tourniquet

[LSkylizard]

Topic kind of came up previously in relation to the military. I provide this information with the reminder that this comes from a military/combat perspective.

...It is a mistake to think that some bleeding is good because it will provide some blood to the limb...The practice of occasionally loosening the tourniquet to get some blood to the limb frequently results in a dead patient. Do not do this.

...In reality, tourniquets can be left on for several hours without permanent damage being done. Thousands of orthopedic surgeries are performed every day with tourniquets left in place for up to two hours without limb damage or loss. However, the longer the tourniquet is left in place the more potential damage that will ensue. If a limb with a tourniquet applied is kept cool, but not allowed to freeze, it extends the time a tourniquet can be left in place substantially...

...when do we remove the tourniquet? The rule of thumb should be to remove the tourniquet as soon as tactically and or medically feasible...Are there now medical personnel available who have more experience in controlling hemorrhage with additional supplies like hemostatic bandages or hemostatic powder? If so, they can be utilized and the tourniquet can be loosened, but make sure the tourniquet is still in place incase the other means of hemorrhage control doesn’t work. Also make sure that any resuscitation fluids are given BEFORE loosening the tourniquet.

...there may be certain times when the bleeding cannot be controlled by any other means, and the tourniquet will need to be left in place. In these instances it is better to risk potentially sacrificing the limb rather than to lose the casualty to fatal bleeding. If the soldier is in shock, do not remove the tourniquet. Finally, if the tourniquet has been on for 6 or more hours, don’t remove it...

You should always ask yourself if your survival objectives are equal to those providing you the guidelines and protocols (i.e. hikers vs combat surgeons). Remember, just because the military does it does not mean it is appropraite for you or your situation.

 

[Cliff Stamp]

From an individual survival mindset, how do you judge if this is the approach to use. Aside from the obvious as in your leg is cut off or similar, at what point do you have to move beyond pressure and elevation? If one pressure bandage rapidly soaks through, say in seconds, and so does another, for example just as rapidly? Assuming you do actually apply one, what do you do then once the bleeding has stopped?

-Cliff

 

[LSkylizard]

From an individual survival mindset, how do you judge if this is the approach to use...at what point do you have to move beyond pressure and elevation? If one pressure bandage rapidly soaks through, say in seconds, and so does another, for example just as rapidly? Assuming you do actually apply one, what do you do then once the bleeding has stopped?...

So, let me address this in as "vague" a manner as I can. I think some of the answers are already in my original post. It will be impossible to teach in this forum all the finer answers to every situation. I will apply one in the field and leave it in place until I can evac the soldier or I have superior means to control hemorrhage. In the trauma room, we apply until the patient arrives into the Operating Room (OR) and adequate fluid resuscitation has been achieved.

You shouldn't be using a tourniquet (TQ) unless you are properly trained In proper use and timing of use.
Second, if direct pressure is not working as you imply in your question, direct pressure is NOT the answer.

Third, a TQ is not an intermediate step to give your body time to stop bleeding. If you require a TQ to stop bleeding/control hemorrhage, your next step should be evac to obtain higher level of care.

...It is a mistake to think that some bleeding is good because it will provide some blood to the limb...The practice of occasionally loosening the tourniquet to get some blood to the limb frequently results in a dead patient. Do not do this...

...when do we remove the tourniquet? The rule of thumb should be to remove the tourniquet as soon as tactically and or medically feasible...Are there now medical personnel available who have more experience in controlling hemorrhage with additional supplies like hemostatic bandages or hemostatic powder? If so, they can be utilized and the tourniquet can be loosened, but make sure the tourniquet is still in place incase the other means of hemorrhage control doesn’t work. Also make sure that any resuscitation fluids are given BEFORE loosening the tourniquet.

...there may be certain times when the bleeding cannot be controlled by any other means, and the tourniquet will need to be left in place. In these instances it is better to risk potentially sacrificing the limb rather than to lose the casualty to fatal bleeding. If the soldier is in shock, do not remove the tourniquet. Finally, if the tourniquet has been on for 6 or more hours, don’t remove it...

It is really important that one does not confuse knowing about some practices with being the same thing as knowing how...

LSkylizard

 

[RickJ]

Well said! Are you an Army Medic?

 

[Cliff Stamp]

Second, if direct pressure is not working as you imply in your question, direct pressure is NOT the answer.

That is self obvious, my question was at point do you have to consider other options (what are the criteria that you use to judge this point) and what other options should be performed?

If you require a TQ to stop bleeding/control hemorrhage, your next step should be evac to obtain higher level of care.

That is always the central goal in a survival situation, getting out of it. However it isn't always possible to rely on immediate rescue, thus the need to know how to start a fire, build a shelter, get food/water etc. .

-Cliff

 

[LSkylizard]

...Assuming you do actually apply one, what do you do then once the bleeding has stopped?...

Let me address this question from a different angle.
Hemorrhage should stop after applying a TQ. That is the objective. If hemorrhage has NOT stopped, you have TQ failure and need to reassess your application. It (hemorrhage) will always stop with a properly placed TQ above the wound on the affected extremity.

Should it be the case that you can not apply a TQ properly for some reason (in a patient/victim that requires one), you should make them as comfortable as possible and start digging a hole once they pass out so their corpse does not attract unwanted wildlife.

Bottom line, civilians engaging in "wilderness" activities should always maintain a means of contacting civilization for rescue. Do not travel alone. Take obvious safety measures when enterring the wilderness... failure to do so can result in death.

 

[LSkylizard]

...what are the criteria that you use to judge this point) and what other options should be performed?...

This is easy for me because I deal with hemorrhage on a daily bases. I know what is treatable with pressure and what is treatable with some skin sutures/staples. I know when a patient is pumping out. I can NOT teach these things to you in this forum. You will require formal schooling to have that answer.

If you are alone (and stupid), hemorrhaging out, do not know jack about ATLS, are not trained in surgery, are not trained in trauma, have no means of contacting civilization (still stupid), and/or have nothing else at your disposal(terminally stupid), you are going to die so knock yourself out... put hot iron into it, put mud into it, or anything else you think you know from the movies or websites (the sepsis will then get you). I would never do that. I do NOT endorse that. But, I am sure people are going to bring the "trapped alone on Mars" scenarios.

LSkylizard

 

[skammer]

Lizard,

This is again about long term first aid. Sure nobody is arguing that a TQ is a good thing in all cases as its not. But then again a TQ with a massive femoral bleed is a serious time sensitive issue with no surgeons around to save the day, and it doesn't take much of a brain to cut off the plumbing to the leaky pipe 24 hrs from an ER.

Battlefield first aid teaches TQ's because it saves lives and is documented war after war to do so when used correctly. The same applies to using a TQ on a distant or remote patient who will die otherwise. If you need a TQ, infection and sepsis is the least of your worries.

Hikers Vs Combat Surgeons huh???
A severed femoral artery is a severed femoral artery hiker, combat or whatever unless there is a hospital within quick reach you may need a TQ.

Of course direct pressure stops the vast majority of bleeding but in the case above a TQ maybe warranted and one should learn how to apply it correctly to minimize limb damage if possible. At the end of the day stop the bleeding with pressure if possible if not with a TQ and hope for the best. Otherwise you are dead so it wont matter.


Skam

 

[LSkylizard]

Skam

I am not sure you have stated anything different or new then what I have posted (except commenting about cutting plumbing), but OK...(not saying OK to "cutting plumbing").

...Hikers Vs Combat Surgeons huh???
A severed femoral artery is a severed femoral artery hiker, combat or whatever unless there is a hospital within quick reach you may need a TQ...

...It is a mistake to think that some bleeding is good because it will provide some blood to the limb...The practice of occasionally loosening the tourniquet to get some blood to the limb frequently results in a dead patient. Do not do this.

...In reality, tourniquets can be left on for several hours without permanent damage being done. Thousands of orthopedic surgeries are performed every day with tourniquets left in place for up to two hours without limb damage or loss...

...when do we remove the tourniquet? The rule of thumb should be to remove the tourniquet as soon as tactically and or medically feasible...make sure that any resuscitation fluids are given BEFORE loosening the tourniquet...

The difference would be the tactical aspect and/or limitations. Sometimes you stop the bleeding to allow the soldier/s to focus on killing the enemy. In the ideal world, a hiker can be evacuated quicker then a wounded soldier under fire.

Another aspect you need to consider is where the "femoral artery" is injured. A high injury would actually preclude a TQ being used. I will avoid the temptation to discuss anatomy with you as you obviously understand all the plumbing.

