Tourniquets

[Eamonn]

In Corrections we do train for the worst type of situations.

We have all sorts of special teams that can be called upon and put to use if needed.

We have a full medical staff that in most "Normal" situations can be in almost any part of the jail within minutes.

The local hospital is less than a five minute drive.

With this in mind, the need to use a tourniquet would rarely be needed.

However as we seen back in October 1989 in the Camp Hill Prison Riots, things can and sometimes are not normal.

In a situation like this when there would be a delay in professional medical help being available the need might very well be a real one.

I don't have any problem following and teaching the course material.

In fact from a liability point to cover my tail and the tail of the Department, I'm bound to do so.

Ea.

[KC9DDI]

Beav - Your digression on the differences between civilian and military EMS is not relevant to how we treat immediate life threats, and only serves to confuse people unnecessarily. Life threatening bleeding is life threatening bleeding, it doesn't matter if it was caused by a machine gun or a boat propeller or a beer bottle. Mechanism of injury, MCI triage, and incident rates don't matter, especially at a basic first aid level, where the goal is to teach how to identify and effectively treat imminent life threats, like severe hemorrhage.

 

Even worrying about re-attachment is a red herring. 1) As you probably know, amputations where there's a good possibility of re-attachment rarely cause life threatening bleeding. 2) Re-attachment will never be possible if your patient bleeds out before you get to the OR.

 

Why would you think that we can't learn from injuries occurring in combat? Does it matter is a guy's leg gets run over by a tank or by a Toyota? It's still broken. Does it matter if a guy gets shot by an insurgent in Iraq or by a drug dealer in Detroit? It's still a gun shot wound. Does it matter if a guy's artery get severed by shrapnel from a hand grenade, or shrapnel from a broken beer bottle? It's still (potentially) a life threat that needs to be treated immediately.

 

You asked for more references. I tried to find some that at least had abstracts freely available on line. The bibliographies on these abstracts are also worthwhile. If you happen to have access to any of these journals, you can obviously find many more full-text results. It sounds like you have some background in advanced first aid as well - I'm sure the bibliography from a recent textbook would be a good place to look as well.

 

From the Journal of Trauma: http://www.ncbi.nlm.nih.gov/pubmed/18376169

From Prehospital Emergency Care: http://www.ncbi.nlm.nih.gov/pubmed/18379924

From the Emergency Medicine Journal: http://www.tacmedsolutions.com/blog/wp-content/uploads/2007/12/tq-civ.pdf

From the Journal of Emergency Medical Services: http://www.jems.com/article/major-incidents/appropriate-prehospital-tourni

 

Now would you mind answering my question: What evidence is there of harm being done due to tourniquet use? What evidence is there that this harm outweighs the positive benefits of tourniquet use?

 

With this in mind, the need to use a tourniquet would rarely be needed.

 

Eamonn - How do you figure? Severe bleeding can cause irreversible damage in less than 5 minutes. And considering that the onset of temporary nerve and muscle damage hasn't been shown to occur in less than two hours, even if a responder did err on the side of caution and apply a tourniquet unnecessarily, it could still be identified and removed promptly at that hospital that's five minutes away.

[Beavah]

Your digression on the differences between civilian and military EMS is not relevant to how we treat immediate life threats, and only serves to confuse people unnecessarily. Life threatening bleeding is life threatening bleeding, it doesn't matter if it was caused by a machine gun or a boat propeller or a beer bottle. Mechanism of injury, MCI triage, and incident rates don't matter, especially at a basic first aid level, where the goal is to teach how to identify and effectively treat imminent life threats, like severe hemorrhage.

 

Yah, I disagree.

 

The differences between civilian first aiders and military EMS may (and probably should) significantly affect policy choices. As a simple example, a military medic is going to be far more likely to be able to distinguish between truly severe bleeding and something less severe, and therefore the risk of overly aggressive action is much less. Military medics are also more likely to perform procedures rapidly and correctly.

