Tourniquet Use: Local Protocols?

[AnthonyM83]

What are your system's rules (if any) on use of tourniquet for uncontrolled hemorrhaging? Are they still considered a "last resort"?

A recent PHTLS class was advising that they might be appropriate after direct pressure and that elevating wound and pressure points have not been found effective. And that tourniquet no longer means the patient will lose that extremity.

It seems counter-intuitive that pressure points wouldn't slow blood loss in an external extremity wound (combined with direct pressure), since it should be stopping the force at which blood is flowing through.

Reminds me of how it seemed counter-intuitive that shock position wouldn't work...but just last night was able to get a blood pressure that had remained steadily in the 90s (systolic) for about 25 minutes to 112(sys) with Trendelenberg on the hospital bed.

So, not sure how much to believe...

[kyle308]

lol believe nothing. The AHA changes their protocols once a week

[Dustdevil]

What are your system's rules (if any) on use of tourniquet for uncontrolled hemorrhaging? Are they still considered a "last resort"?

We have no rules or protocols. We just rely on education, experience, common sense, and a knowledge of the current literature and practices. We just do it. If direct pressure does not immediately take care of it, or if you are too busy shooting back to apply direct pressure, we go straight to a tourniquet. Pressure points can work well. And we will sometimes use them in the ER/OR for temporary control. But your hand/fingers get tired pretty quickly, so it's used pretty sparingly as a transitional measure.

Everything you heard in PHTLS is current, sound practice. However, in civilian practice, I've never even used a tourniquet, and it's pretty damn rare that you would. Serious arterial bleeding I have encountered in civilian EMS was either easily controlled by direct pressure or pressure points, or else it was in the groin or neck, where a tourniquet would not be practical anyhow. Or else they were already dead. Unless it is a disaster or mass casualty situation, you will almost always have an extra pair of hands to hold that pressure in the civilian world. Consequently, the actual need to ever go to a tourniquet is pretty slim.

[Richard B the EMT]

Once a week? I thought once an hour, on a good day.

Last time I checked, the "TK" was still last ditch effort after direct pressure, elevation, pressure point, and pressure bandage, "when it becomes a choice between losing the life or the limb."

Unofficially, add the "diesel drip" therapy, but I live and work in an area where the nearest ED is no more than 15 minutes away from any point in the city.

[brentoli]

Unless it is a disaster or mass casualty situation, you will almost always have an extra pair of hands to hold that pressure in the civilian world. Consequently, the actual need to ever go to a tourniquet is pretty slim.

If you read the VA Tech report, they did attribute some saves to the use of a tourniquet. Maybe they should be stocked up in our MCI kits we assemble?

[Chief1C]

I hope most protocols are based on common sense and good of the patient, because that's how I go about things. If it looks bad, it's getting squeezed off, although I usually find a sensible way around it. Plastic wrap works really well for the ones that bleed through the dressing. Had a man with his arm chewed off by a machine, real nasty, the arm was gone for about 4" to just above the elbow. The hand, and part of the forearm were there, but everything in between were ground up into a fine slurry. The stump was bleeding like a broken fire hose, we weren't exactly prepared for this, nobody spoke english. All the dispatcher got was arm pain with no trauma. So, while someone ran for a trauma kit and to obtain further assistance (ALS, engine crew for an LZ and a chopper), I lopped on a wet trauma dressing and inflated a "foot/ankle" air splint on the stump. It not only held the dressing in place, but it also occluded the bleeding. I put on some kerlix to hold it firmly in place once we boarded him for the chopper. Medic was satisfied with it, didn't need a tourniquet, then they could do what they needed in the OR w/ what was left of the arm. Dunno what happened, they were all deported I believe. I won't use an air splint for a fracture, but I'll use one for this thing as often as possible.

[Dustdevil]

If you read the VA Tech report, they did attribute some saves to the use of a tourniquet. Maybe they should be stocked up in our MCI kits we assemble?

I dunno... by the time those kits get to the scene, those people have already bled to death. But, of course, if somebody has been holding manual pressure up to that point, then yes, it's nice to finally have some TKs to slap on before transport.

...nobody spoke english. All the dispatcher got was arm pain with no trauma.

LOL! That's classic!

[Riblett]

We have tourniquets in our protocols in the larger system I work in. They are a new addition and I have not been able to use them yet. They are military style 'CAT's and are really nice. They are to be used only as a last resort or in MCI.

Most folks used to say that they did more harm than good by resulting in limb loss and other complications. But newer studies have shown that they can be left in place for up to 2 hours (or more depending on other factors) without significant risk and they are being put back into more and more protocols.

We are fortunate because you can be at an ER from just about anywhere in the county in under 15 minutes going emergent traffic. While this amount of time is unlikely to cause limb loss with a tourniquet it is certainly enough time for the patient to bleed out. In any case, if the bleeding is so significant that you are considering the tourniquet then hemodynamic compromise is far more risky than limb loss.

[brentoli]

LOL! That's classic!

Tell your dispatch to hook up with the AT&T language line

[ccmedoc]

We don't use them unless it is mass casualty or not possible to transport right away (as in long extrication).....Life over limb is the rule, but you better be sure!!!...Generally, in my experience, just pack that puppy and lay on the pressure is effective enough to get to an ED..On a limb amputation, we are allowed to clamp any obvious bleeders....we have field amputation training, but they say they will most often rush a doc out to the scene if this becomes necessary....who knows... :roll: