23 August 2008

Tourniquets, Trendelenburg, Tampons, Toilet Paper

...or Four Things that Get me fired up. This will likely be a three or four part post...

Certain subjects inevitably come up whilst discussing Trauma management. This is especially true when discussing such things with individuals in the Military. Two of the subjects I'm referring to are controlling bleeding from an extremity, and preventing/controlling shock.

It's common knowledge that exsanguination from extremity wounds in the Number One cause of preventable death on the Battlefield. The Military is finally getting away from it's complete and total fear of effective tourniquets. From the time we take our very first Boy Scouts and Brownies First Aid class, we're taught to apply a dressing, apply direct pressure, utilize pressure dressings, use pressure points, elevate, and as a very, very, OMIGOD Don't Even THINK about it, last resort, tourniquets are mentioned. Can tourniquets cause tissue damage? Yes. I'm not here to deny that. Is there the potential for neuropathies, necroses, and no-mo-hands-and-footsies? Absolutely. Shutting off distal blood supply is no joke. It's a very serious procedure, applied in some of the most dire of circumstances. Some First Aid guides don't even mention Tourniquets. FR, EMT, and even Paramedic courses skim over them. In Paramedic school they'll discuss "back in my day, we used to push enough epinephrine to give a rock a pulse," giving every code bicarb, or in the more recent past, stacked shocks. Science has shown that those practices aren't necessarily effective, and don't save lives. Yet more time is spent mentioning THEM, than the appropriate and effective application of a tourniquet.

Tourniquets Save Lives. You can read whatever studies you want about the harm done by a tourniquet. Paresthesia, amputation, worst case scenarios. People with those outcomes are Alive. It's common knowledge that a properly applied tourniquet can be left in place for greater than 4 hours before irreversible damage occurs. Ask a surgeon. They perform procedures all the time with tourniquets in place.

Properly applied.
They save lives. Damage is minimal when properly applied. So why are we so afraid of them? Why don't we embrace the fact that they save lives, and spend time actually LEARNING how to apply them properly? I challenge you to go to your crew room, your next refresher, ask someone at the ER, or your new preceptee what they would use to appropriately apply a tourniquet, and how they would go about doing it.

You'll meet quite a bit of resistance. There will be people that insist that they'll never have to apply a tourniquet, and no one ever should. I mean, 4 liters of NaCl is a good replacement for 4 units of blood, right? Tourniquets are evil, right? They are harmful and too much can go wrong.

Now try to have a conversation with the same people about emergency airways, and worst-case scenarios. Discuss intubation, S.L.A.M., crichothyroidotomy, translaryngeal jets, retrograde intubation, bougies, etc. After all, those can be intense, but we're taught skills to manage the airway.

Painful Truth for all you heroes out there. Patients can often be killed iatrogenically by airway management, mismanagement and overmanagement. The same is not said about bleeding control. You don't kill patients by "overmanaging" their bleeding. This is not to say airways don't save lives. But I think I learned somewhere in Physiology that blood might be important too.

We are taught When, Where, Why, What, Who, and How to Intubate. We know the consequences of a poor intubation, and are taught to recognize when things don't go according to plan.

We are taught that tourniquets are a last ditch effort, and we should exhaust all other methods before resorting to a tourniquet. Well my friend, while you're holding pressure for several minutes to see if it will work, your patient has lost half their blood volume. We should be teaching people how to recognize when a tourniquet is necessary. You can assess bleeding fairly quickly, and figure out what tricks are going to work. If you can't, your training, and/or your experience, has let you down. Time is of the essence. When, Where, Why, What, Who, and How.

The answers are not Never, Nowhere, None, Nothing, No one, and Not. Quit teaching it that way. Common Sense has been discarded for Common Practice for far too long.

Outdated tip of the hat to TOTWTYTR

8 comments:

Ambulance Driver said...

Bravo.

TOTWTYTR said...

Nicely said. Thanks for the link. No, I don't know why I didn't have a link to your blog, but I've fixed that.

Keep it up and you'll be Rogue Medic Jr.

Medicmarch. said...

well said.

-MM

Cheating Death said...

Good post! I am a firm tourniquet believer as well. My service doesn't carry them, so I've got one in my cargo pocket.

I've got cpap, a vent, a pump, 2 monitors, and more drugs than the local walgreens, but they won't let us carry a tourniquet--even after I provided them with enough studies about battlefield use to change even the oldest docs mind.

Guess I'll just have to wait for phtls to take 10 years to update so that I can get them to believe me....

Anonymous said...

Just took a patient in to a level one hosp. with a severe laceration to the inner arm with bone, ligamennts and tendons exposed and spurting blood. The pt had every sign of shock under the sun and blood was everywhere. The first thig the ER Dr. said was "is that a tourniquet? Get that off of him that is never to be used." Long story short the er took it off and removed the dressing to have blood coming out everywhere. The pt declined in front of my eyes. How barbaric do we have to live to get good pt. care out there? I say use the tourniquet and save the life of your pt.

Thanks for feeling the same!

dorianp@go-concepts.com

first rule of fire said...

Tourniquets are easy to make with a triangle bandage. Get someone to put a knot in it aroubd the limb and use the #4 Miller to crank it tight. See there is a use for that blade. It is the tourniquet blade.

Great post. Blood in the body is important for living patients. Blood out of the body means break out the big white zippered bag.

Steve Smith said...

i have written a categorical medical equipment that even scouts can rely on. (Common Medical Equipments Found at Home)

Smith | littmann cardiology stethoscope

68W said...

True and tried on the battlefield. Its the first thing I use. Control bleeding with tourniquet, bandage wound, loosen up tourniquet to see if packing and dreesing of wound worked. if the dreesing worked, leave the tourniquet loose, if dreesing didnt work retighten the tourniquet. True and tried technique. Combat Medic, Arghandab, Afghanistan.