When To Use Tourniquets

I am not sure that there is a consensus about their use but here is my opinion about tourniquets in remote and hostile environments.

In brief:

1.  Learn how to use one and practice with it.

2.  Apply to stop bleeding not controlled by well-aimed direct pressure.

3.  Use something wide and firm (but not hard) that can apply circumferential pressure.  The pressure should be sufficient to stop bleeding.  Make sure that it is in good shape and not a knock-off.

4.  Place proximally (upstream) and as close to the wound as possible.

5.  Don’t release in the field if the patient is in shock, has an an amputated limb, or has a wound site that cannot be monitored for re-bleeding.

6.  For a long evacuation, wait an hour before trying to release it.  If bleeding starts again, re-secure.  Note the time and leave it in place until definitive care is reached or arrives.

7.  Under dangerous circumstances, one may be applied before a thorough evaluation is possible.  These should be applied to the proximal thigh or arm if there is any question about the location and/or number of wounds.  Carefully check the wound when it is safe and feasible. As indicated, leave, reposition, or release it or add a second one proximally.

The following is an explanation of my above opinion.  None of this should be misconstrued as a blanket endorsement to buy and carry one on all trips.

Tourniquets have a checkered history and hyperbolic claims continue to muddy the water.  Past and current combat experience in the SW Asian theaters has drawn renewed attention to them because injuries to limbs have been a major source of life-threatening bleeding. There, they are being used successfully to control obvious and potentially serious bleeding.  In the later case, they are applied before a proper assessment is possible e.g., multiple casualties, continued live fire.  The tourniquets used are relatively cheap and can be lifesaving if used properly.  As with anything in medicine, nothing works 100% of the time.

In civilian practice, it is relatively rare for death from limb bleeding to occur because properly applied, well-aimed direct pressure failed. Still, tourniquets have their use outside of theater (e.g., mass casualty), so knowing how to use one is important. The relevant questions include what, where and for how long.

A good tourniquet
ought to be soft (but not mushy) and wide.  Within limits, wider is better. To be effective, the circumferential pressure needs to be sufficient to stop bleeding. A sphygmomanometer (BP cuff) might be ideal except that they usually will not maintain adequate pressure for a long enough period of time. They and similarly designed devices are also bulky and fragile. The gauges break easily and the fabric, bladder and tubes are vulnerable to sharp objects. Cordage, like a rope or 550 cord (parachute), is not a good choice either because of the potential for direct skin and neurovascular injury.

There are a variety of more serviceable versions. Two of them, the CAT (combat application tourniquet) and SOFTT (special operations forces tactical tourniquet), have worked reasonably well in combat. They are compact, inexpensive and easily applied, even by the patient.  Their advantages are a tradeoff for effectiveness.

One needs to have enough remaining limb to hold the tourniquet. I have heard intelligent people argue that they should never be applied to forearms and legs (lower).  Generally, I disagree and experience would seem to bear that opinion out.  They should be applied as close to the wound as possible.  When circumstances prevent a proper assessment for location and number of wounds, some recommend using only the proximal arm (upper) and/or  thigh as default positions.

If limb bleeding will not stop, especially with a thighanother applied in parallel, proximally, may help. Stay off joints.  Controlling junctional (e.g., in the groin) bleeding remains problematic.

How long:
People fear tourniquets because prolonged use can lead to neurovascular damage and tissue death. We know that tissue death from impaired circulation can occur in as little as two hours. We also know that tourniquets have been left on for over 16 hours without any notable harm.

Releasing a tourniquet has its own risks and there are circumstances where removal never makes sense.  These later would include limb amputation, shock, the inability to monitor the wound or continued bleeding.  Intermittently releasing them to temporarily restore circulation has been reported to lead to unrecognized, ongoing blood loss and patient death.   On a long evacuation, if the conditions seem otherwise safe, waiting 1 hour before attempting a removal seems like a reasonable time interval.  If bleeding starts again, resecure,  note the time and leave it in place.

