Page 165 - Journal of Special Operations Medicine - Winter 2015

Hemorrhage Control Devices
Tourniquets and Hemostatic Dressings

John B. Holcomb, MD, FACS, Committee on
Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems
Frank K. Butler, MD, FAAO, FUHM, Chairman, Committee on
Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems
Peter Rhee, MD, MPH, FACS, FCCM, Committee on
Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems

emorrhage control is the highest priority in car- be released until the patient has reached definitive care.
ing for an injured individual. To be maximally The recommendations on hemostatic agents were that:
Heffective, hemorrhage control must occur as soon (1) topical hemostatic agents should be used in combi-
as possible after the wounding event. Unfortunately, nation with direct pressure for the control of significant
uncontrolled hemorrhage remains the single most pre- hemorrhage in the prehospital setting when sustained
ventable cause of death after both military and civilian direct pressure is ineffective or impractical, and (2) topi-
injuries. One of the most important lessons learned in cal hemostatic agents in a gauze can be used to enhance
the last 14 years of war is that using tourniquets and wound packing.
hemostatic dressings as soon as possible after injury is
absolutely lifesaving. The resulting sustained focus on Hemorrhage Control with Tourniquets
1
hemorrhage control has evolved into the widespread use In the 26 years between the end of the Vietnam War
of two devices: commercially manufactured tourniquets in 1975 and 2001, little changed in prehospital hem-
and hemostatic dressings. Recent evidence from thou- orrhage control. As a result, preventable deaths from
sands of injured patients has demonstrated that the use extremity hemorrhage also did not change in almost
of tourniquets does not lead to amputations and the use three decades. After the widespread implementation
of tourniquets should be considered early on. Techno- of the tourniquet recommendations from the Commit-
logical development has also resulted in wound dress- tee on Tactical Combat Casualty Care (CoTCCC), a
ings that are impregnated with materials that help stop 10-year review of 4,596 U.S. combat fatalities noted a
bleeding more effectively than plain gauze. The U.S. mil- significant decrease in combat fatalities from extremity
3
itary experience during the conflicts in Afghanistan and hemorrhage. The dramatic decrease in deaths from ex-
Iraq, with more than 50,000 combat casualties, taught tremity hemorrhage resulted from the now ubiquitous
the military trauma system that both tourniquets and fielding of modern tourniquets and hemostatic dressings
hemostatic dressings are extremely important for qual- on the battlefield and aggressive training of all levels of
ity care and improved outcome. responders in their effective use. 4

Tourniquets in the Civilian Setting As noted earlier, deaths from extremity hemorrhage can
The wounding agents are usually different in battlefield largely be prevented by early use of tourniquets. Because
and civilian trauma, but the lessons learned regarding of their effectiveness at hemorrhage control and the
hemorrhage control and optimal resuscitation are not. speed with which they can be applied, tourniquets are
Recently, the American College of Surgeons Commit- the best option for temporary control of life-threatening
tee on Trauma and the U.S. Department of Transporta- extremity hemorrhage in the tactical environment when
tion working group evaluated the evidence for external under fire. This concept can apply as well in the civil-
hemorrhage control measures. The group’s conclusions ian arena, with its increasing number of mass casualty
2
on tourniquets were that: (1) commercial windlass-type or active shooter events. These concepts become espe-
tourniquets should be used in the prehospital setting for cially applicable in terrorist-style bombing events on
the control of significant extremity hemorrhage when our home soil. Direct pressure and gauze compression
direct pressure is ineffective or impractical, (2) impro- dressings can be effective; however, the lack of dedicated
vised tourniquets should be used only if no commercial personnel to apply continuous direct pressure, a less-
device is available, and (3) a tourniquet that has been than-secure environment, and extremity injuries that
properly applied in the prehospital setting should not could lead to exsanguination are all indications for rapid

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