 

Let's consider a related example, eh? Military medics perform needle decompressions in cases of pneumothorax in the field, but we don't teach that to civilian first aiders, nor is it even a common civilian professional responder protocol. Even though "life threatening respiratory distress is life threatening respiratory distress," the context matters in terms of decidin' on an appropriate protocol.

 

I also disagree that mechanism of injury, triage, etc. don't matter. After all, we do teach those things as fundamental to assessment and deciding on treatment, even in basic MFR/WFR courses. Your citations seem to disagree as well. For example, your JEMS citation above suggests tourniquet use even by professional responders primarily applies to MCI/triage situations and situations where injury mechanism also compromises other vital areas like airway.

 

Let's take some information from da reference you provided which is advocatin' limited tourniquet use in civilian pre-hospital settings. When yeh read the paper past the abstract, yeh discover a long list of reasons for not using tourniquets:

 

1) 47% of tourniquet applications were not clinically indicated even in a military setting;

2) ischemic damage in relatively short periods of time (mean=78 mins),

3) reperfusion injury possible after 60 minutes,

4) increased bleeding from incorrectly applied tourniquet,

5) improvised tourniquets perform very poorly compared with commercial devices,

6) properly applied tourniquets require IV opiates for pain management.

 

How many civilian first aiders carry around IV kits with opiates I wonder? Or a commercial tourniquet product? Da recommendations are specific, eh? "The pre-hospital practitioner should be familiar with a particular commercial tourniquet that has been proven in studies to be effective, rather than using an improvised device that has been demonstrated to take more time to apply or may lead to an increased risk of complications."

 

The paper considers only a few cases where tourniquet use may be applicable in civilian practice - stabbings and gunshot wounds, police officers engaged in tactical firefights, terrorist events with blast injuries, industrial accidents involving entrapment and shredding. And rural/wilderness, which is interestin', but not explained. So this may apply to fellows like Eamonn, who works in a high-risk environment for stabbings with professional medical folks to hand, but probably not to most boy scouts or scouters.

 

Yep, we can certainly learn lots of important things from combat injuries, but we have to be mindful of da limits of what we can learn as well. None of your references seems to be suggesting that tourniquet use is appropriate at the First Aid/First Responder level outside of tactical firefights. Or to bring things around to another civilian "feature", in da military yeh don't have to worry about your patient or his parents suing yeh for loss of use of a limb when yeh slap a tourniquet on when it wasn't necessary.

 

Beavah

(This message has been edited by Beavah)

[KC9DDI]

Beav - We're not talking about policy. We're talking about the best way to treat life threatening injuries.

 

Needle decompression is a skill taught in every paramedic program that I am aware of.

 

We don't teach that MOI is fundamental to treatment, though admittedly many professional responders make inappropraite treatment decisions based only on MOI. MOI can sometimes be fundamental to assessment - but treatment depends on assessment, not MOI.

 

So let's take a look at your list of reasons for NOT using tourniquets:

 

Applied when not indicated? Possibly, but what harm did that do to the patient?

 

Possibility of ischemic damage after more than an hour of prolonged use? Possibly, but was that damage permanent? Did it do more damage than would have been done if bleeding was inadequately controlled? How often are you more than 78 minutes away from definitive assessment and treatment?

 

Reperfusion injury? Mitigated if removal is done appropriately. Beyond that, same questions as above - temporary or permanent injury? More or less severe than damage done by uncontrolled bleeding?

 

Not effective with poor training or poor equipment? Agreed, everything is better with good training and good equipment.

 

IV Pain Management? Well, you need to be alive to feel pain... And IV pain management can be initiated early on by EMS or by the hospital.

 

No doubt that tourniquets have the potential to do harm - just like CPR and needle decompression. In fact, I've seen more instances of harm caused by CPR than by tourniquets. But that doesn't mean we're going to stop teaching CPR.

 

Beav - You seem to be basing your entire argument that tourniquets do more harm than good. Do you have any evidence to support this belief?

[Gunny2862]

Context.

