Emergency tourniquet

An emergency tourniquet is a tightly tied band applied around a body part (an arm or a leg) sometimes used in an attempt to stop severe traumatic bleeding.cite web|url=http://www.cdc.gov/nasd/docs/d000701-d000800/d000799/d000799.html|last=Cyr|first=Dawna L|coauthors=Johnson, Steven B|title=Basic First Aid|publisher=The University of Maine|date=September 2006|accessdate=2008-07-22] Tourniquets are also used during venipuncture and other medical procedures. Severe bleeding means the loss of more than 1,000 ml (1 litre) of blood. This flow of blood can soak a paper or cloth handkerchief in a few seconds. In such a situation, the bleeding will cause the death of the casualty in seconds to minutes.

In most applications, a tourniquet is a "last resort" method of bleeding control as all blood flow below the application of an emergency tourniquet is stopped, and can subsequently kill the tissue, leading to eventual loss of the limb below application.cite journal |author=Ruterbusch, VL; Swiergosz, MJ; Montgomery, LD; Hopper, KW; Gerth, WA |title=ONR/MARCORSYSCOM Evaluation of Self-Applied Tourniquets for Combat Applications |journal=US Naval Experimental Diving Unit Technical Report |volume=NEDU-TR-05-15 |date=2005 |url=http://archive.rubicon-foundation.org/3476 |accessdate=2008-07-22 ] cite journal |author=Hill, JP; Montgomery, LD; Hopper, KW; Roy, LA |title=Evaluation of Self-Applied Tourniquets for Combat Applications, Second Phase. |journal=US Naval Experimental Diving Unit Technical Report |volume=NEDU-TR-07-07 |date=2007 |url=http://archive.rubicon-foundation.org/6870 |accessdate=2008-07-22 ]

Even in cases of amputation, most bleeding can be controlled through alternative methods such as direct pressure. The rare exception is when a limb is shattered by massive trauma or when a major blood vessel is torn along its length. Even in these cases, the use of a pressure point above the wound (i.e. proximal to the wound), or application by a doctor of an hemostat, to clamp the blood vessel above the tear can be used.

However, use of tourniquets is widespread in military applications, and have the potential to save lives during major limb trauma. Analysis has shown that in cases of major limb trauma, there is no apparent link between tourniquet application and morbidity of the limb. [cite journal |author=Kragh JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb, JB |title=Practical use of emergency tourniquets to stop bleeding in major limb trauma |journal=J Trauma |volume=64 |issue=2 Suppl |pages=S38–49; discussion S49–50 |year=2008 |month=February |pmid=18376170 |doi=10.1097/TA.0b013e31816086b1 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00005373-200802001-00008 |accessdate=2008-08-20]

Risks of a tourniquet

As the tourniquet stops the perfusion of the limb, the resulting anoxia can cause the death of the limb, forcing the later surgical amputation of the limb just below the level the tourniquet is applied. This is likely to occur when the tourniquet stays in place several hours. In any event, once a tourniquet has been applied, advanced medical care from a doctor or hospital will be required to salvage the limb if not save the life of the patient.

Usage

United States (civilian)

The decision to employ a tourniquet should be made by an emergency medical technician or preferably a doctor if at all possible. But when severe external bleeding cannot be controlled by other means, a tourniquet may be the only way for a first-aider to save the casualty. (A medical professional might use a hemostat or resort to field surgery.)

Most civilian first aid instruction in the United States no longer teaches the use of the tourniquet for the following reasons:

* the effectiveness of direct pressure, elevation and pressure points (controlling severe bleeding in up to 90% of cases as estimated by US medical sources)
* the increased difficulty of reattaching an amputated limb when a tourniquet has been applied to the victim
* unnecessary use by poorly trained bystanders
* the unavoidable risks to both limb and life even when properly employed
* the rare nature of injuries that require tourniquets, which typically occur in unusual settings such as working with agricultural or industrial machinery and the battlefield

The use of a tourniquet by a layperson in countries where it is considered outside the scope of practice of first aid may result in civil lawsuits and/or criminal charges, especially if the application was later found to have been unnecessary.

United States military

Battlefield experience in Iraq has caused the US military to reconsider the 'conventional wisdom' regarding tourniquets. Life threatening bleeding from extremities is more common because body armor protects the torso. Blast injuries to limbs rarely result in a clean amputation or a salvageable limb, and a rapidly applied tourniquet can be immediately lifesaving when arterial (spurting red) bleeding results from such major injuries.

The US Military has also found (through experience in Iraq) that due to the ability to transport a casualty to a surgeon in less than an hour of being wounded, tourniquets are used far more frequently for injuries from gunshot wounds to amputations. Formerly, tourniquets were not used as much, due to the difficulty of transporting the casualty to a skilled physician in time to save the limb.

All US Army soldiers and US Marines are now required to carry a tourniquet as part of their individual first aid kits. First aid training for soldiers now addresses the "prompt and decisive" use of tourniquets to control life-threatening extremity bleeding. Soldiers are also trained in proper self application of the tourniquet.

In France

In France, the tourniquet is taught to the general public, in the first level of first aid course ("Attestation de formation aux premiers secours", 10 hours without any prerequisite). The French emergency medical service ("Samu") considers that the rhabdomyolysis (destruction of the muscle cells due to the anoxia) is not likely to endanger the limb before six hours, i.e. the casualty receives advanced medical cares by a physician (either a medical prehospital team or at the emergency room of a hospital) long before the risk occurs.

The act is thus considered as proportional to the risk (death by blood loss), and the first aider/rescuer is not likely to be condemned in case the limb is lost (although the legal risk is not totally absent): this loss would be attributed to the wound and not to the saving act. Especially, the tourniquet is considered as an alternative to avoid infection by contact with the blood of the casualty when the first aider has no protecting device (e.g. plastic bag, piece of cloth etc.).

If it is not removed within six hours of being first placed on the injured limb, amputation may be required.

In Australia

In Australia, people undergoing a first aid course will be instructed to never use a tourniquet. They are further instructed that if you have a first aid certificate there can be legal issues with using a tourniquet.

See also

* Tourniquet
* Esmarch bandage
* Surgical tourniquet

References

External links

* [http://www.baltimoresun.com/news/nationworld/iraq/bal-te.tourniquets02may02,0,3165696.story?coll=bal-iraq-headlines US military widening use of tourniquets] (Baltimore Sun)