Improper application is an important cause of failure.  They can also fail when they breakdown from environmental exposure or from poor construction (e.g., older version knockoff).  Always check your equipment before heading out and replace anything questionable.  Practice with any tool before you need it for a real emergency.

There are plenty of good resources online that cover step-by-step application and the identification of knockoffs (e.g., date printed on webbing, red tip on the end of webbing).



7 comments on “When To Use Tourniquets

  1. Greg Friese Greg Friese

    A student was recently arguing with me about their belief in the efficacy of applying pressure to a pressure point before attempting well aimed direct pressure or a tourniquet. Elevation and pressure points are absent from your discussion above and my understanding is they have little efficacy for bleeding control. In your research for this post did you read anything that proposed a role for pressure points or severe bleeding?

  2. Tim Lennon Tim Lennon

    Can releasing a tourniquet cause the person to go into cardiac arrest after a certain amount of time? It may just be a rare occasion but I have heard it can happen. When I research it, not many articles come up but the ones that do mention it happening after a proximal thigh tourniquet is released.

  3. Admin Admin

    Conceivably, yes. But it would be very unlikely under the circumstances that I have outlined, to be caused just by the release of a tourniquet after only one hour. For example, orthopedists regularly use tourniquets for over an hour in the operating room when doing knee surgery. If cardiac arrests were at all common, a different approach would be found.

    I cannot help you with references.

  4. Admin Admin

    If there is much literature, I have not been able to find it. Our explanation for not advocating pressure points relate to collateral flow, the difficulty finding the correct location, and then the difficulty sustaining adequate pressure. Even the American Heart Association’s First Aid Guidelines questioned the utility of pressure points to control bleeding in 2005 and explicitly did not advocate for them in 2010.

    The only article that I am aware of that addresses pressure points appeared in the Journal of Trauma in 2009. Although they were focusing on tourniquets, they also assessed other lower tech solutions for bleeding control, including pressure points. It is not a very good study but it did demonstrate that even when distal flow could be occuluded by using arm and leg pressure points (as measured by doppler), it was difficult to maintain sufficient pressure to sustain the occlusion for even a minute.

    People don’t want to give up old ideas. Here, however, if there really is serious bleeding not controlled by direct pressure, we always have tourniquets, a tool that is easy to apply and is effective.

  5. Dave Dave

    after a tourniquet is applied , should it ever be released , if so when ,(leave it on how long before release)
    if you should release it , how long should it be released before reapplying it ?

  6. Ted Mahar Ted Mahar

    There are 2 primary reasons why a tourniquet (TQ) might be removed in the field. The first is for tissue damage caused by the resulting decreased blood flow (ischemia). The second is if it is unnecessary.

    Under normal circumstances, the time from placement to evaluation by a qualified medical practitioner is well within the 1 – 2 hour worry window after which important ischemia is likely to develop. Under these circumstances, the risk of harm is minimal so leave it on.

    Regardless the time to evacuation, however, if removing a TQ runs the risk that significant bleeding will resume, if the bleeding has resulted from a complete/partial amputation or if your patient is in shock, leave it (them) on. Likewise if it will not be possible to properly monitor the bleeding sources (because of e.g., patient packaging, multiple patients, challenging environments).

    Sometimes TQs are placed when it turns out that they were not necessary to stop bleeding. This can happen in the early stages of an assessment with multiple casualties or when properly visualizing wounds is difficult. Sometimes on further inspection, little or nothing is required. In others, wound packing with well-aimed direct pressure and a compression wrap could suffice. Under these later conditions, loosen the tension and observe what happens. If bleeding is controlled, leave the TQ on loosely and monitor. If it starts up again, retighten and leave it in place. Never repeatedly loosen and tighten a TQ. This has proven to be a dangerous strategy.

    Bottom line: Once a TQ has been placed and deemed necessary, leave it alone and get to help. If the evacuation will be lengthy and there are no compelling reasons not to try, loosen once and see what happens. If bleeding resumes, retighten, note the time, and leave it alone.

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