Look I know we have to have some MD's, probably some RN's and LPN's and EMT's reading this.

 

I'm the next best thing to a lay person, I've had either a Military or Red Cross or AHA cross certification of some type since 1984, mostly the Basic First Aid and CPR certs because I work in electronics... I've also kept current the AED cert for about a decade, and was an early trainee in the Combat Lifesaver program, and kept it as long as I was able to. WFA, for the past 3 years. None of which makes me a medic, or even what I consider a real first responder, especially since having retired from the military the CL hasn't been kept current.

 

With all that out there, IMHO, based on my experiences, tourniquets are useful devices that far too many lay people use way too early in circumstances that a) could have used a lower level intervention b) cause additional damage and suffering that wouldn't have needed to occur if the proper level of intervention had been chosen instead.

 

Never have I opined that we didn't need to have them available, but then, I also believe in the value of cauterization, in the world of the last ditch effort, but to open up that conversation we're pretty much up against the wall for trying to save someone.

 

Never have I opined that a properly trained professional can't make a determination that a tourniquet is the right tool in short order, possibly, given the severity the first option. But I really don't think our typical Scout has the maturity to make that kind of evaluation. And most of our Scout Leaders, probably don't have enough training or experience that they should see "lots of blood" and go straight to a tourniquet, at least not without at least taking the 5-15 seconds to LOOK and THINK if another method wouldn't be a better place to start.

 

(This message has been edited by Gunny2862)

[Eagle92]

May I offer a truce? I thought I posted between BLS classes, but apparently it didn't go through. I'll do some research on the topic for both sides.

 

I know AHA has a conference every 5 years and the results were published in CIRCULATION in OCT 2010. If memory serves, those various articles are available for free via PUBMEDCENTRAL.GOV. It is also available in an international paper on the topic and I'm sorry it is escaping me even though I heard the paper's title twice today. I think it 's the International CPR and ECC......

 

And I'm told that ARC does the same thing for first aid. I'll start looking Sunday.

 

 

[Beavah]

Beav - You seem to be basing your entire argument that tourniquets do more harm than good. Do you have any evidence to support this belief?

 

KC9DDI, all I was doin' was quotin' the references that you provided! You're arguin' against your own evidence. Nobody is proposing includin' tourniquet use for civilian first aiders. Nobody. Even those advocatin' for reconsideration of the current tourniquet protocols are sayin' that it should be limited to professional responders in tightly monitored circumstances. Again, to quote one of your articles:

 

"The importance of case-by-case evaluation and appropriate feedback can_t be underestimated, because an effective prehospital tourniquet policy can be successful only when there_s continued post-operative communication between the trauma surgeons caring for the patients and the prehospital crews making the initial decisions in the field."

 

That doesn't sound like a recommendation for a civilian first aider protocol to me.

 

B

 

[Eagle92]

Ladies and gentlemen,

 

I admit I have not read the entire thing, But from the glancing I did, I believe this is the report based upon the conference I told you about.

 

http://www.ifrc.org/PageFiles/53459/IFRC%20-International%20first%20aid%20and%20resuscitation%20guideline%202011.pdf

 

PP43-44 are on the topic at hand. It appears that research on the topic has both positives and negatives. Me personally, in an emergency situation, I'd like to have all the tools available at my side.

 

Tourniquets

The use of tourniquets by first aid providers to control bleeding has been contro-

versial, and tourniquets have fallen out of use in first aid programmes. Despite

this, tourniquets are routinely and safely used for hemostasis in surgical proce-

dures in operating rooms, where applied pressure and occlusion time are strictly

measured and controlled, and on the battlefield when occlusion time is carefully

documented. But these results cannot be extrapolated to the first aid setting. In

addition, in the past few years the use of tourniquets in military environments

has increased. The effectiveness, feasibility and safety of tourniquets to control

bleeding by first aid providers are unknown. Tourniquets are routinely used in

operating rooms under controlled conditions, and they have been effective in

controlling bleeding from an extremity, but potential undesired effects include

temporary or permanent injury to the underlying nerves and muscles, as well

as systemic complications resulting from limb ischemia, including acidemia,

hyperkalemia, arrhythmias, shock, limb loss and death. Complications are re-

lated to tourniquet pressure and occlusion time. Pressure has been found to be

superior to tourniquets in controlling bleeding, although tourniquets may be

useful under some unique conditions (e.g., the battlefield, when rapid evacuation

is required and ischemic time is carefully monitored). The method of application

and the best design of tourniquets are under investigation.

