Appropriate Prehospital Tourniquet Use
Few medical topics invoke as much passionate debate as the use of tourniquets to control traumatic hemorrhage. Discussions regarding the role that this potentially life-saving device should play in the prehospital environment appear to have polarized the medical community into two distinct camps: staunch advocates and absolute opponents. The truly unfortunate aspect of this division: It’s based largely on unsubstantiated conjecture regarding the perils of tourniquet use.
Looking to the literature, we can begin to sort conjecture from fact. It’s true that inappropriately applied tourniquets can cause unnecessary morbidity. It’s also true that associated morbidity with properly applied tourniquets is proportional to the length of time they remain in place.
Put simply: A poor understanding of indications for tourniquet use, anatomical considerations for placement, employment strategies and materials required for sound devices—as well as prolonged delays in transporting patients to definitive care—will most likely result in a suboptimal outcome.
However, if we examine tourniquet use in terms of risk-benefit in the hands of trained rescuers, we should see the tourniquet as an invaluable asset for facilitating rapid and appropriate management of hemorrhagic trauma and attenuating associated shock within the prehospital environment.
Why They’re Needed
Certain segments of society are at higher risk than others for hemorrhage caused by penetrating trauma. Military forces engaged in combat, law enforcement officers engaged in tactical operations, civilians accidentally or purposely injured by penetrating objects and emergency services personnel exposed to explosions or penetrating objects typify those at highest risk.
Hemorrhage due to penetrating trauma is the leading cause of preventable death during military operations.1,2 The tactical environment requires an approach to appropriate casualty care that accounts for low visibility, active hostilities, austere locations, limited medical resources and unknown evacuation times.3,4 The use of temporary emergency tactical tourniquets is the cornerstone of TCCC hemorrhage control.
Every individual operating within the tactical environment must be trained to apply a tourniquet, and should carry at least one tactical tourniquet at all times (see Table 1, p.20, for desirable tourniquet characteristics). Following a rigorous evaluation process, the Department of Defense selected the Combat Application Tourniquet (C-A-T) as the primary tourniquet issued to every service member in the current theater of operation. Results from combat evaluations indicate that the C-A-T is highly effective and when used appropriately, does not cause significant morbidity.5,6,7
These results can be applied to the civilian prehospital environment. As long as we conduct due diligence for training and education, and match the best available options to the appropriate environment and indications, tourniquets will be an important tool for prehospital providers.
When They’re Needed
The law enforcement environment is most similar to the military tactical environment. An increasingly dangerous society puts our law enforcement officers at higher risk for penetrating trauma. All law enforcement officials should be trained in basic TCCC tenets and adequately equipped to address those same life-threatening injuries identified for the armed forces.
Other situations may arise within the civilian community that make the routine use of temporary emergency tourniquets a very wise option. Mass-casualty situations with multiple traumatic bleeding injuries will overwhelm medical capabilities if rapid treat-as-you-triage methods are not employed. A trained rescuer can effectively employ a modern tourniquet in seconds, allowing them to rapidly address a large number of casualties quickly. Rescuers can then reassess those treated and convert tourniquets to less restrictive hemorrhage control measures.
Even in single-trauma cases, an injury with significant bleeding requires significant effort to maintain direct pressure or apply adequate wound packing and pressure dressings. This reduces the amount of time the rescuer can spend on other necessary and often complex tasks, such as airway or respiratory management, or initiating treatment for shock.
By controlling hemorrhage immediately, the rescuer’s hands are free to attend to other tasks. Transport is not delayed, and hemorrhage control can be attended to under adequate lighting and conditions either inside the ambulance or on arrival in the emergency department.8
A Final Word
Protocols for safe and effective prehospital tourniquet use can and should be implemented (see “Tourniquet First!” p. 24). Although tourniquet use is not without risk, an informed approach that provides adequate education, training, assessment, validation and appropriate device selection will significantly reduce the risk to acceptable levels.
Editor’s note: For more on the subject of civilian prehospital tourniquet use, read “The Return of Tourniquets: Original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries,” in August 2008 JEMS, p. 44–54.
1. Bellamy RF: “The causes of death in conventional land warfare: Implications for combat casualty care research.” Military Medicine. 149(2):55–62, 1984.
2. Holcomb JB, McMullin NR, Pearse L, et al: “Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004.” Annals of Surgery. 245(6):986–991, 2007.
3. Butler FK Jr, Hagmann J, Butler EG: “Tactical combat casualty care in special operations.” Military Medicine. 161(Suppl):3–16, 1996.
4. National Association of Emergency Medical Technicians: Prehospital trauma life support: Military version. 6th ed. Mosby: St. Louis, Mo., 2006.
5. Beekley AC, Sebesta JA, Blackborne LH, et al: “Prehospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes.” Journal of Trauma. 64(2 Suppl):S28–37, 2008.
6. Kragh JF Jr, Walters TJ, Baer DG, et al: “Practical use of emergency tourniquets to stop bleeding in major limb trauma.” Journal of Trauma. 64(2 Suppl):S38–S50, 2008.
7. Kragh JF Jr, Baer DG, Walters TJ: “Extended (16-hour) tourniquet application after combat wounds: A case report and review of the current literature.” Journal of Orthopaedic Trauma. 21(4):274–278, 2007.
8. Doyle GS, Taillac PP: “Tourniquets: A review of current use with proposals for expanded prehospital use.” Prehospital Emergency Care. 12(2):241–256, 2008.