NREMT Bringing back Tourniquets !!??

[Arizonaffcep]

Funny you should say that, the last guy I had who honestly needed a tourniquet also had a misshap with a plate glass window after tying one on. I think I even did a post about it discussing glass injuries and exsanguination. All I can say is that this guy had transected literally everything right down to the mid humerus. It looked like a beef roast.

Had that for dinner...soooooo good!

[Eydawn]

So what is the justification behind the changes? The last I heard on the 'no tourniquet' bandwagon was that the body knows to shut off its own exsanguination...

Are we figuring that minor tissue damage = better than death now? Either way... it should be a procedure that's tried towards the end of the toolbox, not the beginning...

Wendy

CO EMT-B

[Arizonaffcep]

So what is the justification behind the changes? The last I heard on the 'no tourniquet' bandwagon was that the body knows to shut off its own exsanguination...

Are we figuring that minor tissue damage = better than death now? Either way... it should be a procedure that's tried towards the end of the toolbox, not the beginning...

Wendy

CO EMT-B

And it does! The body is smart! It starts a huge chemical release to try to clamp down on the bleeding vessles, plus you've got the whole clotting cascade going on. The problem...the bleeding can be more than the body can handle. That and the body can "run out" of clotting factors (ie, they've been used up, to no avail), leading to DIC. A tourniquet is ment for such instances...which usually manifests itself as arterial bleeds.

Here's a link if you want to read up on clotting cascade stuff...

http://themedicalbiochemistrypage.org/blood-coagulation.html

[Asysin2leads]

And it does! The body is smart! It starts a huge chemical release to try to clamp down on the bleeding vessles, plus you've got the whole clotting cascade going on. The problem...the bleeding can be more than the body can handle. That and the body can "run out" of clotting factors (ie, they've been used up, to no avail), leading to DIC. A tourniquet is ment for such instances...which usually manifests itself as arterial bleeds.

Here's a link if you want to read up on clotting cascade stuff...

http://themedicalbiochemistrypage.org/blood-coagulation.html

I think its simpler than that. I think the problem was that too many uneducated, inexperienced providers were seeing some blood and tying a tourniquet when it wasn't necessary. Perhaps they were of the same conclusion that you and I came too, which is that the body has some excellent compensatory mechanisms for dealing with blood loss, and that the window for use of a tourniquet is actually quite small in the civilian arena. I have seen many amputations. The plate glass window guy was the first and since only that I could honestly say was in danger of exsanguination. That includes several mid-femur transections. I'm still not exactly sure what it is about glass cuts that make them so dangerous, but they really are bad.

[p3medic]

... it should be a procedure that's tried towards the end of the toolbox, not the beginning...

Wendy

CO EMT-B

Why wait for the patient to exanguinate before applying a tourniquet? Every time the heart beats you could be losing another 80mL of blood, trying (and failing) to stop bleeding with direct pressure, elevation, pressure point etc will take how long? Any patient with an apparent exanguinating hemorhage in shock should have a tq applied if in a location suitable for one. There is plenty of research out there showing that the concern of limb loss or massive tissue destruction caused by tourniquets is urban lengend, the fear of causing harm is causing harm.

[Krysteen]

There is plenty of research out there showing that the concern of limb loss or massive tissue destruction caused by tourniquets is urban lengend, the fear of causing harm is causing harm.

Never once have I ever been educated that the dangers of tourniquet application are just urban legends. However I have been taught that the risks increase if the time from when the application is applied to definitive care is beyond 90 minutes, meaning application to surgery. Are you able to provide some information on this research?

the safest approach in the case of the marginally trained and inexperienced person with basic first aid training is probably to rely upon simple direct pressure or basic forms of pressure dressing. This is due to a lack of evidence that such persons can effectively recognize the need for a tourniquet and properly apply such a device- especially given the likely need to improvise under such circumstances.

Unless they are properly trained to recognize the difference between a strong venous or arterial bleed, and how to properly assess after the fact, especially in the rural setting, this can be dangerous. I can see the fact that they can "do it", will lead them to just do it without proper assessment.

The rapid employment of tourniquets may also provide an opportunity to improve the prognosis for those who might otherwise not receive care due to the severity of their injuries in a mass casualty situation where triage principles are applied. The expedient control of extremity hemorrhage may allow a few of these patients to survive long enough for them to be evacuated even when a medic may be forced to move on to another patient due to prioritization.

I do not disagree with the application. As in instances such as above, the benefit will outweigh the risk.

The use of tourniquets, while beneficial to many of those wound in combat or with otherwise uncontrollable bleeding, is not without its hazards and potential complications. Any use of a tourniquet must be with full awareness of the risks involved and to brush these aside would be to abandon one of the basic tenets of evidence based medical practice.

Exactly, all stems down to proper education. Which is not at all on the top of the list to some places these days. See http://www.emtcity.com/forum/index.php?sho...ic=14293&hl=

Most of the complications stemming from tourniquet use are either the result of direct pressure on underlying tissues or the byproducts of ischemia distal to the site of application. While most of the complications that have been reported in association with their use (both for control of hemorrhage and as an adjunct to surgery) have been localized, there are systemic complications that can result including thromboembolic events [78], most notably pulmonary embolism; renal failure due to rhabdomyolysis [79-84]; lactic and respiratory acidosis, hyperkalemia, arrhythmias, and shock[85].

Full Article:http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2151059