Tourniquet

Aka: Tourniquet, Pneumatic Tourniquet, Windlass Tourniquet

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. cvTourniquet.png
  3. Improvised Tourniquet (67% effective)
    1. Risk of secondary injury due to sharp edges on improvised devices
    2. Unevenly distributed pressure with lower efficacy than professionally produced Tourniquets
    3. 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. Mark time of application on Tourniquet and on easily visualized tag
    3. Two side-by-side Tourniquets may be applied if one is insufficient
    4. Wider Tourniquets are more effective
  3. Tourniquet should remain in plain site and never covered
  4. Tourniquet up-time should be reviewed frequently
    1. Conscious patients should be asked to remind providers of Tourniquet's presence
  5. Consider deflation intervals every 30 minutes if prolonged Tourniquet is anticipated (unclear efficacy in limb salvage)

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. Swaminathan and van de Leuv (2013) Crit Dec in Emerg Med 27(8): 11-17
  2. Kragh (2008) J Trauma 64(2 suppl): S38-49 [PubMed]

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Related Studies

Ontology: Tourniquets (C0040519)

Definition (UMD) Devices designed to constrict/compress circumferentially an extremity for a limited period of time in order to control venous and arterial blood flow. The pressure is applied to the extremity upon the limb surface and underlying tissues using the cuff. Pressure is then transferred to the blood vessels which causes a temporary occlusion. Pneumatic tourniquets are used mainly during surgical procedures to provide a bloodless operative field; mechanical (i.e., non-inflatable) tourniquets are usually intended for use in emergency to control hemorrhage after serious limb accidents.
Definition (NCI_NCI-GLOSS) A device, such as a strip of cloth or a band of rubber, that is wrapped tightly around a leg or an arm to prevent the flow of blood to the leg or the arm for a period of time. A tourniquet may be used when drawing blood or to stop bleeding after an injury.
Definition (MSH) Devices for the compression of a blood vessel by application around an extremity to control the circulation and prevent the flow of blood to or from the distal area. (From Dorland, 28th ed)
Concepts Medical Device (T074)
MSH D014111
SnomedCT 38141007
English Tourniquets, Tourniquet, device, tourniquet, tourniquet (treatment), tourniquets, Tourniquet, Tourniquet, device (physical object), Tourniquet, NOS
Swedish Tourniqueter
Czech turnikety
Finnish Kiristyssiteet
Italian Laccio emostatico, Lacci emostatici
Russian TURNIKETY, ТУРНИКЕТЫ
French Garrots, Tourniquets
Croatian STEZAČI
Polish Krępulce, Opaski uciskowe
Norwegian Turnikeer, Årepresser, Turnikéer, Turniké, Turnike
Portuguese Garroteamento, Torniquetes
Spanish torniquete (objeto físico), torniquete, Torniquetes
German Staubinden, Tourniquets, Abschnürbinden
Dutch Stuwband, Stuwbanden, Tourniquets
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Tourniquets, Pneumatic (C0183980)

Definition (UMD) Tourniquets designed to constrict/compress circumferentially an extremity for a limited period of time by applying a precise amount of pressure using a gas-inflated cuff. The pressure is applied to the limb surface and underlying tissues using the cuff; pressure is then transferred to the blood vessels causing a temporary occlusion. The pressure applied should be at least equal or higher than the minimum required to occlude the blood flow (i.e., limb occlusion pressure [LOP]). These tourniquets typically include an inflatable cuff, a compressed gas source, and tubes. Manual devices may use an integral gas cartridge or a manual pump as a compressed air source while automated tourniquets include a control unit that supplies the compressed gas from a central supply system, a small gas container (e.g., a cylinder), or from an integral electric pump. Pneumatic tourniquets are used mainly during surgical procedures in the extremities to enable surgeons to perform delicate procedures in bloodless operative fields.
Definition (SPN) A pneumatic tourniquet is an air-powered device consisting of a pressure-regulating unit, connecting tubing, and an inflatable cuff. The cuff is intended to be wrapped around a patient's limb and inflated to reduce or totally occlude circulation during surgery.
Concepts Medical Device (T074)
English TOURNIQUET, PNEUMATIC, Tourniquets, Pneumatic, Pneumatic Tourniquets
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Tourniquets, Strap (C0183982)

Concepts Medical Device (T074)
English Strap Tourniquets, Tourniquets, Strap
Derived from the NIH UMLS (Unified Medical Language System)

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