Experts recommending tourniquet use benefits Virginia EMS

November 6, 11:20 PMRichmond EMS ExaminerElle Künstlerin

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Soldier practicing with a tourniquet. Image: US Army

From First Responders up through paramedics, every EMS provider learns that tourniquets are the last resort to control massive extremity hemorrhaging.  It is beaten into their heads that tourniquet equals irreversible nerve damage and most likely the loss of the limb from the tourniquet down.  As such, tourniquet usage is very rare, even in cases where they may literally save life and limb.  However, that is changing.

At this year's EMS Expo in Atlanta, Georgia, Jeff Myers, Clinical Assistant Professor of Emergency Medicine at SUNY, Buffalo gave a presentation recommending a wider spread usage of tourniquets.  It turns out, according to Dr. Myers, they are not as bad as we thought.  His presentation traced the history of tourniquets back to their Greek and Roman iterations.  The complications now drilled into every EMS provider's head did not develop until World Wars I and II.  Soldiers wore tourniquets for hour and hours, which inevitably caused nerve damage and loss of limb.  It was then that tourniquet use became a bit taboo.

In her article recounting her interview with Dr. Meyers, Heather Capsi points out that the 3 to 4 hour mark is where complications start to develop, such as muscle necrosis and possible compartment syndrome, along with nerve and vascular damage.  Another complication is hypotension that develops once the tourniquet is released.  The resultant waste products returning to central circulation is a concern, similar to a crush injury.  However, Dr. Meyers said that they do not pre-medicate as one would with a crush injury.

After reviewing the Israeli Defense Forces' data on tourniquet use, which is early and aggressive, he found no deaths due to extremity injury and nerve damage resolved.  It was that knowledge that led Dr. Myers to recommend more widespread tourniquet application, and earlier tourniquet application especially.  He came up with a list of guidelines whenever a tourniquet is applied (as quoted from the article):

    * "Never cover or hide the tourniquet from view

    * "Label the medical or triage tag

    * "Label the patient

    * "If the patient is conscious, tell him to tell his caregivers"

Also, once it has been applied, do not remove it.  It was once taught to release it every 20 minutes but that practice is no longer in protocol.  Dr. Meyer suggested cooling the limb might extend the amount of time the tourniquet can remain in place before damage could occur.

So, what does this mean for EMS agencies, Fire and Police departments in and around Richmond?  Tourniquets are a very effective tool that controls massive extremity hemorrhage effectively and safely if applied correctly and not left in place for hours.  For our urban and close suburban agencies, tourniquets would be the ideal way to control extremity hemorrhage, maybe even first line in some cases.  There would be no worry of prolonged application because chances are the patient would be in surgery long before the 3 to 4 hour time limit.  Instead of wasting precious time going through the hemorrhage control protocol, an EMT or First Responder could apply the tourniquet and be done with that immediate life threat.  Not only will treatment proceed more rapidly because time is not lost holding pressure, but another set up hands is free to assist now.

For our rural squads tourniquets may be even more beneficial due to the prolonged transport time.  If a tourniquet is applied immediately, no more blood is shed, as it would be holding pressure.  This would mitigate hypovolemic shock, which is a major concern especially coming from the rural perspective.  Since First Responders and EMTs can apply tourniquets, they can go a long way to stabilizing the patient.  ALS is not always available at some of the rural squads.  By applying tourniquets immediately, they can gain valuable time until they can either get to the hospital or rendezvous with advanced providers.  OMDs need to review these new studies and possibly move the tourniquets up in the extremity hemorrhage treatment protocol, both traumatic and non-traumatic, such as hemmorhaging dialyisis shunts.

Source:

Heather Capsi, "Tourniquets More Than A Last Resort: Top News Stories at Officer.com."  Officer.com