By Dr. Ken Lavelle, MD, NREMT-P
Like any medical treatment, the risk-benefit ratio must be examined before the treatment is implemented. The risks involve the complications and are mitigated by decreasing the time the tourniquet is in place. The benefit is in lives saved (both the victim the tourniquet is used on and the other victims the provider can move on to treat). In the military setting, this ratio has been examined and it has been concluded that it is beneficial to use a tourniquet for severe extremity trauma and bleeding. But can we translate this to civilian EMS use?
There is a subset of patients and situations where civilian use of a tourniquet is beneficial.
The first is the single patient with severe extremity bleeding that we have been unable to control with conventional means — direct pressure, elevation and a pressure dressing. These are patients we could have used a tourniquet for previously — that last resort. Our hypothetical firefighter who fell through the floor in the last article could be included in this category, since other methods are not controlling his bleeding well.
Other patients to consider for use of the tourniquet immediately include the following:
- MCI: Mass casualty incidents change the way we practice. Multiple victims with severe bleeding require us to move quickly and definitively to save as many as we can. In the words of Spock, "The needs of the many outweigh the needs of the few." We can save more lives even if we risk the complications mentioned above.
- Safety: In a tactical EMS or technical rescue environment it may not be safe for an EMS provider to stay right with the patient and continue direct pressure. The use of the tourniquet allows the provider to initiate some treatment and then move to a safer area.
- Transport considerations: This is especially for when a patient is being transported either in a helicopter or by a limited crew. In this case there is not the luxury of multiple providers to hold direct pressure and elevate the limb. A tourniquet allows the judicious use of resources.
- Multiple injuries on the patient: In a patient that has numerous injuries, the placement of the tourniquet allows the provider to control bleeding and then move on to treat the other life-threatening conditions that are present. Our firefighter also meets this criteria. We have a lot to do and we need to get this multi-system trauma patient off the scene.
With these patients, it is appropriate for the BLS or ALS provider to utilize a tourniquet, even as a first option for bleeding control.
What type to use
Ideally a commercial device designed for this purpose should be used. These are available from several manufacturers and are fairly cheap. One should be obtained for every first-in trauma kit with consideration of multiple tourniquets for use in a mass casualty setting.
Alternatively, a blood pressure cuff can be used but it must be closely monitored to make sure it does not deflate. They are generally not designed to hold air under pressure for longer periods of time.
Once placed, it should remain uncovered. The patient, if awake, should be told to tell every medical provider that they have a tourniquet in place. Consider writing a "T" on the patient's forehead along with the time it was placed. If they have a triage tag this information should be listed clearly on the tag. All patients with a tourniquet should be considered "Yellow" or higher and should be a priority to get them to definitive care.
In the past, only a physician could remove a tourniquet. This resulted in delays and extended use. Current guidelines are as follows:
If transport time is less than 30 minutes, then leave in place. Also leave it in place if the patient is in shock, resources are limited or the transport is in a confined area. If transport time is greater than 30 minutes, and resources and patient condition permits, then the provider can loosen the tourniquet to assess for continued bleeding. If there is none, or it can be controlled by other means, then the tourniquet can remain off. If bleeding recurs, replace the tourniquet.
Be sure to document completely on the patient chart the rationale and medical decision-making used when a tourniquet is placed.
A commercial tourniquet is placed on this patient and bleeding control is achieved. Transport to the local trauma center is initiated, about 15 minutes away. His lungs are clear, although he does have pain on the left side of his chest and concern for multiple rib fractures. IVs are started en route. At the hospital he is diagnosed with a concussion, some fractures to his lumbar spine, multiple rib fractures, and a right femoral artery injury that is repaired in the operating room. He is expected to survive but has a long course of recovery. The placement of the tourniquet allows the paramedic to rapidly control the arterial bleeding while also allowing him to assess and treat other injuries.