A, Quick J, Barnes S. Hemostatic dressings reduce
in wounded personnel is not only tactically important tourniquet time while maintaining hemorrhage control. Am
(cooperative patients are safer to transport) but medi- Surg. 2011;77:152–165.
cally and psychologically important (pain can cause 4. Dayan L, Zinmann C, Stahl S, et al. Complications associated
tachycardia and improved pain control may contribute with prolonged tourniquet application on the battlefield. Mil
Med. 2008;173:63–66.
to lower incidence of posttraumatic stress disorder). 20 5. Patterson S, Klenerman L. The effect of pneumatic tourni-
quets on the ultrastructure of skeletal muscle. J Bone Joint
Surg. 1979;61-B:178–183.
Conclusion 6. Kragh JF Jr, Walters RJ, Baer DG, et al. Practical use of emer-
Arguably, the US military has become the leading au- gency tourniquets to stop bleeding in major limb trauma. J
Trauma. 2008;64:S38–50.
thority in battlefield trauma care with the experience 7. Kragh JF Jr, O’Neill ML, Walters TJ, et al. Minor morbidity
of combat operations over the last 10-plus years. A with emergency tourniquet use to stop bleeding in severe limb
continuous quality assurance program using the Plan- trauma: research, history, and reconciling advocates and abo-
Do-Study-Act methodology, with the institution of the litionists. Mil Med. 2011;176:817–823.
robust Joint Theater Trauma System and the progres- 8. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for
hemorrhage control on the battlefield: a 4-year accumulated
sive development of the TCCC Guidelines has led to experience. J Trauma. 2003;54:S221–S225.
evidence-based trauma care that has improved surviv- 9. Fitzgibbons PG, DiGiovanni C, Hares S, et al. Safe tourni-
ability and decreased morbidity. In particular, the in- quet use: a review of the evidence. J Am Acad Orthop Surg.
creased use of tourniquets for severe extremity wounds 2012;20:310–319.
has contributed significantly to these improvements. 10. Walters TJ. Issues related to the use of tourniquets on the
battlefield. Mil Med. 2005;170:770–775.
11. Kragh JF, Baer DG, Walters TJ. Extended (16-hour) tourniquet
The haphazard release of a tourniquet without use of application after combat wounds: a case report and review of
proper procedures can result in increased hemorrhage, the current literature. J Orthop Trauma. 2007;21:274–278.
morbidity, and mortality rates within seconds. This il- 12. Wolff LH, Adkins TF. Tourniquet problems in war injuries.
12
Bulletin of the U.S. Army Medical Department. 1945:77–85.
lustrates a significant potential complication of the pro- 13. Butler FK Jr, Hagmann JH, Richards DT. Tactical manage-
cedure, and we propose a valid approach to be adopted ment of urban warfare casualties in special operations. Mil
in future protocols: to apply at least one additional Med. 2000;165(4 Suppl):1–48.

84 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015