BP cuff as turniquet

[fiznat]

Just curious, what would be an appropriate pressure to put it at for your IV idea?

Pretty much just tight enough so that you get the flow rate you want. If you're squeezing the bag really tight and youre still not getting flow into the drip chamber, you should start thinking that something else is wrong with the IV line (clamped somewhere, blown, whatever). Too low and the fluid wont flow. Keep in mind you'll have to keep re-inflating the cuff as the volume in the bag gets depleted.

[primemedic01]

For this application, I don't think the BP cuff should be referred to as a tourniquet. A tourniquet is used to shut off all blood flow to an extremity, which isn't what it's being used for in this example. I'd consider it more of a mechanical pressure. It's doing the exact same job as if you were to use a pressure point method, just with a constant and increased force, and it allows you to use your hands for other things. I think the problem a lot of times with being able to control major bleeds is that people usually do not apply enough manual pressure. Most people don't realize that 50-60 lbs of pressure is what is needed to effectively control a bleed. This, along with some who may be in fear of causing pain or further injury hinders their actual ability to control it. This technique would absolutely be acceptable, granted you are just using it to control severe bleeding, and are allowing some to escape, as someone had previously stated. This will help prevent and manage hypoperfusion, and the light flow will prevent it from completely clotting, which will reduce the risk of a blow out when it is removed. I'd think something to consider would be to apply direct pressure to the wound after setting the BP Cuff proximal to the site, which would cause the actual injury to close, instead of only reducing the amount of blood flowing to it.

It's 1am and I'm half asleep. Can someone let me know if what I'm saying makes sense. For some reason something just doesn't feel right, like I'm missing or forgetting something. I'll check back in the morning to re read what I submitted and make edits accordingly.

[Asysin2leads]

It's absolutely appropriate to use a tourniquet to stop the bleeding once other methods (direct pressure, pressure points, pressure dressing) have failed. The thigh cuff makes a great tourniquet. Since it's wide, it will cause less tissue damage than a narrow piece of fabric, and you can control the pressure. Inflate until the serious bleeding stops (you'll still get a tiny bit, but just make sure it's not flowing). You may have to exceed the arterial pressure in order to do this, so don't be surprised if you have to inflate past 200 or 250 to get it stopped.

Tourniquets are getting more attention lately with our combat experience in Iraq and Afghanistan, and it has forced us to re-examine the "taboo" of tourniquet use that we're taught in EMT school. There are a fair number of people who bleed to death in this country from extremities, even in the care of EMS, and that just doesn't need to be so. Tourniquets, appropriately applied for a short period of time (less than 2 hours), do not lead to massive acidosis, hyperkalemia, and cardiac arrest like we've been taught, and they save lives.

'zilla

All right, gonna have to disagree with you on this one. First of all, any time you are reducing circulation to a really important and large limb, such as the leg, that bleed had better be something like a lawn sprinkler or something, because bruddah, if the patient loses his leg because of your BP cuff, he ain't gonna be happy.

There's a difference between a true tourniquet, which completely shuts off blood flow to an affected area, and basically using a modifed pressure point technique, which reduces the arterial pressure of an injured vessel and helps in controlling bleeding.

Yes, tourniquests are getting a lot of attention in Iraq and Afghanistan, but not because they are a safe and easy way to control bleeding, but because they are not often used outside of the battlefield, and there's lots of them over there. The reason tourniquets are used is because on the battlefield, we have to take into consideration such things as bullets and mortars and IED's. A simple bleed that can be controlled with a little time and pressure in civilian EMS may warrant a quick tourniquet to prevent the corpsman or combat lifesaver from getting his head blown off in the process of applying pressure.

Tourniquets do not usually lead to acidosis or hyperkalemia, in fact, that's not usually the reason we don't like to use them. The reason we don't like to use them is because when properly applied they shut off circulation to the affected limp, and cause tissue necrosis and nerve damage, which isn't good for a limb.

In my experience, the body does a much better job stopping serious bleeds then I ever assumed. Unless the transection is particularly jagged, the normal low pressure of the veins and the smooth muscle spasms of the arteries do a pretty good job in slowing or even stopping blood flow in most severe injuries.

I guess I'd say if the BP cuff trick works, use it and be merry, but if the person's bleeding is not life threatening (I wouldn't classify the kid with a hand injury as a life threatening injury), be cautious and be sure to make sure its okey dokey with your medical director and that the person's hand doesn't turn white and go numb while you're doing it.

[Doczilla]

While I respect considering the long term complications of tourniquet use, placing a tourniquet for for a couple of hours will not result in limb destruction. In the typical patient contact times seen in civilian EMS, it's quite safe. Neuropathy is a potential risk after 2 hours of application, but tourniquets can still be safely applied for up to 6 hours without loss of the limb. Tourniquets are routinely applied for 2 hours at a time in all kinds of surgery without any difficulty. If more working time is needed, the tourniquet is released, then reapplied. This is certainly something that can be done in the field. We can also apply tourniquets to quickly control bleeding while getting our stuff together to make a decent pressure dressing, then release the tourniquet and evaluate.

'zilla

[p3medic]

we use tourniquets routinely here, usually on gsw/stab wounds to the extemities, but also any other life threatening hemm, amputations, severe crush etc....surgical tubing and large kelly's, taught by the chief of trauma surgery at one of the cities level 1's, who has been using the technique since his days as a young surgeon in Da Nang....it works, and saves lives....I remember a 14yo who bled out from a popliteal artery stab wound, a tq would have saved that kids life, without a doubt, instead, a half assed pressure dsg did nothing, and a valuable lesson was learned....don't be afraid of tourniquets....

[primemedic01]

I think that the only time I would use a true tourniquet would be for a serious crush injury, in which they are probably going to lose the limb anyway. With a tourniquet I know I'm not gonna save the limb, but atleast I'll keep the pt. from bleeding out. I would certainly not use a tourniquet for a clean amputation. For christ sakes the guy (or girl) just cut off their hand, and you're gonna cut off circulation to the limb so more tissue dies and they have to amputate it even further up? And lets be honest, a lot of people think you cut you hand off and it just squirts out everywhere and doesn't stop. Clean amputations DO NOT bleed that much, and are definitely not a life threatening injury. A tourniquet would (almost always) not be indicated for a clean amputation.

[Spock]

My experience with tourniquets runs along several lines. I have used the BP cuff as a tourniquet for IV starts and patients seem to tolerate it better than traditional tourniquets because of the larger surface area. When I was a student athletic trainer many moons ago our team orthopedic surgeon used a BP cuff to provide a bloodless field while he removed a piece of glass from my finger.

On a more critical level, I have cared for three patients over the past 2 years with traumatic leg amputations; two were run over by trains while working in a steel mill and the other was working at a saw mill (he was cleaning a wood chipper from the inside when some idiot turned it on). All survived after long and stormy hospital stays (ARDS, DIC, ARF) . All had tourniquets applied although the saw mill patient did not get a tourniquet until the helicopter crew arrived. The ground medics did their job but just didn't think about tourniquets because it was always emphasized that tourniquets were a last resort intervention. Problem was all the IV fluid they gave ran out the bottom so it was a last resort situation. The patient had a hemoglobin of 6 after two units of blood in the helicopter on the way in.

One of the guys run over by the train had a most ingenious tourniquet applied by his co-workers. They wrapped battery jumper cables around the leg and tightened it down with a broom handle! Darn contraption worked and saved the guys life.

I suppose a thigh BP cuff might work in some cases but would not have been effective for these three patients because these were some very big thighs! If you need a tourniquet use a tourniquet.

On the subject of post-injury neuropathy, low dose ketamine has been shown to decrease the incidence of not only neuropathy but also phantom pain. It is a biochemical mechanism which I am unable to describe in detail.

Live long and prosper.

Spock

[ptemt]

This is from the 6th edition of Mosby Jems PHTLS text book, chapter 5, page 97;

2. Tourniquets, In the previous edition of this text, tourniquets were described as the technique of "last resort." Military experience in Afghanistan and Iraq, plus the routine and safe use of tourniquets by surgeons, has led to reconsideration of this approach. The use of "elevation" and pressure on "pressure points" is no longer recommended because of insufficient data supporting their effectiveness. Tourniquets are very effective in controlling severe hemorrhage and should be used if direct pressure or a pressure dressing fails to control hemorrhage from an extremity.

Perhaps a protocol change is in the pipeline.

[kevkei]

It's a common sense issue really. If everything else has failed to controll the bleeding, why not? If direct pressure, elevation, pressure points, etc has not had the desired effect, it is fair to assume you can sacrifice the limb to preserve life (life over limb theory).

Keep in mind, venous bleeds tend to be controlled more easily than an arterial bleed. If it is a laceration of the femoral or brachial artery, blood flow is already impaired so how is the application of a tourniquet going to hurt?

Use of a BP cuff is safe and effective as long as it can physically be applied (not effective for example if it is a stabbing located in the femoral triangle). You can more easily titrate it to desired effect than a tourniquet. It's use in hospital for surgery and exploration in the ER happens all the time, it's called a Beer block.

I think if all else fails and you can't control a bleed, you would be negligent not to try to use a BP cuff and/or tourniquet as opposed to allowing the pt to exsanguinate because you don't want to cause tissue damage?

[Spock]

Not to be picky but in the interest of correct spelling it is called a Bier block. You start a 20g IV in the dorsal hand and then exsanguinate the arm with an Eschmark elastic bandage. With the Eschmark in place, you inflate the proximal cuff of a double tourniquet. 40-50cc's of 0.5% lidocaine are then injected and the IV removed. The surgeon then has about 45 minutes to complete the procedure. If the patient complains of tourniquet pain after about 30 minutes, the distal cuff is inflated and the proximal cuff deflated. Heavy sedation with propofol can prolong the duration of the block. When surgery is completed, the cuff is deflated and inflated alternately in order to allow slow reabsorption of the remaining lidocaine. If the surgeon finishes in 5 minutes you must leave the tourniquet inflated for at least 30 minutes to allow the lidocaine to degrade. Sudden loss of tourniquet can result in lidocaine toxicity and severe seizures.

Sorry but off topic.

Live long and prosper.

Spock