A 30 year old male pedestrian was involved in a road traffic collision with a car travelling at speed. On arrival of the paramedics he was found to be unconscious with evidence of severe blood loss. He also had a partial amputation of his right leg below the knee. The paramedics applied a combat application tourniquet to the thigh, above the injury. He then suffered a cardiorespiratory arrest and CPR was commenced. On arrival in the emergency department his trachea was intubated and he underwent bilateral decompressive thoracostomies. Large bore intra-venous access was secured and two units of packed red cells given by a rapid infusion device. He remained haemodynamically unstable requiring a further six units of red cells and associated blood products to maintain a systolic blood pressure of above 80mmHg. Orthopaedic members of the trauma team were persistently keen to remove the tourniquet in order to prevent distal-neurovascular damage. This request was repeatedly denied and he was transferred rapidly to theatre for definitive control of his ongoing haemorrhage with an exploratory laparotomy. No cause for haemorrhage was found on laparotomy so attention shifted to damage control surgery on his leg in order to try and achieve some haemodynamic stability. Unfortunately to achieve this aim the tourniquet was removed. Bleeding was uncontrollable even with reapplication of the tourniquet and the patient exsanguinated and died.
What are the current recommendations for the use of limb tourniquets in trauma, and what is the evidence base for those recommendations?
Few issues in the long and colourful history of medicine have generated as much controversy and confusion as the use of tourniquets to arrest severe extremity haemorrhage 1. In the discussion below I will summarise the problems with tourniquets for control of limb haemorrhage, and discuss some of the current guidelines for their use.
Concerns were raised about nerve damage and limb loss as a result of tourniquet use in the early 20th Century and as a result their use was strongly discouraged 2. The problems relate to excessive direct pressure resulting in nerve and skin injury, as well as the indirect effects of ischaemia of the distal limb increasing the amputation risk. The debate continued and many respected trauma guidelines (for example ATLS) stated that tourniquets should be used only after all other avenues have been explored such as direct pressure and pressure dressings, as a last resort 2.
With the recent military conflicts in Iraq & Afghanistan there has been a renewed interest in pre-hospital tourniquet use to control severe extremity haemorrhage. In 2006 Kragh et al 3 conducted a prospective study of tourniquet use and complications at a military hospital in Iraq. There were 232 patients who had 428 tourniquets applied on 309 injured limbs 3. Tourniquets applied for severe limb injury in the absence of shock was associated with a 90% survival compared to a 10% for those with tourniquets applied in the presence of shock (P<0.001). Survival increased if used pre-hospital. Pre-hospital tourniquet use was associated with an 11% mortality rate whereas mortality rate in those applied the emergency department was 24% (P=0.05). Those casualties that had an indication for tourniquet use but not applied had a 100% mortality and the authors concluded tourniquet use saved 31 lives 3. This study suggests that that despite the historical debate tourniquets, when applied correctly, can be lifesaving. The incidence of transient nerve palsy was 1.7% (at the level of the tourniquet) and the mean duration of tourniquet use was 1.2 hours only in these patients. No other complications from tourniquets were noted. When used correctly, the complication rate from tourniquet use is exceedingly low 2.
Current guidelines: The European guideline on the management of bleeding following major trauma (2010) 4 states that
- We recommend adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting.
- Pressure point control’ is ineffective because collateral circulation can be observed in seconds 4.
- Tourniquets should remain in place until surgical control of bleeding is achieved, but this time should be kept as short as possible.
- Improper or prolonged use can lead to complications such as nerve injury and limb ischaemia. Two hours is the often quoted maximum time for a tourniquet but some studies have kept them for up to six hours and the limb still survived 4.
The American College of Surgeons have recently conducted a meta-analysis of studies looking at external haemorrhage control in the pre-hospital setting of over 1550 patients 5.
- We recommend the use of tourniquets in the pre-hospital setting for the control of significant extremity haemorrhage if direct pressure is ineffective or impractical (Strong Recommendation).
- We suggest using commercially produced windlass, pneumatic, or ratcheting devices that have been demonstrated to occlude arterial flow. We suggest against the use of narrow, elastic, or bungee-type devices.
- We suggest that improvised tourniquets be applied only if no commercial device is available.
- We suggest against releasing a tourniquet that has been properly applied in the pre-hospital setting until the patient has reached definitive care.
The Wessex Major Trauma Network guidelines on tourniquet use in children with major trauma suggest that they should be applied to arrest bleeding from limbs which is uncontrolled by direct pressure, elevation and haemostatic bandages. They also state that the tourniquet should only be removed within theatre by the orthopaedic or vascular surgical team 6. Other guidelines also state specifically when the tourniquet should be removed, for example it must not be removed unless prepared for definitive surgical control of bleeding 7. Tourniquets can be particularly helpful in mass casualty events.
Limitations of evidence: The vast majority of evidence comes from the military setting that is often very different to the civilian setting in a number of ways. Military casualties are often young, fit and healthy. There is often very quick access to quality first aid from colleagues that is often not the case in the civilian world. In addition, military hospitals are often well trained and drilled at managing severe extremity injuries. This might not be the case in the average UK trauma center hence results may not be as good. In addition the civilian population is different, with a wider age range and more co-morbidities potentially increasing the risk of both haemorrhage and tourniquet injuries.
Learning points
- Tourniquet use in the pre-hospital setting to arrest severe extremity haemorrhage (unresponsive to direct pressure or impractical to apply) is recommended and saves lives.
- In the military setting, complications from tourniquet use are very low.
- Tourniquets should be removed with caution, ideally when you are in a situation to gain definitive control of the haemorrhage.
- Improvised or narrow tourniquets should only be used in extreme circumstances.
- It is best to use commercial, broad, specially designed tourniquets, preferably over a large muscle belly over a single bone, and the time kept on minimised.
References
2. Fox et al. Evaluation and management of penetrating lower extremity
arterial trauma: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012: 73(5); S315-320
3. Kragh et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery 2009: 249; 1-7.
4. Rossaint et al. Management of bleeding following major trauma: an updated European guideline. Critical Care. 2010: 14; R52
5. Bulger et al. An Evidence-based Pre-hospital Guideline for External Haemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Medicine. 2014: 18(2);163-173.
6. Wessex Major Trauma Network: Tourniquet use in children with major trauma in the emergency department [online]. Available: http://www.uhs.nhs.uk/OurServices/Emergencymedicine/Majortraumacentre/WessexTraumaNetwork.aspx. Accessed 26/04/2014.
7. Chesters A & HEMS. UK HEMS Crash Cards [online]. Available: http://www.uk-hems.co.uk/UK%20HEMS%20Medical%20Crash%20Cards.pdf. Accessed 26/04/2014.
ICM Case Summaries 