optimal use of limb tourniquets
DESCRIPTION
Disclosures Presenter has no interest to disclose. PESG and AMSUS staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, and all accrediting organization do not support or endorse any product or service mentioned in this activity.TRANSCRIPT
Optimal Use of Limb Tourniquets
U.S. Army Institute of Surgical Research Col Stacy Shackelford,
USAF, MC Disclosures Presenter has no interest to disclose.
PESG and AMSUS staff have no interest to disclose. This continuing
education activity is managed and accredited by Professional
Education Services Group in cooperation with AMSUS. PESG, AMSUS,
and all accrediting organization do not support or endorse any
product or service mentioned in this activity. Learning Objectives
At the conclusion of this activity, the participant will be able
to: Review the use of tourniquets on the battlefield, past and
present Report recent TCCC guideline updates to include early
conversion of tourniquets to hemostatic/pressure dressings,
evaluation of effective tourniquets, tourniquet placement during
care under fire, and specific suggestions for CAT tourniquet use.
Describe the recommended method for converting a tourniquet to a
hemostatic/pressure method. Overview Historical Perspective
Categorization of Potentially Preventable Deaths Combat Data
Indications for Pre-hospital Tourniquet Use Complications of
Tourniquet Use Training issues Pitfalls Summary of TCCC Guideline
updates The Hartford Consensus Historical Perspective
Surgical amputations American Civil War Union Army recommended
issue to every combat soldier Associated with poor limb outcomes
WWI Battlefield medic Prolonged transport to surgical hospitals
Tourniquet is last resort for uncontrolled limb hemorrhage WWII
Surgeons advocated for more effective tourniquets and early use
Korea/Vietnam Iraq/Afghanistan
Helicopter evacuation from the battlefield WWII tourniquet still in
use, although ineffective Many improvised tourniquets Last resort
Iraq/Afghanistan Doctrine change: tourniquets are the primary means
of first aid Tactical Combat Casualty Care
Summary Tactical Combat Casualty Care Care Under Fire Tactical
Field Care Tactical Evacuation Care Formal evaluation of tourniquet
devices Training and issuing tourniquets to ALL TROOPS Battlefield
Acute Lethality Potentially Survivable n=1,075 Hemorrhage Focus
(n=984) Can We Have An Impact? Combat Data Israeli Defense Force
2003 Bagdad 2006-2007
91 tourniquets: 78% effective, 47% not indicated, 6.4% nerve injury
Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for
hemorrhage control on the battlefield: a 4-year accumulated
experience. J Trauma. 2003;54:S221S225. Bagdad 267 casualties, 428
tourniquets, 309 limbs Indications: 87 amputation, 86 vascular
injury, 81 open fx, 45 soft tissue injury 90% mortality when TQ
placed after onset of shock 10% mortality when TQ placed before
onset of shock 28% ineffective, distal TQ more effective than
proximal 1.7% transient nerve palsy Kragh JF Jr, Walters TJ, Baer
DG, et al. Practical use of emergency tourniquets to stop bleeding
in major limb trauma. J Trauma. 2008;64:S38S50. 75th Ranger
Regiment 2011 Combat Data
419 casualties, 89 limb tourniquets, 66 casualties No complications
16% required amputation, no amputation attributed to tourniquet use
42% applied by non-medical personnel Kowal RS, Montgomery HR,
Kotwal BM, et al. Eliminating Preventable Death on the Battlefield.
Arch Surg. 2011;146: Civilian data Boston Marathon
152 patients, 66 with extremity injury, 29 with life-threatening
bleed 17 amputations 12 major vascular injuries 27 tourniquets
appliedall improvised 1/3 of tourniquets applied by EMS, 1/3 by
bystanders, 1/3 unknown King DR, Larentzakis A, Ramly EP.
Tourniquet use at the Boston Marathon bombing: Lost in translation.
J Trauma. 2015;78: Civilian data Multi-institutional Analysis of
Prehospital Tourniquet Use Retrospective chart review, 9 Level 1
trauma centers 197 patients Mortality significantly lower than
reported by military 3.0% mortality (not different with vs. w/o
shock) 20% expedient tourniquet by bystanders Schroll RW, Smith A,
McSwain NE, et al. Military to civilian experiencea preliminary
multi-institutional analysis of pre-hospital tourniquet use.
