Know How to Improvise a Tourniquet

[Music in My Heart]

One of the things that I like about ED nursing is the unknown that's always right around the corner and the zero-to-sixty rush...

We had an upper extremity arterial bleed walk into the lobby... greeter got some pressure on the pumper and got him STAT to the trauma bay. The docs say, "we need a tourniquet on him, now!" A couple nurses, including me, say "we don't have those" - referring to those slick CAT tourniquets (like I keep in my home medical kit)... the order gets repeated several times and we have this room full of people all standing there sort of looking at each other.

Finally, I grab a roll of kerlix and a yankaur and make a very effective tourniquet... patient gets packaged (now complaining of the pain of the tourniquet rather than the repeated expressions of fear for his life) and straight to the OR.

Lesson to all of my ED colleagues... a tourniquet is one of those things that you rarely need but, when you need one, you need it right now.

So, if you don't stock CATs, take a few minutes to figure out how to make a tourniquet... not just in theory (which is exceedingly simple) but in actuality, with what you actually have at hand.

In my case, the kerlix was obvious... then I'm standing there looking around thinking, "what to use as a windlass?" Things that ran through my head...

• 12-cc syringe (too short, too slipery)...
  
• bite stick (too short... probably too flimsy)... .
  
• trauma shears (didn't have mine in my pocket and figured the handle might break off)...
  
• vacutainer tubes (hey, I was brainstorming in the midst of an arterial bleed... at least I recognized the immediate stupidity of the idea)
  
• Bougie... (um... see, vacutainer)
  
• Then, I see the yankaur staged on the sxn cannister... nice and long... grab it, nice and rigid... nicely shaped... BINGO.
  

Ten seconds later, hemostasis...

Obviously, the time for me to have considered how to fab a tourniquet would have been BEFORE the arterial bleed was squirting but I came through in a pinch.

So... to all who read these words... figure it out now, not when you actually need it.

And for heaven sake, ED managers... stock some stinking CATs!

The cuffs don't work on proximal bleeds

And even more so with a large cuff...

...smart thinking with the kerlix!

Thanks. I was actually more proud of the Yankauer-for-a-windlass... but they're both essential components.

For a while there were counterfeit/poorly made CATs out there...so make sure there is a red semicircle at the end of the velcro on yours.

I heard this from one of my ED techs who's also a medic in the Guard.

...their steel windless will not break...ever. We always prepped a second CAT in case when you were cranking down one someones thigh, the CAT snapped.

This was my concern as I was trying to come up with a windlass... I kept picturing the windlass snapping and having blood shoot out all over the place... bad for the patient... and for whoever happens to be standing downstream.

In this case, they started out trying to use a BP cuff. We have two: One is a standard size wall-mount used primarily for an initial palp on an incoming trauma and the second is the one on the wall monitor... for which we have regular and large... but the monitors won't hold arterial pressure... and for most patients, a large still won't make it over a thigh... sometimes not even over a biceps.

And the monitor cuff won't travel.

And, as you point out, for proximal bleeders, the cuff won't work anyway.

++++++

In this case, the problem was that the manual cuff was too small and the monitor cuff wouldn't hold pressure.

I don't know how common Combat Gauze is in civilian EDs, but for inguinal and axially bleeders, it is the bomb! Just pack and press.

Is that similar to SurgiCell? We use that stuff to pretty good effect but I've never tried it on a "garden-hose bleeder"

I wish we had some ED nurses with recent combat medic/corpsman experience.

I'm not an ED nurse, so humor me please.

That's why we're here talking about it... to learn from each other.

Why would a disposable rubber tourniquet (such as used for IV starts), applied tightly, not work in this case?

Tough to get SBP + 10% necessary to clamp off a deep artery with a thin piece of nitrile... and a pretty fragile set-up, even if you could... don't want your tourniquet to pop while you're on your way to the OR.

The lesson in this is:

Know what you have at hand and what is your fall-back plan when your first plan doesn't work.

Badness happens in the tails of the normal distribution, not within a few standard deviations of the median.

