II. Indications: Extremity Hemorrhage

  1. Indicated for rapid extremity bleeding not controlled with direct manual pressure

III. Precautions

  1. Tourniquets are a last resort when rapid bleeding cannot be controlled with direct manual pressure
  2. Tourniquets can be life saving but have significant risks associated with use (see below)
  3. Temporizing only until surgical intervention within 1-2 hours
  4. Tighten Tourniquet enough to obstruct both venous and arterial flow
    1. Otherwise, increased risk of venous Tourniquet (with continued bleeding, Compartment Syndrome)

IV. Preparations

  1. Pneumatic Tourniquet (92% effective)
    1. Cuff (3.5 inch wide) is inflated in similar fashion to Blood Pressure cuff
    2. Inflate to minimum pressure needed to control active bleeding
  2. Windlass Tourniquet (79% effective)
    1. Strap tightened by winding a rod
    2. Apply Tourniquet and rotate the windlass 1-2 complete turns until arterial bleeding stops
    3. cvTourniquet.png
  3. Improvised Tourniquet (67% effective)
    1. Use A band of fabric at least 3 inches wide
      1. Wrap the band snugly around the limb and tie a half knot
      2. Insert a rigid cylinder (metal bar or stick) as a windlass above the half knot
      3. Tie a full knot over the cylinder
      4. Rotate the cylinder 1-2 complete turns until arterial bleeding stops
      5. Secure the cylinder in its rotation
    2. Risk of secondary injury due to sharp edges on improvised devices
    3. Unevenly distributed pressure with lower efficacy than professionally produced Tourniquets
    4. Replace improvised Tourniquet with professionally produced Tourniquets as soon as available

V. Protocol

  1. Notify Trauma surgery of emergent surgical intervention for rapid, uncontrolled bleeding
  2. Apply Tourniquet to appropriate site
    1. Avoid applying over the top of wounds of in junctional locations (see contraindications below)
    2. Apply directly to skin (without interceding clothing or material)
    3. Apply 2-3 inches above any wound and 2-3 inches above a joint
    4. Mark time of application on Tourniquet and on easily visualized tag
  3. Two side-by-side Tourniquets may be applied if one is insufficient
    1. Wider Tourniquets are more effective than 2 single Tourniquets
    2. Two Tourniquets should be applied immediately adjacent without a gap
      1. Gap between Tourniquets creates a localized Compartment Syndrome
  4. Tourniquet should remain in plain site and never covered
  5. Tourniquet up-time should be reviewed frequently
    1. Conscious patients should be asked to remind providers of Tourniquet's presence
  6. Prolonged Tourniquet (delayed intervention or transport)
    1. Consider deflation intervals every 30 minutes (unclear efficacy in limb salvage)
    2. Reposition Tourniquet closer to bleeding site (if initial one is too proximal)
      1. Apply a second Tourniquet loosely 2-3 cm above the wound
      2. Release first Tourniquet and observe for recurrent uncontrolled arterial bleeding
      3. If bleeding persists, tighten the new, most distal Tourniquet
      4. If bleeding still persists, re-tighten the initial proximal Tourniquet without a gap between 2 Tourniquets

VI. Contraindications

  1. Obviously unusable at the neck and trunk
  2. Ineffective in junctional sites (e.g. axilla, groin)
  3. Ineffective at adductor canal (Hunter canal)
    1. Canal runs through medial aspect of the distal one-third of the thigh
    2. Carries femoral artery, femoral vein and femoral nerve

VII. Adverse Effects

  1. Metabolic disturbance (local accumulation with systemic release)
    1. Lactic Acidosis
    2. Hyperkalemia
    3. Increased Creatinine phospokinase (CPK) with Renal Failure risk
  2. Local injury
    1. Peripheral Nerve palsy
    2. Post-Tourniquet Syndrome
  3. Extremity ischemia, infarction, necrosis and gangrene
    1. Tourniquet for 1 hour: Safe without significant longterm complications
    2. Tourniquet for >2 hours: Significantly increased risk of longterm sequelae
    3. Tourniquet for >3 hours: Amputation required in >62% of cases
    4. Tourniquet for >6 hours: Amputation required in 100% of cases

VIII. Efficacy

  1. Tourniquet application has resulted in dramatic mortality benefit (96% vs 4% survival)
    1. Kragh (2011) J Emerg Med 41(6): 590-7 [PubMed]
  2. Tourniquet effectiveness in relation to limb circumference
    1. Leg: 100% effective
    2. Forearm: 92% effective
    3. Arm: 81% effective
    4. Thigh: 73% effective

IX. References

  1. McCollum and Knight (2023) EM:Rap 23(9)
  2. Swaminathan and van de Leuv (2013) Crit Dec in Emerg Med 27(8): 11-17
  3. Kragh (2008) J Trauma 64(2 suppl): S38-49 [PubMed]

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