Page 166 - Journal of Special Operations Medicine - Winter 2015

bleeding do require a tourniquet. As in most trauma sit-
One of the most important lessons uations, overtriage is acceptable, as tourniquets found
learned in the last 14 years of war is not to be needed can be safely removed on arrival at
that using tourniquets and hemostatic a hospital. The following descriptions are provided as
dressings as soon as possible after examples of trauma victims for whom tourniquet use is
appropriate:
injury is absolutely lifesaving.
• There is pulsatile or steady bleeding from the wound.
• Blood is pooling on the ground.
tourniquet application. In routine emergency medical • The overlying clothes are soaked with blood.
services (EMS) care, the so-called pressure dressing for • Bandages or makeshift bandages used to cover the
massive external hemorrhage is frequently inadequate wound are ineffective and steadily becoming soaked
and only effective when continuous direct manual com- with blood.
pression is applied. Because of the personnel constraints • There is a traumatic amputation of the arm or leg.
on most civilian EMS runs, tourniquets and hemostatic • There was prior bleeding, and the patient is now in
dressings are both medically and logistically beneficial. shock (unconscious, confused, pale).
5
Despite the overwhelming evidence of benefit from the
military experience, recent data indicate that only a few
EMS systems are using recommended commercially Commercial windlass-type tourniquets
manufactured tourniquets and hemostatic dressings for should be used in the prehospital
exsanguinating hemorrhage. setting for the control of significant
extremity hemorrhage when direct
This situation continues despite numerous military pub- pressure is ineffective or impractical. . . .
lications documenting the lifesaving benefit and low in-
cidence of complications from prehospital tourniquets
and hemostatic dressings used in combat casualties. When treating an individual who is in obvious shock
Although it is somewhat obvious, tourniquets are most from bleeding wounds, hemorrhage control should be
effective in saving lives when applied early, before the in- the first priority, before fluid resuscitation. Effective
dividual has gone into shock from blood loss. Although hemorrhage control does not stop with the initial tour-
tourniquet use has been discouraged by EMS systems in niquet application. The military experience with tour-
the past because of concerns about ischemic damage to niquets has provided some key teaching points about
the extremity, this complication is actually very rarely their use:
seen. Prolonged use of a tourniquet can potentially re-
sult in amputation, but saving the life of the individual • Waiting too long to place a tourniquet is a mistake.
must always take precedence if the tourniquet cannot • Tourniquets should be applied just proximal to the
be removed. Because of their proven lifesaving value, site of the severe bleeding and never placed directly
tourniquets are now ubiquitous on the modern battle- over a joint.
field, yet adoption has been slow in many civilian EMS • Tourniquets should be tightened as necessary to stop
systems. bleeding from the distal injury.
• If bleeding is not controlled with one tourniquet, a
Although limited, there are reports that the adoption of second tourniquet should be applied just proximal to
the military practice of tourniquets and hemostatic dress- the first.
ings into civilian EMS and emergency medicine practice • The need for a second tourniquet is especially appli-
is increasing. One of the key concepts that emerged was cable when applying tourniquets to generously sized
placing the hemorrhage control devices in the hands of lower extremities.
not only all medical providers, but also the much more • The purpose of tourniquets is to stop arterial bleed-
numerous nonmedical first-responding personnel. In the ing. If a distal pulse is still present, the tourniquet
civilian sector, many police officers and firefighters now should be tightened or a second tourniquet applied
carry these devices, making them widely and rapidly just proximal to the first, and the pulse should be
available. Effective training in, and use of, hemorrhage checked again.
control devices by nonmedical personnel has been a crit- • If a tourniquet is used, it should be an effective arte-
ical element in reducing preventable deaths. rial tourniquet and not an ineffective venous tourni-
quet, as use of the latter can increase bleeding.
In patients with severe extremity bleeding, hemorrhage • Casualties with tourniquets in place should be re-
control is a priority. Most extremity injuries do not checked periodically to ensure that the tourniquet is
require tourniquets, but patients with life-threatening still working and that hemorrhage is controlled.

154 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015