Indications for Pre-hospital Tourniquet Use
Care Under Fire Mass casualty events Total darkness Multiple
injuries (particularly if airway or breathing intervention required
M-A-R-C-H Massive hemorrhage Airway Respiration Circulation
Head/Hypothermia Complications of Tourniquet Use
Pain Nerve palsy Clot Fasciotomy Amputation
Myonecrosis/Rhabdomyolosis } Pain control } Wider tourniquet }
Avoid venous tourniquet } Limit tourniquet time Venous tourniquet
Arterial blood continues to flow into extremity
Venous blood flow from extremity is occluded Result: Increased
swellingand compartment syndrome Increase bleeding from injured
veins Tourniquet time 2 hours is considered safe
TQ times > 100 minutes associated with increased complications
in TKA Complications increase 20% for every 10 min (range minutes)
Olivecrona C, Lapidus LJ, Benson L, Blomfeldt R. Tourniquet time
affects postoperative complications after knee arthroplasty. Int
Orthop. 2013;37:827832. Traumatic injury and blood loss reduce
ischemic tolerance of the limb Gifford SM, Propper BW, Eliason JL.
The ischemic threshold of the extremity. Perspect Vasc Surg
Endovasc Ther. 2011;23:8187. Hancock HM, Stannard A, Burkhardt GE,
et al. Hemorrhagic shock worsens neuromuscular recovery in a
porcine model of hind limb vascular injury and
ischemia/reperfusion. J Vasc Surg. 2011;53:10521062. Shorter
tourniquet time is always best Tourniquet time How long is too
long? No definitive answer
6 hours is a rough guideline Likely shorter for more proximal
tourniquets May be as short as 3 hours with traumatic injury and
shock Hancock HM, Stannard A, Burkhardt GE, et al. Hemorrhagic
shock worsens neuromuscular recovery in a porcine model of hind
limb vascular injury and ischemia/reperfusion. J Vasc Surg.
2011;53:10521062. Longer for distal tourniquets and cool
environment Dont kill the patient by attempting limb salvage Place
hemostatic/pressure dressing
Tourniquet Conversion=Convert tourniquet to a pressure/hemostatic
dressing Care under fire: Apply high and tight over clothing
TFC/TACEVAC: Expose wound Place hemostatic/pressure dressing Loosen
tourniquet and move down-monitor for rebleeding Tourniquet
Repositioning
Care under fire: Apply high and tight over clothing TFC/TACEVAC:
Expose wound and Place second tourniquet 2-3 inches above wound on
skin.Loosen high and tight original tourniquet. If needed, move
loosened high and tight tourniquet to position side by side with
second tourniquet and tighten both until bleeding stopped and
distal pulse not palpated Criteria for Tourniquet
Loosening/Conversion
Casualty is not in shock It is possible to monitor the wound
closely Not an amputation Pitfalls Rebleeding Forgotten
tourniquet
Placing the tourniquet distal to an unseen wound Removing the
tourniquet Reperfusion injury Loosening the tourniquet in unstable
patient Periodic loosening of the tourniquet to reperfuse the limb
CTA Dont kill the patient by attempting limb salvage TCCC guideline
update supports high and tight placement during CUF
Summary of Updates: Clarification of the location of
tourniquetplacement during CUF TCCC guideline update supports high
and tightplacement during CUF Consider high and tight placement
whenever assessmentis limited: Masscal, low light, multi-trauma
patient Experienced medics may use judgment: if the wound
isobviously distal, then place the tourniquet 2-3 inchesabove the
wound All high and tight tourniquets require repositioning
orconversion at the EARLIEST opportunity (2 hours max) Summary of
Updates: Clarification of effective tourniquet placement
Optimal use of limb tourniquets must stop both bleeding and the
distal pulses Ineffective venous tourniquets Occlude the vein but
not the artery Loss of blood from the bodys core Swelling of the
limbcompartment syndrome Increased bleeding from the veins
Rebleeding is common Blood pressure increases Muscle relaxation in
the limb Re-evaluate often Summary of Updates: Clarification of
tourniquet conversion guidelines
General principles: Shortest tourniquet time is best Complications
of nerve injury, compartment syndrome, muscle damage increase with
time Attempt to convert as soon as possible (< 2 hours) If:
Casualty is not in shock It is possible to monitor wound closely
for bleeding Not an amputated extremity In most cases only one
