Did you ever use a tourniquet?

[tniuqs]

These are being manufactured for CAF a friend Brian Kroon that is ex PPCLI textiles specialist.

http://www.dropzonetactical.com/

Click on ZULY NINE

I just may know his medical advisor te he.

[Chief1C]

I had a buddy give me one that looks like that, about two years ago, when they were only available in gov't contract catalogs from North American Rescue. We did our own in house training, using an IV Dummy arm, a bad of red watery stage blood, and a BP cuff for pressure. It ruins the arm, so I suggest inventing something, like a rubber hose in a roll of foam-rubber. I found that when your hands get sticky-wet, or greasy-wet, like they are when you have copious amounts of human blood on them (on your gloves). That the little baton slips, the pressure doesn't slip much, but it was difficult to set with one hand. I still have one in my forestry coat (chain saws), but I switched to the Mechanical Advantage Tourniquet for my kits and the ambulance..as I'm the supply guy. We use what I feel is best economically, which doesn't necessarily mean what's cheap. The commonwealth supplied us with eight Combat Action Tourniquets, four for an ambulance, two for a squad unit.

Edited July 24, 2011 by 2c4

[JMedic]

The Hudson Valley Region just re-approved, and effective immediatly, the use of turniquets. The deal is, you should apply direct pressure, and continuosly apply dressings to the wound. If this does not work, we use QuikClot dressings which absorb and "seal" up the blood leak, granted it's a vein or artery. If this does not work, we will now be allowed to place a turniquet closest to the laceration. We are allowed up to 2 turniquets be applied.

Also, studies show no more elevating the legs, because the pressure from lower extremities push on the diaphram to labor breathing.

Interesting what time and study will do.

[Chief1C]

Raising the legs is an assumed treatment, like many things, it's not covered by our protocols. Just one of many things you're expected to know what to do, and when to do it; as it's needed.

[Bernhard]

Raising the legs is an assumed treatment, like many things, it's not covered by our protocols. Just one of many things you're expected to know what to do, and when to do it; as it's needed.

Really? It helps what?

Contraindications are too much to consider this as a treatment plan of severe shock/trauma: painful and disturbing movement of legs/pelvis/spine, pressure on the diaphragma/lung. Plus no real benefit over a flat laying position gives a bad cost/risk ratio.

[tniuqs]

Interesting topic's and quite dear to my heart, actually discussed in great depth before, not "have you ever used one" request for war stories but the EBM is:

http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=ADA480277

NB: The study is protected from reproduction therefore I highly suggest that one reads the full meal deal, noting the conclusions, it pretty clearly smashes the old school F.A. myths of:

1- It should only be considered "last ditch"

2- That it causes damage.

3- That it can be taught in a 16 hour First Aid course.

Conclusion: Tourniquet use before shock onset saves more lives than

after shock; use them before extraction or transport.

Logically the idea of placing secondary Pressure Dressing over a Pressure Dressing that has not arrested life threatening bleeding (the theory being that it will dislodge clots) is false, akin to the idea of putting another diaper on a child that has pooped in the first diaper. In passing in one post it appears the Student has now become the Teacher.

Forgive the extensive data I provide concerning Trandelenberg and the associated EBM studies, but it become fairly clear that the 16 hour first aid course or EMT or Paramedic programs still stuck in the paradigm are not doing anyone any favours.

Db=pubmed&Cmd=ShowDetailView&TermToSearch=16120887&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

The Neurointensive Care Unit, Vanderbilt University Medical Center, Nashville, TN, USA.

OBJECTIVE: To review the literature on use of the Trendelenburg position as a position for resuscitation of patients who are hypotensive. METHODS: PubMed online, cited bibliographies, critical care textbooks, and Advanced Cardiac Life Support guidelines were searched for information on the position used for resuscitation. Because of the heterogeneity of the data, only pertinent articles and chapters were summarized. RESULTS: Eight peer-reviewed publications on the position used for resuscitation were found. Pertinent information from 2 critical care textbooks and from the Advanced Cardiac Life Support guidelines was included in the review. Literature on the position was scarce, lacked strength, and seemed to be guided by "expert opinion." CONCLUSION: The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.

PMID: 16120887 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7762369&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

Martin JT.

The steep head down tilt surgical posture, popularized in the 1870s by Trendelenburg as a means of improving access to pelvic pathology and espoused by the American physiologist, Walter Cannon, during World War I as a resuscitative position with which to treat shock, has a history of widespread, ritualistic acceptance. An awake patient placed in steep head down tilt usually objects to the posture after only a short time. Now recognized as potentially harmful in the presence of cardiac, pulmonary, ocular, and central nervous system pathology and essentially useless for vascular resuscitation, steep tilt should be limited to selected circumstances in which alternatives are unacceptable. Shallow head down tilt, a more recent variety, also offers serious questions about its surgical usefulness as well as its applicability for patients with diseased hearts, lungs, and heads. As an aid to resuscitative procedures, the contoured supine position offers assets that merit serious consideration. Means of restraining a tilted patient on an operating table include wristlets, shoulder braces, and bent knees with ankle restraints. Considerations that aid in the selection of head down tilt are presented, as is a plea for the abandonment of the Trendelenburg eponym and a suggestion for future investigation.

PMID: 7762369 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8135435&ordinalpos=17&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Department of Surgery, Graduate Hospital, Philadelphia.

