The rise of the tourniquet, or… a lot of EMS is based on myth and assumption.

When I went through EMT – B training, the idea of using a tourniquet was frowned upon. In fact, the answer they usually gave was something along the lines of “only as a last resort to save someone’s life…and even then be careful.” We learned that using a tourniquet was a dangerous last-ditch procedure that often did more harm then good. It made sense to me at the time, “if an EMT cut off the blood supply to a limb, the limb would quickly die.” It would be a bad day if I killed a patient’s arm just because I didn’t give my pressure dressing another few minutes to form a clot.

What we didn’t know at the time was that the instructors didn’t have any hard evidence that tourniquets were bad; they were just repeating things that they had been told. More importantly, patients have died during those “few minutes” that EMT’s have waited for the dressings to clot.

With the conflicts in Iraq and Afghanistan, new medical data in regards to traumatic injuries has been pouring in. One part of this has been data that shows the benefit of tourniquet use. Several studies have shown that using a tourniquet is both a highly effective method of bleeding control, and also does not endanger the rest of the limb during short-term usage. The following is from a study that followed 165 severely injured soldiers in Iraq:

Tourniquet use was not deemed responsible for subsequent amputation in severely mangled extremities. Analysis revealed that four of seven deaths were potentially preventable with functional prehospital tourniquet placement.

Conclusions: Prehospital tourniquet use was associated with improved hemorrhage control, particularly in the worse … subset of patients. Fifty-seven percent of the deaths might have been prevented by earlier tourniquet use. There were no early adverse outcomes related to tourniquet use. ¹

This study also showed that when tourniquet times were less then 6 hours, there was no increased risk of amputation or permanent limb damage as compared to the non-tourniquet group. This is far from the only study that has reached the same conclusion in recent years. Tourniquets are now issued equipment for US Soldiers and Marines. Standard operating procedure is to use them early and aggressively for severe bleeding injuries.

Thankfully, it seems that some of these lessons are actually moving their way into the education and protocols of civilian EMT’s. I received an email only recently that NJ updated its protocols. On July 21 of this year, the State of NJ officially changed its EMT-B bleeding protocol to the following:

Bleeding/shock control will be in the following order –  direct pressure, tourniquet, elevation, prevent heat loss/treat for shock.

Tourniquet application is now the next step if direct pressure fails. This is a great step forward in using evidence-based medicine to help save lives in the pre-hospital setting.

How are we doing at Brown? Do we have the scope of practice, the training, or the equipment to implement some of this new knowledge?

Further Reading:

Agerwal et al. The Return of Tourniquets JEMS. http://www.jems.com:80/news_and_articles/articles/jems/3308/the_return_of_the_tourniquets.html

Beekley AC, Sebesta JA, Blackbourne LH, et al: “Prehospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes.” Journal of Trauma. 64(2):S28–37, 2008.

Klenerman L: “The tourniquet in surgery.”  J Bone Joint Surg Br. 44B:937–943, 1962.

Wakai A, Winter DC, Street JT, et al: “Pneumatic tourniquets in extremity surgery.” Journal of the American Academy of Orthopaedic Surgeons. 9(5):345–351, 2001.

http://www.jems.com:80/resources/supplements/the_war_on_trauma/tourniquet_first.html

Military Issued Tourniquet: http://www.narescue.com/liCombat-Application-Tourniquet-C-A-T–C188.aspx

Tourniquet application video: http://www.combattourniquet.com/tourniquet-videos.php