Page 167 - Journal of Special Operations Medicine - Winter 2015

• Pulses distal to every tourniquet should be checked. battlefield and were carried by medical and nonmedi-
• Correctly applied tourniquets can cause significant cal personnel. Transitioning this experience and lessons
6
pain, but this pain does not signify that the tourni- learned to the civilian arena is extremely important. 7
quet has been applied incorrectly or that it should be
removed. Hemorrhage Control with Hemostatic Dressings
• Pain should be managed with analgesics as appropri- Dressings in various forms have been used for thou-
ate, but not for patients in shock. sands of years to help stop bleeding. At the start of the
war in Afghanistan in 2001, the U.S. military used a
Mistakes regarding tourniquets include the following: gauze dressing that had not changed appreciably since
World War I. Early in the war in Afghanistan, hemo-
• Not having an effective commercial tourniquet static dressings were developed that were lightweight,
available durable, and much more effective than standard gauze
• Not using a tourniquet when one should be used at stopping bleeding. After significant feedback from ex-
• Using a tourniquet for minimal or minor bleeding perienced military medics, in 2003 the CoTCCC recom-
when one should not be used mended a hemostatic dressing that could be packed into
• Putting the tourniquet on too proximally a wound but that had hemostatic performance that was
• Not making the tourniquet tight enough to effectively superior to standard gauze. These dressings were often
stop the bleeding used in conjunction with tourniquets but were especially
• Not using a second tourniquet if needed useful in wounds not amenable to tourniquet use. 8
• Waiting too long to put the tourniquet on
• Not reevaluating the tourniquet’s effectiveness Hemostatic dressings have been clearly shown to be a
• Periodically loosening the tourniquet to allow blood valuable adjunct in external hemorrhage control when
flow into the injured extremity the source of the bleeding is from a site not amenable
to tourniquet placement. As with all devices, to ensure
The time when a tourniquet is applied should always maximum effectiveness, the application of hemostatic
be noted on the individual’s body, customarily by writ- dressings requires training. Critical elements are to en-
ing the letter T on the person’s forehead, along with sure a correct packing technique and sustained manual
the time that it was tightened. This notation should be compression for a minimum of three minutes. Simply
done with an indelible ink marker to ensure that this applying the agents without maintaining pressure is not
important information does not wash or wipe off. The adequate to achieve the best possible hemostatic effect.
information should also be recorded on the individual’s Afterward, a standard pressure dressing can be applied
run sheet and total tourniquet ischemia time recorded to cover both the wound and the hemostatic dressing.
in the hospital chart. Finally, all manufactured tourni-
quets are designed for a single use. A separate group Selection of Tourniquets and Hemostatic Agents
of tourniquets should be used for training, and training As civilian EMS systems make decisions about hemo-
tourniquets should not subsequently be issued for actual static agents, they need to be aware that research has
casualty use. shown that not all tourniquets and hemostatic agents are
equally effective despite the manufacturers’ claims and
advertising. During the wars in Iraq and Afghanistan,
The time when a tourniquet is applied the Department of Defense developed standardized mod-
should always be noted on the els and techniques for evaluating tourniquets, hemostatic
individual’s body. . . . dressings, junctional tourniquets, chest seals, and other
items designed to be used in prehospital trauma care. A
review of this literature should be part of the selection
process for any agency making procurement decisions
Improvised Tourniquets about prehospital trauma equipment. Any item selected
Noncommercial, or so-called improvised, tourniquets for procurement should ideally be (1) reasonable in price;
are not nearly as effective as tested and recommended (2) laboratory tested for safety and effectiveness; and (3)
tourniquets. In 2001, at the start of war in Afghanistan, experience proven for safety and effectiveness.
the U.S. military’s plan was to use improvised tourni-
quets. Improvised tourniquets have been found to be Individual and Pre-positioned Trauma Kits
difficult to assemble and secure. Military experience has Military experience suggests that there should be at
shown that improvised tourniquets sometimes result in least two lists of trauma equipment: large kits that are
preventable deaths. After unnecessary deaths early in pre-positioned for multiple people and smaller mobile
the war, the military’s strategy changed. By 2005, thou- kits for officers or first responders. All professional first
sands of commercial tourniquets had been sent to the responders should be equipped with bleeding control

The Hartford Consensus 155