 

In the more recent military studies, including a retrospective military field case

series, 110 tourniquets were applied to 91 soldiers by medical (47%) or non-

medical (53%) personnel. The tourniquets controlled bleeding in most (78%)

of the victims, typically within 15 minutes. Penetrating trauma was the most

common mechanism of injury, and ischemic time was 83 52 minutes (range:

1 to 305 minutes). The rate of success was higher for medical staff than for non-

medical personnel, and for upper limbs (94%) than for lower limbs (71%, P

[Eamonn]

Thanks Eagle92.

I spend a fair amount of my time at work presenting a lot of different trainings, everything from Transportation of inmates, Suicide prevention, to Combating negativity in the work place with another dozen or so courses thrown in for good measure.

Trying to keep up to date with all the changes that are made is at times hard.

I'm not exactly sure when I became a ASHI Instructor, it was a few years back.

When all the changes came along and there were a lot! I was required to take an on-line course that was supposed to cover all the changes.

The on-line course came along before the new presentation materials were available and with permission from ASHI we kept on presenting the old course. At the start of this year we received the new course material, new student books, new videos, new power point presentations.

I don't remember tourniquets being mentioned in the upgrade on-line course and was surprised when they did pop up on a power point presentation slide.

While all of our classes are small, rarely more than 20 and everyone has been trained at our academy making what we do a recertification course. Trying to cover all the material and having to do two exams in the time set (3 hours) Is really difficult.

I'm trying to see if we can be given more time.

Some of our other instructors have somehow come up with the idea that we in the department do not teach the use of tourniquets. I'm not sure where they are seeing this? So far the department has not informed me and there has been no word from ASHI.

So until I get something in black and white I'm going to present the material as is.

 

Back when I was a Scout in the UK learning Fist Aid. I took the Saint John's Ambulance course. Saint John's being the UK equivalent to what the American Red Cross is here in the USA.

At that time (About 40 years ago!!) Tourniquets were part of that course. At that time the practice of loosening them every twenty minutes was still around.

As a Scout in the UK, I remember spending many happy hours practicing the art of bandaging, splinting and all that good stuff.

I am qualified as a Basic Wilderness First Aid Instructor, Wilderness First Responder and have the Wilderness EMT Upgrade.

But for First Aid in the work place we as a rule cover what is needed until professional help will arrive. Sure we do touch upon bandages and splinting, but do not have the time to really go into much depth.

While I do see that there are times when a tourniquet might be needed, my feeling is that for most situations at work our in house medical staff would arrive before I'd get a tourniquet on and in most cases direct pressure would suffice.

Having said that, I'm willing to admit that no two situations are the same and ensuring that the students I teach do have the knowledge and know how to be able to deal with what might come along is very important.

We do tailor some of what we teach for where we are but this is set down in guidelines set by the department.

Ea.

 

 

[KC9DDI]

Beav - Respectfully, you're extrapolating invalid conclusions from the data and recommendations presented.

 

To compare this to CPR again -

 

Less than half of lay responders perform CPR effectively (http://jama.ama-assn.org/content/274/24/1922.short). However, we still teach lay people to do CPR because the benefits still outweigh the risks.

 

In out-of-hospital cardiac arrest, even with rapid access to EMS and hospitals, survival rates are abysmal (http://ohsonline.com/articles/2009/12/05/report-outofhospital-cardiac-arrest-survival-rate-unchanged-in-30-years.aspx). But yet, we still rely on CPR, as it's necessary to have ANY chance of successfully resuscitating a patient whose been in cardiac arrest for longer than a few seconds.

