Tourniquets are getting a new look as research indicates that "They aren't as bad as we were all taught," according to Jeff Myers, Clinical Assistant Professor of Emergency Medicine at SUNY, Buffalo, in a presentation at EMS Expo/Firehouse Central/Enforcement Expo in Atlanta, Ga.
Though there are some risks, some concerns have been disproven, and the tourniquet has a rightful place not only on the battlefield and in a tactical setting, but in the responder's toolbox.
Myers began with a history lesson on this device, which has evolved in form and function since Greek and Roman times. Varieties have been used throughout history to reduce blood loss during amputations, and in more recent times, to control hemorrhage and ideally save limbs.
It was only during World Wars I and II that complications were observed and attributed to tourniquet use, Myers said. Soldiers wore the devices for extensive time periods, leading to reports of nerve damage and loss of limb. The U.S. Army reacted by ordering tourniquets to be released and reapplied every 20 minutes. "We were losing our soldiers 20 minutes at a time," Myers said.
Observations during the Korean War and Viet Nam, where injured troops were moved more rapidly, indicated no limb loss due to the use of a tourniquet. Reports suggest that more than 2500 soldiers could have been saved had tourniquets been more broadly applied, Myers said.
Nerve injury, arterial injury and permanent damage are very rare. More common is muscle injury from the squeezing, he said. Complications can include skin damage, which may be mitigated by using a wider band. At the 3-4 hour mark, muscle necrosis may begin that may not be reversible. Additional risks are compartment syndrome, nerve compression and vascular damage.
When released, the refilling of the limb may potentially cause a drop in blood pressure and the release of waste products into the bloodstream. However, "In general we don't need to pre-treat if we're releasing a tourniquet, as with crush injury," Myers said. Additional risks are swelling, systemic complications and organ failure. Also, "tourniquet pain can be very severe," Myers added.
Myers next reviewed current literature, including a study on the Israeli Defense Force, which has been aggressive in quickly applying tourniquets and getting troops to continued care. During the four-year review they experienced no deaths from extremity injury, and any nerve complications were resolved.
"The concerns of nerve damage that were beaten into our brains -- we're not seeing it," Myers said.
Myers discussed additional studies, the varieties of tourniquets now available and considerations for self-application, as well as recommendations for appropriate tourniquet use and removal, including:
- Never cover or hide the tourniquet from view
- Label the medical or triage tag
- Label the patient
- If the patient is conscious, tell him to tell his caregivers
In addition, Myers noted that cooling the limb can extend the safe tourniquet time.
The session ended with the following quote:
"[The tourniquet is] to be regarded with respect because of the damage it may cause, and with reverence because of the lives it undoubtedly saves. It is not to be used lightly in every case of a bleeding wound, but applied courageously when life is in danger."
-- Hamilton Bailey, Surgery of Modern Warfare, 1941