PS: Skam & Stamp, though, I do find you replies and comments to sometimes be amusing when they are not dangerous; the two of you seem to want so much to be able to function like physicians & surgeons... I would suggest you go to school and do so...

 

[FlightMedic]

Let me address this question from a different angle.
Hemorrhage should stop after applying a TQ. That is the objective. If hemorrhage has NOT stopped, you have TQ failure and need to reassess your application. It (hemorrhage) will always stop with a properly placed TQ above the wound on the affected extremity.

Should it be the case that you can not apply a TQ properly for some reason (in a patient/victim that requires one), you should make them as comfortable as possible and start digging a hole once they pass out so their corpse does not attract unwanted wildlife.

Bottom line, civilians engaging in "wilderness" activities should always maintain a means of contacting civilization for rescue. Do not travel alone. Take obvious safety measures when enterring the wilderness... failure to do so can result in death.

Very Well Said. Those who fail to plan...Plan to fail. We need to always keep in our front brain.. Risks Vs Benefits. and use common sence.

 

[Ravaillac]

From my civilian first aid worker training (done by red-cross medical doctor):
Tourniquet should be used only when no other method (compressive bandage, compression points...) is not possible or effective. When applied always keep notice of the hour it was set.
Loosening tourniquet should always be monitored by professional medical worker, as it may result into an heart attack/shock, resulting in death.
Tourniquet should stop or at least significantly reduce hemorrage. If not, you should try again.
Applying tourniquet always create risks for permanent nerve damages, and ultimately loosing concerned limb. You have to balance this with other needs such as taking care of several patients in critical conditions, leaving patient alone to find some rescue...

 

[skammer]

Skam
In the ideal world, a hiker can be evacuated quicker then a wounded soldier under fire.


PS: Skam & Stamp, though, I do find you replies and comments to sometimes be amusing when they are not dangerous; the two of you seem to want so much to be able to function like physicians & surgeons... I would suggest you go to school and do so...

Liz,

You amuse me.

There are plenty of situations where a hiker is hell and gone from help (Arron Ralston being one) and most military injuries have full medical support nearby or at least close granted it maybe under fire.

Yes, the common sense, tell someone and cell phone routine is of help but rescue is not imminent nor easy for many lost or injured people. It can take 24 hrs to evac someone half a mile in the bush depending on situation.

The facts are you are NOT a wilderness medicine expert so criticising wilderness training should only happen within your DR peer group. I gave you the people to contact and complain to?

Don't fire shots at me or others who are just following protocols we were trained for and can validate.

Bark up your peer groups tree Doc this is the wrong forum as I did not learn wilderness casualty care from you and you have done nothing to contribute to that education and apparently haven't the guts to confront those peers on your issue with THEIR protocols not mine. When this has been done get back to me with the new protocols and I will adopt them. Until then, you are like everyone else here, words to be taken with a grain of salt.

For the record I never claimed to be or wanna be a surgeon. I/we are talking first aid here not operating rooms, I thought that was obvious, apparently not.

Up until now I have not gotten personal but you have and feel the need to demean.:thumbdn: I would suggest you go back to school and get some bedside manners and while you are there take a basic wilderness first aid course. Of course your patients maybe stupid, more stupid or terminally stupid.


Rant off.

Skam

 

[LSkylizard]

Skam...I am not sure you have stated anything different or new then what I have posted (except commenting about cutting plumbing), but OK...(not saying OK to "cutting plumbing")...

...common sense, tell someone and cell phone routine is of help but rescue is not imminent nor easy for many lost or injured people...

...I gave you the people to contact and complain to?...Don't fire shots at me or others who are just following protocols we were trained for and can validate...

If you are spreading a certain protocol then you should stand-up and defend and know what you are defending. I do not advise you spread some teaching and then duck from challenges with ~"don't complain to me I'm just the messenger":thumbdn:


What are you are saying you do with a TQ from your wilderness "training"? You have yet to say. I have read your replies repeatedly. I have found comments without content. What are you trying to say different on this topic? You posted about wilderness protocols...yet have posted none in reference to this topic? Maybe you were thinking of a point but did not post it.
Are you suggesting you do wilderness first aid surgery...operate on the femoral artery??? Are you suggesting you intermittently release/open the TQ??? Or, are you suggesting nothing because you are just the messenger and not sure what you are saying???
I appreciate you have some reading in this area (maybe a booklet or maybe a course?). However, you do NOT seem ready, willing or able to support "something" as
1. you refer me to a wilderness first aid training group
2. You really haven't said much different yet but only hinted at a difference.