STUDY OBJECTIVE: To evaluate the effect of the Trendelenburg position on oxygen transport in hypovolemic patients. DESIGN: A prospective, self-controlled sequential design. INTERVENTIONS: All patients had indwelling pulmonary artery catheters, and hypovolemia was confirmed by a pulmonary artery wedge pressure of 6 mm Hg or less. Hemodynamic and oxygen transport variables were measured with the patient supine and again ten minutes after placing the patient in the Trendelenburg position. SETTING: University-affiliated tertiary care surgical ICU. TYPE OF PARTICIPANTS: Eight postoperative adults. RESULTS: Mean arterial blood pressure increased from 64.9 +/- 4.9 to 75.6 +/- 3.5 mm Hg (P < .05), pulmonary artery wedge pressure increased from 4.6 +/- 1.1 to 7.9 +/- 0.8 mm Hg (P < .05), and the systemic vascular resistance rose to 2,965 +/- 210 from 2,302 +/- 199 dyne.sec/cm5 (P < .05). There was no significant change in cardiac index, oxygen delivery, oxygen consumption, or oxygen extraction ratio. CONCLUSION: The increase in blood pressure from Trendelenburg position is not associated with an improvement in blood flow or tissue oxygenation.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8000462&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

Ostrow CL, Hupp E, Topjian D.

West Virginia University School of Nursing, Morgantown 26506.

BACKGROUND: Although we have insufficient knowledge about the effects of Trendelenburg positions on various hemodynamic parameters, these positions are frequently used to influence cardiac output and blood pressure in critically ill patients. OBJECTIVES: To determine the effect of Trendelenburg and modified Trendelenburg positions on five dependent variables: cardiac output, cardiac index, mean arterial pressure, systemic vascular resistance, and oxygenation in critically ill patients. METHODS: In this preliminary study subjects were 23 cardiac surgery patients (mean age, 55; SD, 8.09) who had a pulmonary artery catheter for cardiac output determination and who were clinically stable, normovolemic and normotensive. Baseline measurements of the dependent variables were taken in the supine position. Patients were then placed in 10 degrees Trendelenburg or 30 degrees modified Trendelenburg position. The dependent variables were measured after 10 minutes in each position. A 2-period, 2-treatment crossover design with a preliminary baseline measurement was used. RESULTS: Five subjects were unable to tolerate Trendelenburg position because of nausea or pain in the sternal incision. In the 18 who were able to tolerate both position changes, no statistically significant changes were found in the five dependent variables. Changes in systemic vascular resistance over time approached statistical significance and warrant further study. CONCLUSIONS: This preliminary study does not provide support for Trendelenburg positions as a means to influence hemodynamic parameters such as cardiac output and blood pressure in normovolemic and normotensive patients.

PMID: 8000462 [PubMed - indexed for MEDLINE]

cheers

edit to add personal conclusion.

Edited July 26, 2011 by tniuqs

[Quakefire]

Never had to use one, dont really have a protocol provision for them either. I have heard for bleeding into the pelvis, the use of a large bowl and a pelvic binder, but I dont know how much internal damage that would cause.

[tniuqs]

Never had to use one, dont really have a protocol provision for them either. I have heard for bleeding into the pelvis, the use of a large bowl and a pelvic binder, but I dont know how much internal damage that would cause.

Quake, do you carry many large bowls in your Ambulance ?

We do in industry but that's for puking into or great for a nice foot bath, OH+S regs, and don't get me going on that rant .

I would file that "I heard" in the G section of data banks along with MAST Garment, Leaches and Butter on burns ++++++ just saying ...

Edited July 27, 2011 by tniuqs

[Chief1C]

Really? It helps what?

Contraindications are too much to consider this as a treatment plan of severe shock/trauma: painful and disturbing movement of legs/pelvis/spine, pressure on the diaphragma/lung. Plus no real benefit over a flat laying position gives a bad cost/risk ratio.

Just learn to read today? Just where did I say I'm for or against it? All I said was it's not covered by our protocols. Like bandaid use, how to splint something, etc. One of those go with your brain things.

[Bernhard]

Just learn to read today? Just where did I say I'm for or against it? All I said was it's not covered by our protocols. Like bandaid use, how to splint something, etc. One of those go with your brain things.

My brain told me that "Raising the legs is an assumed treatment, like many things, it's not covered by our protocols. Just one of many things you're expected to know what to do, and when to do it; as it's needed." means, it's not in the protocol but you (specific you) would do it anyway because it's an "assumed treatment" and "to do it, as it's needed" (my brain added "...even if not beeing in the protocols because it's self evident...").

Therefore my lousy brain wondered, why you think it would be needed, even outside the protocol. Sorry, if totally misunderstood your statement. No reason to personally attack my reading or thinking ability as well in a discussion.

It lead us to an important fact for the quiet lay reader anyway: there is no such thing as a life rescuing leg lift in shock, even if some protocols/books/TV shows still say this. As I recently read, the man who applied the Trendelenburg for fighting shock in World War I several years later warned about it himself. However, this detail was lost somewhere in history, lifting legs became famous.

BTW: if you have protocols, why aren't there such things as bandaids ("sterile cover") or splintings ("immobilization") covered? Just wondering. Or maybe misunderstanding.