Tourniquets in EMS
Dan White // April 1, 2011
Tourniquets have been used on the battlefield since 1674, while the earliest known usage of a tourniquet dates back to 199 BCE-500 CE. They were used by the Romans to control bleeding, especially during amputations. These tourniquets were narrow straps made of leather and bronze.
My first exposure to tourniquets was in the Boy Scouts, where we learned how to fashion one from readily available parts like our kerchief. In EMT school, I was taught that tourniquets are a solution of last resort. Not that you should never use them, but that using one came with a terrible price.
Back then, we were taught that the price of complexly cutting arterial blood flow was loss of the distal limb. It made sense that for a tourniquet to stop hemorrhage, it therefore had to block atrial blood flow. With loss of blood flow, tissue necrosis and death seemed an inevitable conclusion. However, like many things I was taught when I was young, this one is apparently not entirely true either.
Recent combat medical military experience has taught us something different. Tourniquets both save lives and using one does not by itself cause limb loss1. Tourniquets have been applied for hours and many limbs still saved. This has created a renewed interest in what was once perceived as the "lowly" tourniquet.
As in any conflict of war, our EMS systems learn invaluable lessons from the horrible price our soldiers pay. One of the lessons learned in Iraq is that when elevation and direct pressure fail, a tourniquet can work.
Today, many soldiers and paramilitary types carry one. It has become popularized in our EMS culture, too. This has resulted in a number of commercially manufactured tourniquets entering the EMS market. Many of these were originally built to military demand or, rather, military sales opportunities. The tourniquet is suddenly now so popular it is being built into pant belts or even clothing2.
The EMS professional usually has more medical training than the average soldier or even corpsman. EMTs and paramedics understand that each therapy has a place in context. The place for the tourniquet is when direct pressure and elevation fail. It is only for when the potential for loss of life outweighs the risk of losing a limb. It is not a therapy competition; all three treatments have a place in the control of bleeding.
The reality is injuries requiring the use of a tourniquet are much more common in combat. The kind of bleeding direct pressure can't always stop are injuries from large projectiles and explosive devices that tear arteries down their length, or create massive wound channels.
Fortunately, these are not the kind of things we see every day in civilian EMS. I can recall only one case in my 30-plus years where a tourniquet became necessary. The other reality today is we have a new treatment option — the modern hemostatic dressing. It offers a new way to control severe bleeding that a simple bandage and pressure cannot. But when you don't have a hemostatic dressing available and you do need a tourniquet, you better know how to use it.
The easiest way to make a tourniquet on an ambulance is with a triangular bandage. Roll it long ways into a 1-2" wide band, encircle the limb and tie in a firm square knot. Then, find a windlass to tighten it. A stick or even an oxygen wrench will work fine.
Slide the windlass under the bandage and twist until arterial blood flow to the distal extremity is occluded. Tape the windlass down into a secure position and document the time is was applied. It's really pretty simple. For those who want a ready-to-use version, there are several good ones on the market.
The SOF Tactical Tourniquet features a black nylon webbing strap, with an integrated windlass. There is a retainer to secure the windlass "stick" once correct pressure is achieved.
The MAT, or Mechanical Advantage Tourniquet, features a rotary dial; you twist an innovative windlass mechanism to apply tension. Both of these commercially available tourniquets come ready to use, and take up very little space.
When you are confronted by severe bleeding, the kind you can't control with direct pressure, they can prove to be indispensable. I strongly suggest you open and practice with once until you can use it in the dark. Remember, always mark the time of application and re-check distal pulses and the bleeding site periodically.
1. Kragh JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb, JB (February 2008)."Practical use of emergency tourniquets to stop bleeding in major limb trauma". J Trauma 64 (2 Suppl): S38–49; discussion S49–50. doi:10.1097/TA.0b013e31816086b1. PMID 18376170.