The Cutting Edge of Hemorrhage Control

Alex Egan, LPN, EMT-B

"The application of a tourniquet is only ok if you are in a life or limb scenario, loose the limb to save the life". That was the extent of my training on tourniquets in my EMT training in the year 2004. The common knowledge at that time was that tourniquets caused damage, often irreparable damage to the limbs they were applied to, and that generally bleeding could be controlled with direct pressure only. While direct pressure remains the first step to treatment, there has been a rapid evolution in the control of severe hemorrhage, and arterial bleeding in the past several years. Advances that many nurses not involved in emergency care may be unaware of. Tourniquets are back in use, and if nurses in the camp setting are not prepared to apply tourniquets in cases of severe hemorrhage, they are not meeting the standards of care on this topic.

Tourniquets have been a fixture in medicine since the late 1600s especially in battlefield injuries and surgery. By the 1900s problems with prolonged tourniquet use were well known, and the use of them in the field began to loose popularity.(1) Many Harsh criticisms of tourniquet use were voiced after both world wars, mostly due to the devices being applied improperly, or forgotten under blankets, or in the confusion of evacuation. In World War Two the army surgical division established the directive that tourniquets should be used only for active spurting hemorrhage from a major artery and established guidelines on care and time restrictions in tourniquet use. (2) Through the 19th century military use of the tourniquet continued, with the opinion of military surgeons becoming slightly more favorable by the end of the Vietnam War. Civilian use of tourniquets was minimal to nonexistent, being used primarily in vascular surgery, field use was strongly discouraged.

Going into our most recent war the routine use of tourniquets was still generally frowned upon. The implementation of the Joint Theater Trauma System, allowed for real-time evidence-based practice evaluations of both causality treatments and outcomes. This clear and ample data demonstrated very clearly that hemorrhage was a leading cause of death, and that tourniquet application in the field made a huge difference in outcomes. It also demonstrated that the concern over limb loss and nerve damage was overstated, in the present medical system definitive surgical intervention is almost always achieved before any serious side effects of tourniquet application can set in. Over the past decade military training has focused on early hemorrhage control, and has seen a dramatic rise in causality survival. The US armed forced have made the Combat Application Tourniquet (CAT) standard issue to all ground forces, deploying over 400,000 CATs in the field. (3)

As with many other advances in emergency care, the military medical community leads the civilian community in techniques and science. The tourniquet has returned to civilian EMS, and first aid, in a big way. Most recently with the Department of Homeland Security's "Stop The Bleed" Program. This program provides information to the lay person as well as professional rescuer on tourniquet use. (4)

Tourniquet application in the camp setting is important for a few reasons. Most camps are in rural locations, prompt and complete control of severe arterial hemorrhage is very important, as EMS response and transport times may be prolonged. Camps should also be equipped and trained in tourniquet use due to the low, but present risk of active shooting scenarios. Many nurses are not especially familiar with tourniquet application and may fail to recognize when a tourniquet is necessary.

Direct pressure over absorbent dressings remain the first step in control of most hemorrhage. In cases where bleeding from an extremity is severe, the victim presents with hypovolemic shock, or the injury's are from explosive devices, a tourniquet should be applied as close to the site of the would as possible. A second tourniquet may be applied even closer to the would if bleeding doesn't cease. (5).

Having established that tourniquet use has been added back into the first aid skill set for hemorrhage control, and established the parameters and techniques for application. The next issue to confront is what type of tourniquet to use. There are many commercial options on the market today, however many nurses may be most familiar with basic improvised tourniquet, that uses a triangle bandage folded so the with is about 1-2 inches, and tied tightly around the limb with a square knot. An improvised windless, such as a stick, is slid under the bandage and twisted until arterial occlusion is achieved, the windless is secured and time noted. (6)This style of tourniquet is cheap and effective, the major drawback being that it requires a bit of skill to apply, and there never seems to be a good sturdy enough stick around when you need it.

The most popular commercially available tourniquet is the Combat Application Tourniquet CAT. This easy to apply device has an attached durable windless, that tightens an internal band, that applies circumferential pressure. The windless is easily secured with a hook and Velcro fastener, and a label is prominent on the front to note the time of the application of the device. (6)The CAT has been extensively used by the armed forces, gaining more time in the filed and more real life applications than most other commercially available devices. It will be a familiar device for veterans and most EMS providers, for that reason if you decide to buy a tourniquet, I would recommend the CAT. However there are any number of options for commercial tourniquets, and any can be used with proper preparation and training.

Whatever type of tourniquet your camp employs, all nurses regardless of experience and background should be able to demonstrate its use, and articulate the conditions where a tourniquet will be necessary. Training is important to insure that providers are able to correctly use tourniquets in a correct and timely fashion in an emergency.

Severe hemorrhage and arterial bleeding, are low occurrence high acuity events in the camp setting. However preparation for such events is key to good outcomes and patient survival. Camps offer a wide verity of potential for injury's and as nurse we must be prepared to cope with any level of event that occurs at our camps. Tourniquets must be a readily available tool for camp nurses to use in the event of emergency, and modern science supports their use in the civilian realm when necessary.

References

1.David R Welling MD, A brief history of the tourniquet, Journal of Vascular Surgery, 2012

2.G.A. Cosmas, A.E Cowdry, The Medical Department: Medical service In the European Theater of Operations, 1992, Center of Military History, United States Army

3.Alec C Beekley, Prehospital Tourniquet use in Opperation Iraqi Freedom: Effect on Hemorrhage Control and Outcome, Journal of Trauma, Injury, Infection, and Critical Care, 2/2008

4.Stop The Bleed, www.dhs.gov/stopthebleed, 11/20/2015

5.Bleeding Control Statewide BLS Protocol, PA BLS Protocol 601, 6/1/2015

6.Dan White EMT-P, Return of the Tourniquet, http://www.multibriefs.com/briefs/exclusive/return_of_the_tourniquet.html#.Vuue3_krLIU

The Cutting Edge of Hemorrhage Control

About Alex Egan, LPN, EMT-B

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