attempt at conversion before reaching surgery May consider a second
attempt if conditions have improved (better light, supplies,
manpower, etc) Summary of Updates: Clarification of tourniquet
conversion guidelines
Do not convert a tourniquet that has been in place morethan 6 hours
unless close monitoring and lab capability areavailable No exact
time when an ischemic limb becomesunsalvageable Risks of tourniquet
removal include hypotension,rhabdomyolysis, kidney failure,
acidosis, and hyperkalemia Cooling helps: expose the limb but DO
NOT pack in ice orsnow Analysis of recovered tourniquets showed
that 1/3 are single-routed
Summary of Updates: Review recommendations for CATrouting of band
through buckle Currently manufacturers instructions recommend
double routing of the CAT tourniquet band through its buckle,
except for self-application to upper extremity Analysis of
recovered tourniquets showed that 1/3 are single-routed Recent lab
study confirms single routing is faster and reduces blood loss 6th
generation CAT is 37.5 inches, compared to 31 inches for earlier
version (more Velcro contact area) Buckle breakage has never been
reported Trainers observe that the critical first step of
tightening the band (before tightening the windlass) is facilitated
by single routing Care Under Fire Stop life-threatening external
hemorrhage if tacticallyfeasible: Direct casualty to control
hemorrhage by self-aid if able. Use a CoTCCC-recommended limb
tourniquet forhemorrhage that is anatomically amenable to
tourniquetuse. Apply the limb tourniquet over the uniform
clearlyproximal to the bleeding site(s).If the site of the life-
threatening bleeding is not readily apparent, place thetourniquet
high and tight (as proximal as possible)on the injured limb and
move the casualty to cover TFC and TACEVAC c. Reassess prior
tourniquet application. Expose the wound and determine if a
tourniquet is needed. If it is, replace any limb tourniquet placed
over the uniform with one applied directly to the skin 2-3 inches
above wound. Ensure that bleeding is stopped. When possible, a
distal pulse should be checked. If bleeding persists or a distal
pulse is still present, consider additional tightening of the
tourniquet or the use of a second tourniquet side-by-side with the
first to eliminate both bleeding and the distal pulse. TFC and
TACEVAC d. Limb tourniquets and junctional tourniquets should be
converted to hemostatic or pressure dressings as soon as possible
if three criteria are met: the casualty is not in shock; it is
possible to monitor the wound closely for bleeding; and the
tourniquet is not being used to control bleeding from an amputated
extremity. Every effort should be made to convert tourniquets in
less than 2 hours if bleeding can be controlled with other means.
Do not remove a tourniquet that has been in place more than 6 hours
unless close monitoring and lab capability are available. Hartford
Consensus Met in Hartford, CT, Apr 2013, Jul 2013, Apr 2015
Joint committee to create a national policy to enhancesurvivability
from mass casualty shooting events Initiated by ACS FBI Law
enforcement Fire EMS Trauma care Military Hartford Consensus
Excerpt from findings: Response to Active Shooter Events
T threat suppression H hemorrhage control RE rapid extrication to
safety A assessment by medical providers T transport to definitive
care Response to Active Shooter Events
T threat suppression H hemorrhage control RE rapid extrication to
safety A assessment by medical providers T transport to definitive
care Public response Bystanders provide initial response
Design education programs for public response to activeshooter or
mass casualty event B-con course CPR model Pre-position necessary
equipment Bleeding kit + AICD Run, Hide, Fight Law enforcement
Train all LE officers to assist EMS
External hemorrhage control Tourniquet application Hemostatic
dressings (Combat gauze, Celox) Triage possible internal hemorrhage
forimmediate evacuation EMS/Fire/Rescue Increase training on
initial response
No longer acceptable to stage and wait forcasualties to be brought
to the perimeter Training must include tourniquets,
pressuredressings, hemostatic agents Rapid triage of torso
hemorrhage fortransport to definitive care TCCC model Guidance
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