 

There is a high risk of complications from CPR, even when performed correctly (http://chestjournal.chestpubs.org/content/92/2/287.full.pdf) - but we still do CPR anyway. And we still teach lay persons to do CPR.

 

In any study that concludes that CPR should continue to be done, you will find mentions of complications and risks. There's risks and complications associated with any medical procedure. It shouldn't be surprising that studies which support the use of tourniquets include mentions of risks and complications.

 

But, my question still is - can you show that these risks and complications are more significant than the benefits of the procedure? So far, you have not.

 

[Eamonn]

KC9DDI

Any discussion about the pros and cons of tourniquets could go on for some little while.

My feeling is that there is a time and place for them.

I'm really not sure if trying to teach and instruct the correct methods of application and use of them in what is a very basic first aid course is such a good idea?

My big problem doesn't lie with how useful or how harmful tourniquets might or might not be. My problem is trying to cover all the material in 3 hours.

In the student workbook tourniquets get a two line mention and in the power point presentation tourniquets appear as part of one slide.

Dumbed down is not a term that I'd like to use when it comes to First Aid, maybe the correct term might be User Friendly?

The basic First Aid course presentation has gone to great lengths to make administering and performing first aid as easy, simple and user friendly as possible.

Tourniquets don't fall under the heading of being easy or user friendly.

While I might be wrong! A lot of the changes over the past few years have been aimed at trying to ensure that the average person feels that they have enough knowledge and know how so as to be able to help when needed without feeling that because they aren't qualified enough. Which has at times led good people to do nothing.

 

While maybe it is food for another thread?

I think that it's also important that instructors are aware of who they are instructing.

The good person who signs up to take a First Aid class because he or she feels that it is for whatever reason important. Is very different from the person who has no real interest in First Aid, but has to sit through the training every year because he or she is mandated by the employer to do so.

While of course the material remains the same and the instructor should put the same amount of effort and professionalism into each and every presentation, the interest of the participants will vary greatly.

Like it or not this interest does play a part in the learning of the participants.

Rightly or wrongly? My feeling is that just about anyone can grab a pad and apply direct pressure to a wound, but when we start making it more complicated we give them a reason tho question their ability and they could end up doing nothing.

Ea.

[Scoutfish]

"As a simple example, a military medic is going to be far more likely to be able to distinguish between truly severe bleeding and something less severe, and therefore the risk of overly aggressive action is much less. Military medics are also more likely to perform procedures rapidly and correctly. "

 

And how do you come to this conclusion?

 

As a former fifefighter/ EMT myself, I have to ask.

 

So a medic - in hostile circumstances ( gun fire, fighting, thinks expolding around him) - will have a better chance of determining how bad a wound( that is covered by more clothing, body armour, dirt, flying debris) based on looks? The bleeding ( which may be at a higher, faster rate due to adrenalin, stress, and the excitement of what is going on) can be from a bad cut, puncture wound or who knows what. Not only is he looking out for the patient, he is also looking out for himself and trying to avoid getting shot at, hit by shrappenel, bombs, etc..and still looking out for the enemy.

 

NOw the medic - who has a limited supply of equipment due to space constraints) may improvise or just do without. And while that improvising is a very cool and skilled thing...it doesn't always work our.

 

Now take your typical EMS worker who is not in a war zone, is not getting shot at, and isn't trying to examone a person on the ground who may or may not have been rolling around in dirt, have shrappenal burns,...with a stocked ambulance or first responder vehicle at his disposal. Not to mention that ALS ( advanced life support) is only minutes away........

 

WEll, guess who is calmer, more relaxed and not as rushed to make a evaluation of the partient.

 

Also, you figure a medic does two main things : Stabilize ( same as ems) but also will give a filed dose of morphine/ dilatin, etc ...which , while halping the patient with pain, also causes a cvhange in BP, pulse and patient reaction and response. At this point, you may make a diagnosis of the patient that is wrong.