[504 medic]

Tough to get SBP + 10% necessary to clamp off a deep artery with a thin piece of nitrile... and a pretty fragile set-up even if you could... don't want your tourniquet to pop while you're on your way to the OR.[/quote']

Also, the pressure necessary to shut off an artery needs to be distributed over at least a 1-2 inch area, otherwise you will cause a decent about of soft tissue damage in the process. You'll cut right into them. Plus an IV start tk doesn't have the tensile strength to hold up. If they aren't brand new, they tear with even moderate force.

CG is similar: http://www.z-medica.com/healthcare/Products/QuikClot-Combat-Gauze.aspx

But CG is non absorbable...it for quick and dirty applications, if you know what I mean. To be removed later in a surgical environment. It works really well. But you have to be very careful about disturbing the casualty and dislodging the clot.

I wish we had some ED nurses with recent combat medic/corpsman experience.

Just because some things are worth repeating...

[mcknis]

Had a ptcome in with a right brachial artery lac that we had difficulty with controlling the bleeding from while in the ED. Medics had already placed a pressure dressing that was saturated by the time he got to the ED. When coming in, the ED physician of course wanted it removed, but as soon as it was uncovered, spurting began again. None of our surgeons wanted to deal with the case so he had to be taken by ground to the nearest trauma facility (over an hour away). Sure could have used a doc that wouldn't have minded have a tourniquet in place to secure the bleed, or if nothing else, try sewing up something. Pressure dressings were all the doc allowed us to use and unfortunately by the time he left (1.5hrs from time of injury) right arm began having decreased pulse and less color to that limb. Doc kept saying it was the dressing, and yes may have had a little to do with that, but a brachial lac that continues to bleed is going to require some additional resources. Ugh. Done with the rant...and yes, tourniquets are very much a necessity!

[Lunah, MSN, RN]

Big fan of the CATs ... have applied those suckers, they work! Yes, they hurt, but they keep the blood where it needs to be. :) We were required to have one on ourselves at all times while in Afghanistan. Combat gauze is standard in our issued first aid kits.

The SOF tourniquets are even better, as 504 Medic mentioned ... https://www.tacmedsolutions.com/product/sof-tactical-tourniquet-wide/. Also a fan of the Olaes modular bandage, very cool stuff ... https://www.tacmedsolutions.com/product/olaes-modular-bandage/

[skylark, BSN, RN]

Uncomfortable for the patient, but as a last resort knot some gloves together.

Two will likely do it for an arm, and 3 or 4 for a leg, tie the thumb of the 1st glove to the pinky of the second, and add more if needed.

Really uncomfortable, even if you pad the limb with gauze first, so its really just to buy you a couple of minute to find something better.

Uncomfortable for the patient, but as a last resort knot some gloves together.

Two will likely do it for an arm, and 3 or 4 for a leg, tie the thumb of the 1st glove to the pinky of the second, and add more if needed.

Really uncomfortable, even if you pad the limb with gauze first, so its really just to buy you a couple of minute to find something better.

Novel idea. Gonna try it out today on myself.

[sweetdreame, BSN, RN]

Uncomfortable for the patient, but as a last resort knot some gloves together.

Two will likely do it for an arm, and 3 or 4 for a leg, tie the thumb of the 1st glove to the pinky of the second, and add more if needed.

Really uncomfortable, even if you pad the limb with gauze first, so its really just to buy you a couple of minute to find something better.

I've used gloves as a tourniquet for an IV in a pinch! Works pretty well!

[tech1000]

I can't imagine gloves working as an effective tourniquet for an arterial bleed. We stock CAT tourniquets but if not and it was a bad bleed, stick a knee on it while you make something else. We've often jumped up on our patients and sat on them while improvising things. Jump on the stretcher for CPR, jump on them to occlude their artery, whatever.

I can't imagine gloves working as an effective tourniquet for an arterial bleed. We stock CAT tourniquets but if not and it was a bad bleed, stick a knee on it while you make something else. We've often jumped up on our patients and sat on them while improvising things. Jump on the stretcher for CPR, jump on them to occlude their artery, whatever.

Sounds much too messy for me. I'll improvise the tourniquet but I'm not climbing up on top of a patient with an arterial bleed.