Recent studies coming out of the War on Terrorism suggest that hemorrhage from extremity wounds is the leading cause of preventable death on the battlefield. The use of tourniquets can greatly increase survivability if applied within the first few minutes. Since their effectiveness depends on a timely application, this means that first responders, combat medics, and others on scene are ultimately the ones providing the life-saving interventions. For this reason, the need to educate first responders on proper tourniquet use can’t be stressed enough.
Why the Mistrust?
A common misconception regarding tourniquets is that they should only be used as a last resort. In the civilian world, definitive medical care is often just a short ambulance ride away. Because of this luxury, civilian pre-hospital care tends to reserve tourniquet usage for only the most extreme situations. Traditional civilian courses such as Advanced Trauma Life Support (ATLS) even suggest that for major arterial hemorrhages, “the judicious use of pneumatic tourniquet may be helpful and lifesaving.” The lack of tourniquet training from even advanced civilian courses has led to incorrect tourniquet applications, which has increased the mistrust surrounding their usage in the civilian environment.
But when operating in austere and remote environments, aggressive and liberal tourniquet application has proven to be extremely effective in increasing survivability when managing uncontrollable hemorrhaging. Aggressive tourniquet usage is a military concept that emerged from the War on Terrorism, where catastrophic penetrating and blast injuries were commonplace. While aggressive tourniquet usage seems like an obvious concept on the battlefield, there are numerous civilian applications where tourniquets have a role.
-Civilian police working in tactical environments.
-Instances of workplace violence.
-Terrorist events that include penetrating and blast injuries (i.e. Boston Marathon bombing).
-Home defense to treat penetrating or stab wounds.
-Backcountry/wilderness medicine where definitive medical care is delayed (i.e. crush injury or amputations).
-Industrial accidents that cause severe hemorrhaging or amputation from machinery.
When to Use a Tourniquet?
-Uncontrollable hemorrhage, where direct pressure and elevation is ineffective.
-All traumatic amputations.
-For mangled limbs with multiple bleeding points where traditional methods are ineffective.
-“Life over limb” concept. The benefit of preventing death from hypovolemic shock (blood loss) outweighs the risk of losing the limb caused by tourniquet damage.
-Mass casualty incident where first responders lack the manpower or resources to effectively control bleeding using more conservative methods.
Two types of commercial tourniquets are recommended for use in TCCC (Tactical Combat Casualty Care).
Combat Application Tourniquet
Special Operations Forces Tactical Tourniquet
When considering where to setup a tourniquet on your gear, you should consider a location that's easy to access. During a stressful situation when tunnel vision sets in and dexterity is lost, you don't want to be fumbling with a zippered compartment trying to locate your tourniquet.
You also want to consider a location that allows for ambidextrous access. If your right arm sustains trauma and your tourniquet is setup on the far right side of your body, your left hand may not be able to reach it. Ensure that both hands can easily access your tourniquet.
Consider carrying two tourniquets in the event that multiple limbs are involved, or when a single tourniquet is ineffective and an additional tourniquet is required for tension.
When setting up a CAT tourniquet on your gear, you want to consider "staging" that tourniquet for use. The photo below demonstrates a staged CAT tourniquet being applied to an arm. The tourniquet strap is only threaded through a single opening on the plastic buckle. This allows for one handed operation in the event that you need to provide "self aid." Simply pull the tourniquet strap through the single buckle opening, secure the velcro, and tighten the windlass rod to the desired tension.
Leg injuries require a significantly greater amount of tension. The above "staged" tourniquet is ideal for arm injuries, but the single buckle and velcro approach won't support the tension required to occlude an arterial leg bleed. For leg applications, the tourniquet should be staged with the strap threaded through both ends of the plastic buckle. In addition, the tourniquet opening should initially be very large, which allows for easier application when dealing with mangled leg injuries. The picture below demonstrates this-
During the "care under fire" phase, tourniquets should be placed over the casualties uniform or clothing and tightened until the bleeding stops. Exact tourniquet placement at this point isn't crucial, just ensure that the tourniquet is placed proximal (above) the wound site.
During the "tactical field care" phase, the wound should be reevaluated and a more precise approach should be taken. First responders should ensure that the tourniquet is placed directly to the skin. Tourniquet placement should also avoid joints.
While in this more controlled phase, you want to ensure that the tourniquet is placed as distally as possible on the limb. This means placing the tourniquet as far down on the limb as possible, but no closer than 5cm from the wound site. Since prolonged tourniquet use can lead to the eventual death and amputation of that limb, you don't want to necessarily kill a larger portion of that limb beyond the actual wound site. From a prosthetics standpoint, the more of that limb that you are left to work with following amputation, the better.
All tourniquets should be placed above the knees and elbows. The lower limbs contain many deep arteries that are located near the interior of bones such as the radius/ulna and cannot be occluded by tourniquets. Applying tourniquets to single boned limbs such as the femur allows the tourniquet to "clamp" the arteries between the bone and the tourniquet strap.
The time of tourniquet application should be recorded in a clearly visible area, such as the patients forehead. In addition, the tourniquet should be checked frequently for adequate tension, especially when the casualty is moved. Just because you can't feel a distal pulse below the tourniquet, doesn't mean that the tourniquet is effectively occluding the artery. Tourniquets can actually INCREASE blood loss if the veins are effectively occluded but the arteries are still bleeding. Think of it like a hydraulic system, if you block off the veins you are actually creating more blood pressure in the arteries, so blood is being lost at a faster rate. This is why adequate tension to shut off the arteries is vital!
This blog post intends to educate first responders, average citizens, and even experienced military personnel alike on tourniquet usage. Tourniquets should not simply be reserved for the battlefield. From domestic terrorism like the Boston Marathon Bombing to everyday accidents, far too many people die from extremity wounds that otherwise could have been prevented with a tourniquet and some basic knowledge.