Optimal Use of Limb Tourniquets U.S. Army Institute of Surgical Research Col Stacy Shackelford, USAF, MC

Disclosures Presenter has no interest to disclose. PESG and AMSUS staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, and all accrediting organization do not support or endorse any product or service mentioned in this activity.

Learning Objectives At the conclusion of this activity, the participant will be able to: Review the use of tourniquets on the battlefield, past and present Report recent TCCC guideline updates to include early conversion of tourniquets to hemostatic/pressure dressings, evaluation of effective tourniquets, tourniquet placement during care under fire, and specific suggestions for CAT tourniquet use. Describe the recommended method for converting a tourniquet to a hemostatic/pressure method.

Overview Historical Perspective Categorization of Potentially Preventable Deaths Combat Data Indications for Pre-hospital Tourniquet Use Complications of Tourniquet Use Training issues Pitfalls Summary of TCCC Guideline updates The Hartford Consensus

Historical Perspective Surgical amputations American Civil War Union Army recommended issue to every combat soldier Associated with poor limb outcomes WWI Battlefield medic Prolonged transport to surgical hospitals Tourniquet is last resort for uncontrolled limb hemorrhage WWII Surgeons advocated for more effective tourniquets and early use

Korea/Vietnam Iraq/Afghanistan Helicopter evacuation from the battlefield WWII tourniquet still in use, although ineffective Many improvised tourniquets Last resort Iraq/Afghanistan Doctrine change: tourniquets are the primary means of first aid

Tactical Combat Casualty Care Summary Tactical Combat Casualty Care Care Under Fire Tactical Field Care Tactical Evacuation Care Formal evaluation of tourniquet devices Training and issuing tourniquets to ALL TROOPS

Battlefield Acute Lethality Potentially Survivable n=1,075

Hemorrhage Focus (n=984)

Can We Have An Impact?

Combat Data Israeli Defense Force 2003 Bagdad 2006-2007 91 tourniquets: 78% effective, 47% not indicated, 6.4% nerve injury Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma. 2003;54:S221–S225. Bagdad 2006-2007 267 casualties, 428 tourniquets, 309 limbs Indications: 87 amputation, 86 vascular injury, 81 open fx, 45 soft tissue injury 90% mortality when TQ placed after onset of shock 10% mortality when TQ placed before onset of shock 28% ineffective, distal TQ more effective than proximal 1.7% transient nerve palsy Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008;64:S38–S50.

75th Ranger Regiment 2011 Combat Data 419 casualties, 89 limb tourniquets, 66 casualties No complications 16% required amputation, no amputation attributed to tourniquet use 42% applied by non-medical personnel Kowal RS, Montgomery HR, Kotwal BM, et al. Eliminating Preventable Death on the Battlefield. Arch Surg. 2011;146:1350-8.

Civilian data Boston Marathon 152 patients, 66 with extremity injury, 29 with life-threatening bleed 17 amputations 12 major vascular injuries 27 tourniquets applied—all improvised 1/3 of tourniquets applied by EMS, 1/3 by bystanders, 1/3 unknown King DR, Larentzakis A, Ramly EP. Tourniquet use at the Boston Marathon bombing: Lost in translation. J Trauma. 2015;78:594-599.

Civilian data Multi-institutional Analysis of Prehospital Tourniquet Use Retrospective chart review, 9 Level 1 trauma centers 197 patients Mortality significantly lower than reported by military 3.0% mortality (not different with vs. w/o shock) 20% expedient tourniquet by bystanders Schroll RW, Smith A, McSwain NE, et al. Military to civilian experience—a preliminary multi-institutional analysis of pre-hospital tourniquet use.

Indications for Pre-hospital Tourniquet Use Care Under Fire Mass casualty events Total darkness Multiple injuries (particularly if airway or breathing intervention required M-A-R-C-H Massive hemorrhage Airway Respiration Circulation Head/Hypothermia

Complications of Tourniquet Use Pain Nerve palsy Clot Fasciotomy Amputation Myonecrosis/Rhabdomyolosis } Pain control } Wider tourniquet } Avoid venous tourniquet } Limit tourniquet time

Venous tourniquet Arterial blood continues to flow into extremity Venous blood flow from extremity is occluded Result: Increased swelling and compartment syndrome Increase bleeding from injured veins

Tourniquet time 2 hours is considered “safe” TQ times > 100 minutes associated with increased complications in TKA Complications increase 20% for every 10 min (range 39-156 minutes) Olivecrona C, Lapidus LJ, Benson L, Blomfeldt R. Tourniquet time affects postoperative complications after knee arthroplasty. Int Orthop. 2013;37:827–832. Traumatic injury and blood loss reduce ischemic tolerance of the limb Gifford SM, Propper BW, Eliason JL. The ischemic threshold of the extremity. Perspect Vasc Surg Endovasc Ther. 2011;23:81–87. Hancock HM, Stannard A, Burkhardt GE, et al. Hemorrhagic shock worsens neuromuscular recovery in a porcine model of hind limb vascular injury and ischemia/reperfusion. J Vasc Surg. 2011;53:1052–1062. Shorter tourniquet time is always best