 

 

So, now if you want to say a medic has to work in hasher, more stressful and extreme circumstances - well, I agree completely with you on that one. But to say he make better decisions is unvalidated and wrong.

 

Being next door to a military installation or two ( Camp Lejune, Camp Johnston, Camp Geiger, Camp Davis) WE had our share of military people we transported in. We trasnported to 5 different hospitals( Naval @ Lejune, Onslow, Pender, Cape fear, and New Hanover) hospitals. When it came to our Marines and Navy, they prefered EMS 10 to 1 over the corpsmen. They prefered civilian ems over medics.

 

Why? Medics tend to do more triag evaluation that treatment. Patient is gonna make it ( try to stabilze for eventual transport to MASH unit ( ot whatever they call it now)or patient not gonna make it - shoot him up so it doesn't hurt.

[Scoutfish]

As to the OP:

 

Touriquets are like everything else...

 

One year they are promoted, next year they are discouraged, next year they are banned, next year, they are considered the most advanced item ever.

 

Look at CPR: Does anybody even know how many times it has been updated, changed, modified, changed again in the last 20 years?

 

Then look at proticals : State to state are different. Counties within a state are different, The sponsoring hospital ( when multiple within a county) the head Dr who is in charge of protocal and S.O.P.'s .

 

THen you have the AHA who says this, but the Red Cross say that. Somebody has to choose which way to go.

 

First aid policy is almost like a city borad of commissioners . Every time somebody new is in charge, about half the policies and rules get changed.

 

Back when I ran EMS, Tourniquets were allowed, but you only used them in very extreme cases. This was usually due to loss of limb or extremely sever cuts/ mualings.

 

Never used them for snakebites or stuff like that as it turns out..sonner or later the tourniquets has to come off and all it did so far was allow the level of poison to build up - so when you released the tourniquet you ended up with a big concentrated dose being let loose at once instead of a small amount to slowly get through.

 

And as KC9DDI alluded to, in cases where there is clean amputation, muscle, nerves and arteries and viens tend to pull back and close off quite q bit. It's not the same as cutting a waterline and watching a full diameter pipe spray out under full volume.

 

With clean amputation( and by clean, I do not mean butcher shop meat slicer neat) blood flow is way less.

 

One more thing: Supose you have a nasty gash on your calf. You do not just put a tourniquet at your knee to stop blood flow. Why? Because you stop blood flow to everything below the tourniqet if you do. This means you are starving your entire calf ( not just the cut) the front of your leg, your foot, ankle, toes, etc...of bllod and oxygen.

 

The best thing to do is apply pressure to the wound and elevate if possible.

 

Again, that was back when I was running EMS. I'm not going to even try and guess how many times protocol and standard operating procedures have changed back then.

 

 

KC9DDI..... what was your policy of MAST trousers?

Bet it was about the same as ours.

 

Can't tell you how many times we put them on for wrecks, but I think we only ever inflated them once

at the direction of the dr on call at the hospital.

 

[Eagle92]

SMART ALACK ALERT:

 

Does anybody even know how many times it has been updated, changed, modified, changed again in the last 20 years?

 

major changes in 2011, 2006, 2001. 1996, 1991 Update on compression only 2008 or thereabouts.

 

SMART ALACK ALERT OVER

 

Seriously I also do not like the current approach to doing FA: basically watching a video with little hands on. Sorry I think it needs more hands on, and I say that my FA MB class from summer camp way back when is STILL the best class b/c we had a lot of hands on in realistic outdoor situations.

 

Now AHA's watching a video and then doing it with the video is OK, But I can go to sleep since I've seen it so many times.

[Scoutfish]

Absolutely hand on!

 

The FA class I taught to our sister troop was totally hands on. Brought a pack of magic markets and bologna with me. Drew wounds, drew cuts, made bologna injuries.

 

Every scout had a turn being the victim and getting carried, bandaged, worked on , etc..... by the rest of the scouts.

 

Nothing beats handsw on.