A FRENCH ARMY SURGEON named Etienne Morel first reported in 1674 using a tourniquet for control of battlefield hemorrhage. By the early 1900s, inappropriate use of tourniquets caused so many complications that their risks seemed to outweigh their benefits. Today, most knowledge of tourniquets comes from elective vascular and orthopedic surgery cases, where their use limits bleeding during operations. The military has reintroduced tourniquet use into modern medical practice. Trauma experts suggest prehospital providers also get up to speed on tourniquet use.1 Although odds are you’ll never need to apply one, it is imperative that you know when and how to use a tourniquet.
A military study of 91 tourniquet applications over a four-year period found them very effective with almost no complications.2 Military trauma protocols now place control of major arterial bleeding before airway and breathing assessment. This is likely because of the recognition that 10 percent of all deaths on the battlefield result from exsanguination from extremity wounds, resulting in 60 percent of all preventable troop deaths. (1,2) Although civilian injury patterns are not the same as those found on the battlefield, there are clear lessons to be learned from the military experience. Fear of complications from appropriate tourniquet use is not substantiated in medical literature and can be considered irrational today.
Nearly all external bleeding can be controlled by direct pressure with a dressing; occasionally, the affected limb may have to be elevated. Use of pressure over the supplying artery is an additional option taught when bleeding persists. Topical agents, often impregnated into dressings, are appropriate at any time to aid in the control of severe external bleeding. Instances where immediate application of a tourniquet should be considered include the following (1):
- Life-threatening extremity bleeding or severed/mangled limbs with multiple bleeding areas, to allow immediate airway management. Use of the tourniquet can be reassessed once airway and breathing are stable.
- Extremity bleeding not controlled by conventional methods.
- Bleeding from an entrapped limb not accessible to rescuers.
- Multiple casualties with extremity bleeding when rescuers lack the resources to control all bleeding casualties with simple methods.
The caveat to all situations is that use of a tourniquet to prevent death from hemorrhagic shock must have greater benefit for the patient than the risk of limb damage or ischemia from tourniquet-induced loss of circulation. Time is the obvious enemy; and while studies show that a tourniquet can be left in place for up to two hours with minimal risk of permanent damage, the studies involved stable elective orthopedic and vascular surgery cases, not multiply injured trauma patients. (1) A prehospital study of 110 tourniquet applications found a 5.5 percent complication rate (mean total tourniquet time: 78 minutes) (1); the military study mentioned previously (2) had the same complication rate with a mean total tourniquet time of 83 minutes. No patient in either study required amputation as a result of tourniquet-induced extremity ischemia; most complications were neurological (affecting sensation or movement).
TOURNIQUET USE IN EMS
Could this old trick work for you? On July 21, 2007, it helped the Port Authority (PA) of NY & NJ Police Department officers at John F. Kennedy International Airport responding to a crash between a minivan and a New York City (NYC) transit passenger bus. The PA manages and maintains the bridges, tunnels, bus terminals, airports, PATH (Port Authority Trans-Hudson rail line), and seaport that are critical to the NYC metropolitan region. The agency also controls the 16-acre World Trade Center site. The PA Police Department is responsible for aircraft rescue firefighting, EMS first response and emergency service/technical rescue, and law enforcement at all PA facilities.
The initial impression of a member who observed the crash found the driver of the minivan severely injured. Additional officers, the PA Police Department ambulance, and Emergency Service Unit (ESU) Truck 8 were called to the scene.
(1) The hydraulic ram is inserted to lift the dashboard off the victim’s legs. (Photo by Lieutenant Daniel Carbonaro, courtesy of the Port Authority Police Department.)
Medics entering the vehicle from the front passenger door began assessing the patient. The driver, a male about 50 years of age, was in a side/front impact MVC. He was alert and oriented and complained of pain to the left leg. He was sitting in almost a bolt upright position; from the midchest up, he was leaning forward and over the steering wheel because of the impact. His pelvis had shifted to the left and into the corner of his seat against the B post. His left leg had an open mid- to lower-shaft femur fracture angulated approximately 45 degrees outward with gross internal and external blood loss. The remainder of his left leg was angulated at a 45-degree angle back toward the center of the vehicle. His right foot was on top of his left foot; both were trapped under the vehicle brake pedal. The dashboard was pinned down onto his legs.