Another point, I did post this from a military/combat perspective. you first state:

...Hikers Vs Combat Surgeons huh???
A severed femoral artery is a severed femoral artery hiker, combat or whatever unless there is a hospital within quick reach you may need a TQ...

Now you write:

...There are plenty of situations where a hiker is hell and gone from help... and most military injuries have full medical support nearby or at least close granted it maybe under fire...

...When this has been done get back to me with the new protocols and I will adopt them. Until then, you are like everyone else here, words to be taken with a grain of salt...

Yes, I think I shall run off and do as you say...immediately. Far be it from me to question you without following the proper protocol to do so. I feel such an obligation to give you a broad and thorough education. It should be every physicians objective to to dedicate their time to dispelling the protocols YOU seem so vested in upholding... what is this like religion to you? It is clear that all these topics should be screened by you (but posted only after your superiors have been rebuked) prior to posting. Of course, I should take what you say as gospel because of the extensive training and experience you have in the area of first responding. My training and understanding in human anatomy, physiology, shock, resuscitation, trauma are of course irrelevent because you (sorry, I forget, your higher powers) say so (I shall be but a grain of salt).

...is superior to formal medical education and years of professional experience. I believe there is a term for that - Hubris...

 

[Temper]

Uh oh Skam has lit another fuse

*quickly digs fox hole

 

[LSkylizard]

From my civilian first aid worker training (done by red-cross medical doctor): ...Loosening tourniquet should always be monitored by professional medical worker, as it may result into an heart attack/shock, resulting in death...

This is actually a significant point. Without going into the physiology too much, opening/releasing a TQ is akin to blowing a hole in the second floor while you are standing on it. The floor falls out under you. Basically, you loose peripheral pressure and perfussion fails. Hemorrhage and resultant hypovolemia result in a "distributive shock". The response to low volume is peripheral constriction (decrease the "tank" size) with increased heart rate (increase cardiac output). You apply the TQ. Ideally get some fluids into the patient (by IV preferred, but maybe drinking if no other option). The individual settles out. Some of the compensation measures relax. The peripheral vaso-constriction/tone decreases and the heart rate comes down. Why? because, TQ has abated the hemorrhage and your body is in a compensation mode. Now, say you have not really tanked the patient up with fluids. You release the TQ and there is no longer the peripheral vascular tone from previous and boom...the floor drops out and the the tank is relatively empty...no resistance to flow through the vessels draining to air (infinite sized tank)!

Needless to say, it can be a problem. Even worse when you are all alone and you suddenly pass out from drop in blood pressure from releasing the TQ...no longterm survival, not alot of first aid.

...It is a mistake to think that some bleeding is good because it will provide some blood to the limb...The practice of occasionally loosening the tourniquet to get some blood to the limb frequently results in a dead patient. Do not do this.
...when do we remove the tourniquet? The rule of thumb should be to remove the tourniquet as soon as tactically and or medically feasible...make sure that any resuscitation fluids are given BEFORE loosening the tourniquet...

The "austere wilderness" not withstanding, I dare say (though it may NOT be "protocol" and I may have no clue about it) human anatomy and physiology do not change for the positive once you exit civilization . If it is dangerous to loosen a TQ 1/2 hour out from a hospital it does not become less so 24 hours out from a hospital. You could even make the argument that low levels of decreased nutrition and dehydration would make the situation more dangerous.*


*Though there is evidence that says a degree of hypothermia can prolong survival in a certain shock situation...but that is a whole other matter...for another thread (I am NOT advocating hypothermia as a treatment in the woods).

 

[skammer]

Lizzy,

I am tired:yawn: .

I am a Wilderness Medical First Responder or WMFR.

It does make me qualified to speak to what I have been trained for. I refuse to get into a my proof vs yours as I know I am right and I know what I am doing in the field and thats good enough for me. Besides you bore me to tears and you troll like a sailfishing tourist.

Again (for the learning impared ) Liz take it up with your peers not me.

