Bleeding control need not cost an arm and a leg: Part 3

Current uses of tourniquets for prehospital bleeding control

Editor's note: This is the first article in a three-part series on tourniquets. Read part 1 and part 2.

By Aaron Brosius, EMS1 Contributor

Attacks with small arms and improvised explosions and the resulting injuries, like those seen on the battlefields of Iraq and Afghanistan, are relatively uncommon in the United States. However, they happen with enough frequency that EMS must be prepared. Mass shootings, such as those at Umpqua (Ore.) Community College, Planned Parenthood in Colorado Springs and San Bernardino among others are increasing in number and lethality. Bombings such as the ones in Boston and Paris are also a rare, but a potential threat to any community.

After the Sandy Hook school shooting, a group of experts discussed the proper response to mass shooter attacks and how to best improve victim survival. This collaboration, known as the Hartford Consensus, included leaders from the American College of Surgeons, PHTLS, FBI, Major Cities Chiefs Association and the Committee on Tactical Combat Casualty Care.

The experts concluded that the number one cause of preventable death in victims of penetrating trauma is hemorrhage and that controlling the hemorrhage was paramount to victim survival. The Hartford Consensus determined that bleeding from an extremity is initially best controlled by a tourniquet.

In addition to shootings, mass casualty incidents and other violent criminal attacks aside, there are many other reasons for civilian EMS providers to carry tourniquets. Some more common occurrences where a tourniquet may be of benefit to the patient and the responder are natural disasters, structural collapse, crush injuries, industrial and mechanical accidents and motor vehicle and motorcycle collisions.

With the proper application, a tourniquet may assist responders to a crush injury patient by allowing them to remove the crushing object and extract the patient while prolonging the onset of crush syndrome and rhabdomyolysis until the patient can be transported to definitive medical care. For motor vehicle collision and industrial accident patients, it is imperative that the responder suppress the hemorrhage and prevent further blood loss and shock.

In the civilian setting, there are rarely times when we are more than two hours from a hospital or definitive care. With research showing that tourniquet application times of less than two hours seldom leads to long-term nerve or tissue damage, there are few reasons not to quickly apply one to a patient with any major extremity hemorrhage [1].

Tourniquet application training
Training officers need to determine how much training emergency responders need before they can use and apply a tourniquet.

Philadelphia cops who applied life-saving tourniquets had two different levels of training. One officer had been a military medic with years of experience in proper tourniquet application. A second officer had only received the department's mandatory four-hour hands-on clinic [2].

Even though the officers had very different experience and exposure to tourniquets, each was able to save a victim's life. These examples reinforce the simplicity and ease of use for these invaluable tools.

EMS agencies that authorize their providers to apply tourniquets need to both train and equip their personnel. When the need arises, some EMS crews are still reaching for cravats and trauma shears or anything else they can use to improvise rather than one of the widely-available commercial devices.

Some patients may require multiple tourniquets. PHTLS and TCCC guidelines dictate that if one tourniquet does not suppress the hemorrhage then a second should be applied proximal to the first tourniquet. With this in mind, it is necessary for each ambulance to be supplied with at least two tourniquets. Based on the likelihood and time of additional response units — ambulances, police — it might make sense to carry four or more tourniquets on each ambulance.

EMS and health care are constantly changing and moving forward. Tourniquets are an evidence-based practice for prehospital care. EMS leaders, based on research from the wars in Iraq and Afghanistan and civilian applications at home, need to support early and aggressive application of a tourniquet to a patient with severe extremity bleeding.


1. 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.

2. Vinny Vella. (2014) Police-issued Tourniquets Save Two Lives.

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

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