(2) The bottom of the B post at the floor panel after being cut with the K-12 saw. (Photos by author.)
From inside the vehicle, medics could access only the patient’s head, face, neck, chest, abdomen, hips, and right leg. Outside personnel had access to the left side of the patient. The patient was given oxygen and was rapidly assessed for trauma. Physical findings included severe facial trauma with blood compromising the airway. This was easily managed by periodically removing the nonrebreather face mask and sweeping the patient’s mouth out with 4 × 4s. Once exposed, there was no deformity to the chest, no injuries to the torso, lung sounds were clear bilaterally, there was equal expansion of the chest, and there was no pain on palpation to the abdomen. An examination of the hips and pelvis revealed no pain to palpation or deformity. His right leg was bent at the knee at a 90-degree angle, as it normally would be when driving. He did not complain of pain anywhere other than to his left leg. The patient had a rapid and strong pulse of approximately 130 and a blood pressure of 130 by palpation. When the JFK Airport contract paramedic team arrived, members placed IVs in both arms. The plan was for ESU to remove the B post and bring the patient out through the open driver’s side of the vehicle.
(3) A cross-section of the B post.
ESU personnel displaced the driver side door and cut the top of the B post. As they attempted to cut the bottom of the B post, the cutters locked onto, but not through, the material. The B post contained a tubular boron steel-reinforcement rod approximately 1/4 to 3/8 inch thick and could not be cut by the hydraulic extrication tools in use. ESU attempted to use a reciprocating saw with a standard metal cutting blade, without success. Because of the patient’s position in the vehicle, the use of a partner saw was ruled out.
(4) Tourniquet application, cutting the brake pedal, and c-spine stabilization. (Photo by Lieutenant Daniel Carbonaro, courtesy of the Port Authority Police Department.)
Plan B was to attempt to pie cut the B post from the floorboard; however, with the hydraulic ram in place at the junction of the B post and the floorboard lifting the dash off the patient’s upper legs, this proved unfeasible. Blood loss became more severe once the dashboard was no longer compressing the patient’s legs. Personnel outside the vehicle described the bleeding “like a faucet.” The patient had been fully alert and conversing with rescuers until this point. He was now responding only to direct verbal stimuli, indicating onset of decompensate hemorrhagic shock.
(5) The extrication continues. The open-fracture external hemorrhage has been arrested. (Photos by Officer Scott Jablow, courtesy of the Port Authority Police Department.)
Since the victim was facing a prolonged extrication, the contract medics made a critical decision-they contacted medical control and asked for permission to apply a tourniquet. The medics had to do some quick thinking to apply the tourniquet without endangering the patient. Officers folded a cravat to a width of about four inches, laid it proximal to the fracture, and tied a surgeon’s knot. They placed a screwdriver with a blade approximately eight inches long in the knot and applied torsion until external blood loss stopped. They then secured the screwdriver and knot with duct tape and wrapped the duct tape around the leg and finished it off. It worked like a charm.
(6) Preparing for victim removal.
Extrication took approximately another 25 minutes. It was about 24 minutes from the time of extrication until the application of the tourniquet and about 40 minutes from the application of the tourniquet until the patient’s arrival at the emergency department.
The patient had multiple internal injuries in addition to the obvious fracture and underwent several surgeries. The trauma surgeon credited the tourniquet with saving the patient’s life.
Tourniquet use is not a “last resort” skill. EMS providers should be familiar with modern-day indications for using this simple and time-tested device. As this case example shows, it could be needed at any time.
1.Lee, C, KM Porter, TJ Hodgetts. “Tourniquet use in the civilian prehospital setting,” Emergency Medical Journal, 2007; Aug, 24(8):584-587.
2.Lakstein, D, A Blumenfeld, T Sokolov, G Lin, R Bssorai, M Lynn, R Ben-Abraham, “Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience,” Journal of Trauma Injury, Infection, and Critical Care, 2003; 54(5):S221-S225.
BARRY S. DASKAL is a police officer/aircraft rescue firefighter with the Port Authority of New York and New Jersey Police Department at John F. Kennedy International Airport in New York City. He is also a certified EMT-critical care and clinical lab instructor at the Nassau County (NY) EMS Academy. He previously served as a police officer with the New York City Police Department and as a supervising fire alarm dispatcher with the Fire Department of New York. He has been a volunteer firefighter since 1990 and has served as a captain and training officer.