Tourniquets

[Bieber]

So I was just watching Cops ('cause I'm that cool) and they had a guy call 911 because he had shot up some speed and, thinking he had taken an overdose, used a lamp cord as a tourniquet thinking that would stop it from entering his system. The cops cut the cord off of him (his arm distal to the cord was blue and purple) and he was transported by EMS, however it got me thinking. Exactly what IS the appropriate treatment for makeshift tourniquets? I know that the rule is to not release a medical tourniquet once placed, but do the same rules apply for makeshift tourniquets? Especially if they've been MacGyvered from unsafe tourniquet materials such as string or rope? It seems like the obvious answer should be to leave it there, but I'm not too proud to admit that this isn't something that came up often during paramedic school for me and seeing it on that TV show got me curious.

So what do you guys think? Am I just over thinking this or should we remove unsafe tourniquets if they're in place prior to our arrival? I did a bit of reading and according to at least on article I read there is actually a fairly low risk of complications of tourniquet use or removal such as rhabdomyolysis, artery or nerve damage.

[tcripp]

To this specific scenario, did they give any indication as to how long that tourniquet had been in place?

[Chief1C]

Can't say I've ever consider this scenario myself, either. Maybe we could get one of our Forum Physicians to chime in?

If the arm was blue and purple, I'm guessing it was on there for quite some period of time. Granted, the only time I've ever used a TK, was on someone who didn't have an extremity to turn blue or purple.

[ERDoc]

I doubt you will be able to find any randomized, double-blind, placebo controlled trials addressing this issue. In something like this, it is going to be best guess medicine. Put 10 doctors in a room to discuss it and you will get 14 different opinions. My take on it is, take it off. If the arm is changing colors, the torniquet was probably too tight and cutting off arterial flow. 4c6 brings up a good thought, how long has it been on for? I would assume not too long given the scenario but I guess when you are trying to get high anything is possible.

[Bieber]

I don't recall anyone stating in the show how long the tourniquet had been on. The guy had intact neurological function and his arm pinked up again after they got the tourniquet off, though it looked darker red than the rest of him. Didn't look swollen or anything. I would assume that he called 911 right after or as he was putting it on because in one scene he was still wrapping more cord around his arm.

Now you all know what my preceptors had to deal with, me thinking of the most obscure scenarios and asking them what they would do in them.

[Doczilla]

I agree with ER Doc to just take it off. You've got 6 hours of cold ischemic time before you have to worry about lactic acidosis that would be clinically significant.

'zilla

[46Young]

Would having a tourniquet on for several hours bear any similarity to crush syndrome? Should we worry about admin. IV fluids, bicarb, an albuterol neb if signs of hyperkalemia? Obviously this would apply to an entire limb, not a hand tied off at the lower forearm, or some other insignificant amount of tissue. I'd worry about renal failure, to for starters..

[tniuqs]

46 agreed with your post, this also could be compared similar effects observed in suspension trauma. The exact cause is hypothesised. A basic document http://www.stagesafe.co.uk/user_files/Suspension-trauma.pdf There are bedside blood test strips available for Myoglobin that could prove to be very valuable in our future of EMS.

I doubt you will be able to find any randomized, double-blind, placebo controlled trials addressing this issue. In something like this, it is going to be best guess medicine.

But you will find a plethora of first aid courses and over 30 years old condemning Tourniquets. Now with permissive hypo tension in the polytrauma patient the current "trend" so as to not screw up electrolytes and negatively affect clotting factors (ie make pink cool aid) the research I believe is thanks to to IED injuries experience and efficacy of Tourniquets over in the sandbox, we just could be lagging behind in public delivery of care.

I believe there is some studies, well in UK military .. I did not time to look through all the pdfs but if I remember correctly there is some reference burred in BTALS. I think it was a 90 minutes limits but then again most made for TV shows only last 60 min ? http://www.ciomr.org/en/service/res/MilTC/batls

That said the Brits had a better survival rate of wounded in the Falklands than the US did in Viet Nam ... yes a different environmental playing never the less "jolly good info"

Put 10 doctors in a room to discuss it and you will get 14 different opinions.

OK that just straight up hit my funny bone ... so true.

My take on it is, take it off. If the arm is changing colors, the torniquet was probably too tight and cutting off arterial flow. 4c6 brings up a good thought, how long has it been on for? I would assume not too long given the scenario but I guess when you are trying to get high anything is possible

I have used T's in Industry for a crushed leg and a de gloving arm injury, after the T was applied and then good dressings I slowly decrease pressure and observe for big leaks .. my plan is not to loose as much of the red stuff .. then I do not need as much as the salty water stuff to make up the difference.

ps really wasted posting this ... long day but a worth while thread.

cheers