Bleeding control need not cost an arm and a leg: Part 1

Tourniquets: History, myths and evidence for current use in 21st century emergency medicine


Editor's note: This is the first article in a three-part series on tourniquets. Read part 2 and part 3.

Throughout history, tourniquets have been used to control extremity hemorrhage and their effectiveness has been well-researched and documented. However, even with the vast amount of research available on tourniquets and the knowledge gained from the wars in Iraq and Afghanistan, there are many in civilian medicine, including EMS, who do not yet accept the many benefits and lifesaving capabilities of this simple piece of equipment.

The EMS response to multiple casualty incidents, mass shootings and explosive detonations necessitates that we use lessons learned on the battlefield, and here at home, to give our patients the greatest chance of survival by using the highest standard of care.

Historical use of tourniquets
Prior to their use as a field intervention to stop severe bleeding, tourniquets were applied by surgeons during amputation procedures to prevent the patient from bleeding out. Tourniquets have been in use, in some form, since the reign of the Greeks and Romans. The first documented use of a tourniquet was in 1517 by the German surgeon Hans Von Gersdoffin in his book Feldtbueh der Wundtartzney [1].  

In 1593, another German surgeon, Wilhelm Fabry, recommended the use of a "twisting stick" or windlass-type tourniquet during surgical amputations. This design was not very different from the windlass design tourniquets in use today. At this time, tourniquets were used almost exclusively during surgical amputations.

In 1674, Etienne J. Morel, a French Army surgeon, became the first man to use a tourniquet to prevent blood loss during battle [1]. Morel placed a stick under a wounded soldier's bandage and twisted it until the injury stopped bleeding.

John Louis Petit, who is credited as the first to name the device a tourniquet, modified the windlass devices of the time with a wider leather strap and a mechanical screw to make it more adjustable and comfortable. This design was preferred through the American Civil War [1].

During the Civil War, tourniquets were a part of every surgeon’s kit and were used extensively on the battlefield. Although tourniquets saved many lives during the Civil War, this is also where many of the myths and fallacies of tourniquet use originated.

Tourniquets were applied on the battlefield, but evacuation to definitive care could take hours or even days. This resulted in severe tissue ischemia and necrosis in the limbs which led many of the surgeons to believe that it may be more advantageous to allow the injured soldier to continue to bleed out rather than apply a tourniquet [2]. Despite this assumption and lack of expedient medical evacuation, tourniquets were still routinely issued. However, the negative opinion on their use continued to grow.

During the 1960s, there was a movement to remove tourniquets from all military medical kits and training curricula [2]. That belief lasted into the early 21st century with EMS programs only teaching tourniquets as a very last resort after direct pressure, pressure points and elevation had failed. Then, and only then, could a tourniquet be applied. However, the overwhelming majority of departments did not carry any type of commercial tourniquets.

Instead, many EMS providers would simply use a bandage and some sort of makeshift windlass — not unlike Morel in 1674. The stigma around the application of tourniquets included the belief that it led to inevitable limb amputation, permanent nerve injury and even increased fluid loss from venous occlusion without complete arterial occlusion.

Though modern combat evidence shows that with early application and expedient transport to medical care, tourniquets undoubtedly save lives, this has not fully crossed over into civilian medicine and many still avoid their use altogether. In Part 2, we will discuss some of the evidence and research supporting tourniquet use and how they are saving lives today.

References

1. MAJ Robert L. Mabry, et al. (2006) Tourniquet Use on the Battlefield. Military Medicine, 352-356.

2. Gerard S. Doyle, MD, MPH, et al. (2008) Tourniquets: A Review of Current Use with Proposals for Expanded Prehospital Use. Prehospital Emergency Care, 241-252.

About the author
Aaron Brosius is paramedic and currently works for Montgomery County EMS in Clarksville, Tennessee. Prior to working in EMS he spent five years in the U.S. Army as a Green Beret. Aaron can be contacted at brosius.aaron@gmail.com

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