Heres a couple to start you off.

Dr Paul S. Auerbach, MD, MS; Clinical Professor of Surgery, Div Emergency Med., Stanford Univ School of Medicine, CA.
And
Dr Eric A Weiss, is the Associate Director of the Trauma Service at Stanford Medical Center and Assistant Professor of Emergency Medicine at Stanford University. He is an Expedition Physician and medical consultant for the National Geographic Society, a member of the Board of Directors of the Wilderness Medical Society, and Medical Consultant for the U.S. Army Special Forces.

The 2 above helped shape the protocols for the organization below and whos protocols are what I am following. Both are extensive writers on the subject look them up on amazon.

Contact http://www.wemsi.org for all the information you want to know and or question, they will gladly get back to you I am sure. Please let us know how it goes.

I am too tired these days.:yawn:

Skam

 

[LSkylizard]

...I am a Wilderness Medical First Responder or WMFR...

Good. My only point with regards to your "participation" in this thread is that you have not said anything. You have posted NO opposing view. You have failed to state what you disagree with in my posting of this thread. You have simply demonstrated you are tired. That of course is your own choice.

Have a nice day.

 

[skammer]

Good. My only point with regards to your "participation" in this thread is that you have not said anything. You have posted NO opposing view. You have failed to state what you disagree with in my posting of this thread. You have simply demonstrated you are tired. That of course is your own choice.

Have a nice day.

Err ok

I did not agressively challenge as I am not willing to educate you as its pointless and thats why I am tired.

In your mind you know all about wilderness medicine so there is no point in even discussing it.

A waste of time.:yawn:

Let us know how your peer review on the subject goes.

Skam

 

[RunzWithScissors]

I too am a first responder. We operate in the rugged mountains of Southern AZ , often hours away from a road or a helicopter landing sight. We were taught never to apply a tourniquet. If we feel one is needed as an option of last resort we have to get the doctors ok over the radio.

The application of a tourniquet can do more harm than good causing damage to nerves muscles and blood vessels. They are also often used improperly.

"It does make me qualified to speak to what I have been trained for. I refuse to get into a my proof vs yours as I know I am right and I know what I am doing in the field and thats good enough for me."

I don't know where you first respond, since every bit of information about you is classified but I doubt the people in your organization condone this type of attitude.


Chad

 

[LSkylizard]

Not sure what Skammer's point is??? The following is from his gospel WEMSI:

…On occasion, you may find it difficult to adequately stop bleeding, because you can't precisely identify the bleeding vessels. In such a situation, you may be able to use a temporary tourniquet as a tool to identify the bleeding sites.
…you can use a tourniquet to locate the bleeding vessels; you then apply direct pressure, and release the tourniquet.
…However, you shouldn't need a tourniquet for more than a few minutes. (You should only apply a tourniquet with on-line medical command or standing orders from your medical director)…

The following are items from the US Military on this topic.

…If you're shot in the main artery in the thigh—the femoral artery—you can easily lose a liter of blood a minute. It takes a trained medic about 4.4 minutes to apply the improvised tourniquet, and the human has about five liters of blood. That's one liter a minute, 4.4 minutes, and you only have five liters. You can do the math and figure out what the problem is.…

… the big change in the doctrine is allowing medics to remove the tourniquet and switch to a less damaging wound dressing (i.e. advanced hemostatic dressing) (Special Operations forces have changed their doctrine to allow medics to use them (TQ), especially in conjunction with hemostatic dressings)

…Ideally…we will develop tourniquets and dressings to the point that a tourniquet can be applied as temporary vascular control, just to get the bleeding under control. Then an advanced hemostatic dressing of some kind … gets placed on there and the tourniquet can come off…

... The rule of thumb should be to remove the tourniquet as soon as tactically and or medically feasible...Are there now medical personnel available who have more experience in controlling hemorrhage with additional supplies like hemostatic bandages or hemostatic powder?
…Also make sure that any resuscitation fluids are given BEFORE loosening the tourniquet.
... If the soldier is in shock, do not remove the tourniquet...

...The military....nobody has more experience than they do with dirty wounds...

Dr. Anthony Pusateri works with hemostatic—blood-stopping—dressings and powders at the U.S. Army Institute of Surgical.

I think this topic is done. Not sure what Skammer was trying to say but doesn't matter.