Many different military publications cite severe hemorrhage as the #1 preventable cause of death on the battlefield. Many different military and civilian publications cite extremity hemorrhage as a common cause of significant military and civilian morbidity and mortality. In a study in Houston (published in 2005) “57% of those dying in metropolitan Houston is due to isolated penetrating extremity trauma had bleeding sites amenable to tourniquet therapy.” (1, 3, 6, 7, 9 )
There is general agreement from multiple sources for the initial management of extremity hemorrhage. Generally the first step in the control of rapid extremity bleeding is to provide direct pressure at the site of bleeding. Raising the extremity or the bleeding site above the level of the heart might also aid in hemostasis. Elevation decreases the hydrostatic pressure of venous and arterial bleeding and allows the normal physiologic mechanisms of hemostasis and coagulation to begin. Another technique to aid in hemostasis for extremities is the use of pressure points. This is done by applying strong deep pressure to the artery proximal to the site of bleeding. Traditionally pressure is applied to the brachial, axillary, femoral or popliteal artery as appropriate. There are a variety of hemostatic dressings, made of different substances that have become available over the last 8 years for use in the civilian and military communities that also can be used to stop the bleeding from extremities. (4, 5)
The factors that affect the use of a tourniquet are dependent on:
- Effective training of the user
- The type of wound or hemorrhage that is present
- Transport time to resuscitative surgery or trauma center
- Medical situation (i.e. battlefield, mass casualty event, complex disaster, traditional civilian emergency medical system response)
According to Advanced Trauma Life Support “In the worst cases, tourniquets are used. While there is a real risk of limb loss with a tourniquet, blood loss must be stopped to save the life of the patient.” (4)
This does not mean that a step wise progression of hemostasis intervention is appropriate; one does not apply direct pressure, elevate the limb, use pressure points and then place a tourniquet. If there is moderate to severe extremity bleeding a tourniquet should be placed on the casualty immediately. It should be placed close to the hemorrhage site as possible and tightened to the point where distal bleeding ceases. Once a tourniquet is applied it should be left in place until the casualty reaches a hospital or a location with resuscitative surgery capability. (2, 6, 7, 8)
Tactical Combat Casualty Care is the current U.S. military medical doctrine for medical and non-medical personnel on the battlefield. This doctrine states…“The temporary use of a tourniquet to manage life threatening extremity hemorrhage is recommended. Direct pressure and compression dressings are less desirable than tourniquets in this setting because their application at the site of injury may result in delays getting the casualty and rescuer to cover and they may provide poorer control of hemorrhage while the casualty is being moved.” (5, 8)
Dr. John Kragh, a U.S. military surgeon, studied tourniquet use in Iraq in 2006 and published a series of papers in support of tourniquet use for moderate to severe extremity hemorrhage. 97% of the tourniquets were applied for the appropriate indications. In this series of studies, 862 tourniquets were applied to 651 limbs of 499 wounded service members. These were very severe multiple wounds and of this group was an 87% survival rate. Survival rate was analyzed by when the tourniquet was applied; by the first responder/prehospital versus applied in the emergency department of the field hospital. 60% of the tourniquets were applied by the first responder/prehospital environment. The first responder/prehospital survival rate was 89% with tourniquet usage. When the tourniquet was applied in the emergency department the survival rate was 78%. Tourniquet use before shock (closely related to first responder/prehospital tourniquet application) saves more lives than tourniquets applied aftershock (in the emergency department). Another finding was that improvised tourniquets were better than no tourniquets at all. Complications, normally or anecdotally associated with tourniquet were about 1.7%. Most of these were transient nerve palsy. There were no amputations as a result of tourniquet usage. (9, 10, 11)
The U.S. military is a firm supporter of early tourniquet usage based on Kragh’s articles and others. Every service member is deployed with a tourniquet as part of their first aid kit. There are standardized training programs that are given to medical and non-medical personnel (including Tactical Combat Casualty Care) during initial and pre-deployment training.
A number of articles have advocated that it is time to reconsider civilian EMS usage based on recent US military experiences. “Emergency medical personnel, both civilian and military, should be trained in and equipped for the proper use of tourniquets…” This is especially true during manmade or naturally caused mass casualty events (MCE). The use of tourniquets in a MCE extends resources; the tourniquet can be applied and tightened and the patient’s life can be saved. A pressure dressing requires manual pressure for 5-15 minutes and the application of any type of pressure dressing does not ensure that the appropriate amount of direct pressure is applied at the correct location. (1, 2, 6, 8)
A study was conducted at the Boston Medical Center from January 1999 and April 2006. This study reviewed the presentation, treatment and outcomes of patients that came to the emergency department with a prehospital tourniquet in place. All patients were taken to the operating room for definitive care. The conclusion of the study was that “prehospital tourniquets can be appropriately applied to control life-threatening hemorrhage from an extremity injury and that their use is not associated with neurovascular complications.” (3)
A series of independent, protocol regulated, studies were conducted on a variety of commercially available tourniquets by U.S. Naval Sea Systems Command, Navy Experimental Dive Unit, between November 2005 and April 2007. In these studies the MAT® average application time was 51 seconds (with dominant hand 50 seconds, non-dominant hand 53 seconds). The MAT® was preferred by the test group users over all other tourniquets tested.