Procedure

Tourniquet

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Tourniquet, Pneumatic Tourniquet, Windlass Tourniquet

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