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

2. 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.

3. 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.

4. 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

5. 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

6. 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

7. 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

8. Battlefield Acute Lethality Potentially Survivable n=1,075

9. Hemorrhage Focus (n=984)

10. Can We Have An Impact?

11. 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
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.

12. 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:

13. 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:

14. 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.

15. 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

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

17. 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

18. 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 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

19. 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

20. 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

21. 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

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

23. 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

24. 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)

25. 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

26. 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)

27. 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

28. 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

29. 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

30. 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.

31. 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.

32. 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

33. Hartford Consensus
Excerpt from findings:

34. 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

35. 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

36. 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

37. 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

38. 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

39. Guidance

40. CE/CME Credit
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