Tourniquet time How long is too long? No definitive answer 6 hours is a rough guideline Likely shorter for more proximal tourniquets May be as short as 3 hours with traumatic injury and shock Hancock HM, Stannard A, Burkhardt GE, et al. Hemorrhagic shock worsens neuromuscular recovery in a porcine model of hind limb vascular injury and ischemia/reperfusion. J Vasc Surg. 2011;53:1052–1062. Longer for distal tourniquets and cool environment Don’t kill the patient by attempting limb salvage

Place hemostatic/pressure dressing Tourniquet Conversion=Convert tourniquet to a pressure/hemostatic dressing Care under fire: Apply “high and tight” over clothing TFC/TACEVAC: Expose wound Place hemostatic/pressure dressing Loosen tourniquet and move down-monitor for rebleeding

Tourniquet Repositioning Care under fire: Apply “high and tight” over clothing TFC/TACEVAC: Expose wound and Place second tourniquet 2-3 inches above wound on skin. Loosen “high and tight” original tourniquet. If needed, move loosened “high and tight” tourniquet to position side by side with second tourniquet and tighten both until bleeding stopped and distal pulse not palpated

Criteria for Tourniquet Loosening/Conversion Casualty is not in shock It is possible to monitor the wound closely Not an amputation

Pitfalls Rebleeding Forgotten tourniquet Placing the tourniquet distal to an unseen wound Removing the tourniquet Reperfusion injury Loosening the tourniquet in unstable patient Periodic loosening of the tourniquet to reperfuse the limb CTA Don’t kill the patient by attempting limb salvage

TCCC guideline update supports “high and tight” placement during CUF Summary of Updates: Clarification of the location of tourniquet placement during CUF TCCC guideline update supports “high and tight” placement during CUF Consider “high and tight” placement whenever assessment is limited: Masscal, low light, multi-trauma patient Experienced medics may use judgment: if the wound is obviously distal, then place the tourniquet 2-3 inches above the wound All “high and tight” tourniquets require repositioning or conversion at the EARLIEST opportunity (2 hours max)

Summary of Updates: Clarification of effective tourniquet placement Optimal use of limb tourniquets must stop both bleeding and the distal pulses Ineffective venous tourniquets Occlude the vein but not the artery Loss of blood from the body’s core Swelling of the limb—compartment syndrome Increased bleeding from the veins Rebleeding is common Blood pressure increases Muscle relaxation in the limb Re-evaluate often

Summary of Updates: Clarification of tourniquet conversion guidelines General principles: Shortest tourniquet time is best Complications of nerve injury, compartment syndrome, muscle damage increase with time Attempt to convert as soon as possible (< 2 hours) If: Casualty is not in shock It is possible to monitor wound closely for bleeding Not an amputated extremity In most cases only one attempt at conversion before reaching surgery May consider a second attempt if conditions have improved (better light, supplies, manpower, etc)

Summary of Updates: Clarification of tourniquet conversion guidelines Do not convert a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available No exact time when an ischemic limb becomes unsalvageable Risks of tourniquet removal include hypotension, rhabdomyolysis, kidney failure, acidosis, and hyperkalemia Cooling helps: expose the limb but DO NOT pack in ice or snow

Analysis of recovered tourniquets showed that 1/3 are single-routed Summary of Updates: Review recommendations for CAT routing of band through buckle Currently manufacturers instructions recommend double routing of the CAT tourniquet band through its buckle, except for self-application to upper extremity Analysis of recovered tourniquets showed that 1/3 are single-routed Recent lab study confirms single routing is faster and reduces blood loss 6th generation CAT is 37.5 inches, compared to 31 inches for earlier version (more Velcro contact area) Buckle breakage has never been reported Trainers observe that the critical first step of tightening the band (before tightening the windlass) is facilitated by single routing

Care Under Fire Stop life-threatening external hemorrhage if tactically feasible: Direct casualty to control hemorrhage by self-aid if able. Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use. Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life- threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover

TFC and TACEVAC c. Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above wound. Ensure that bleeding is stopped. When possible, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse.

TFC and TACEVAC d. Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available.

Hartford Consensus Met in Hartford, CT, Apr 2013, Jul 2013, Apr 2015 Joint committee to create a national policy to enhance survivability from mass casualty shooting events Initiated by ACS FBI Law enforcement Fire EMS Trauma care Military

Hartford Consensus Excerpt from findings:

Response to Active Shooter Events T – threat suppression H – hemorrhage control RE – rapid extrication to safety A – assessment by medical providers T – transport to definitive care

Response to Active Shooter Events T – threat suppression H – hemorrhage control RE – rapid extrication to safety A – assessment by medical providers T – transport to definitive care

Public response Bystanders provide initial response Design education programs for public response to active shooter or mass casualty event B-con course CPR model Pre-position necessary equipment Bleeding kit + AICD Run, Hide, Fight

Law enforcement Train all LE officers to assist EMS External hemorrhage control Tourniquet application Hemostatic dressings (Combat gauze, Celox) Triage possible internal hemorrhage for immediate evacuation

EMS/Fire/Rescue Increase training on initial response No longer acceptable to stage and wait for casualties to be brought to the perimeter Training must include tourniquets, pressure dressings, hemostatic agents Rapid triage of torso hemorrhage for transport to definitive care TCCC model

Guidance

CE/CME Credit If you would like to receive continuing education credit for this activity, please visit: http://AMSUS.cds.pesgce.com