Bleeding control need not cost an arm and a leg: Part 2

Continued evidence for the expanded use of tourniquets


Editor's note: This is the second article in a three-part series on tourniquets. Read part 1 and part 3.

By Aaron Brosius

The historic reservations about tourniquet application were driven by myths and fears. The routine use of tourniquets by first responders is supported by current evidence.

The false stigma of the tourniquet began to change in the 1990s and early 2000s. Special Operations Forces favored the use of tourniquets and evidence showed that early tourniquet application may have saved many U.S. Army Rangers in Somalia [1]. This finding sparked more research into the use of tourniquets as well as the development of newer, more advanced tourniquet devices.

During the Iraq and Afghanistan wars, more than 40 different types of commercial tourniquets were developed and all service members in a combat theater were issued two tourniquets each [2]. As the wars progressed through the early 2000s, the military gained more insight into the use of tourniquets as an early and aggressive means of hemorrhage control.

The "Emergency War Surgery Manual" states, "Use a tourniquet early, rather than allow ongoing blood loss. Substitutes for issued tourniquets include belt, torn cloth, gauze and rope, among others. A tourniquet does not require constant attention; allows first responders to care for others, extends resources [3]."

Combat casualty survival
Due to the high-caliber weapons and explosive devices currently used in combat and the overwhelming use of body armor, the number one cause of preventable combat death is extremity hemorrhage (60 percent). One study conducted at a hospital in Iraq, during two different time periods, examined the morbidity and mortality of casualties brought in with tourniquets applied for extremity hemorrhage. The first period surveyed 232 casualties resulting in a survival rating of 87 percent. Morbidity levels were very low with 1.7 percent of the patients suffering from nerve palsy and only 0.4 percent resulting in any major limb amputation.

The second period studied revealed very similar results. A total of 267 casualties were studied with a survival rate of 87 percent. Morbidity remained very low with nerve palsy at 1.5 percent and major limb amputation remaining at 0.4 percent [4].

The second study showed that if the tourniquet was applied when shock was absent, the patient had a 90 percent chance of survival. The evidence also demonstrated that a tourniquet may be in place up to two hours with no permanent injury to the patient.

Another study, conducted in the Middle East, compared casualties with similar abbreviated injury scales and injury severity scores. The study examined the survival rate of soldiers with a tourniquet applied to soldiers with no tourniquet application. The results showed, that of the soldiers with no tourniquet applied, none survived, whereas the survival rate for the casualties in which a tourniquet had been applied was 77 percent. The study further revealed that of the soldiers' who died without a tourniquet, each had only one limb injured and each died within 15 minutes of injury.

Of the patients who did survive with tourniquet application, over 50 percent had two limbs injured [5]. This further supports early and aggressive application of a tourniquet and rapid transport is more beneficial to the patient with severe extremity hemorrhage and significantly increases the survivability.

Civilian traumatic injury survival
Civilian first responders, including law enforcement, have increasingly accepted and implemented tourniquets. Immediately following the terrorist attack at the finish line of the Boston Marathon in 2013, many bystanders came to the aid of those who were wounded. Using their shirts, belts and anything else they could improvise, they applied makeshift tourniquets to the limbs of the injured. Doctors invariably state that it was the quick thinking of those first responders and bystanders that significantly minimized the loss of life that day [6].

Police have used tourniquets to save the lives of crime victims, injured assailants and their partners. In December 2015, paramedics credited police-issued tourniquets with saving an officer's life. A Denver police officer was conducting a traffic stop when he was suddenly shot multiple times in by a suspect.

When paramedics arrived on scene, they noticed a lot of blood around the officer. They also noticed that a fellow officer had applied a department-issued tourniquet prior to their arrival. They determined that the tourniquet had been placed appropriately to control the hemorrhage and had more than likely saved the officers life [7].

In a 2014 incident, a Dallas police officer responded to a shooting. Arriving on scene, the officer found a victim with blood spurting from a gunshot wound to the left leg. The officer immediately applied his department-issued tourniquet to stop the bleeding. Both the paramedics and the surgeon treating the patient credited the officer's quick reaction and tourniquet application with saving the patient's life [8].

The key to successful tourniquet application, and ultimately the increased survival rate of casualties, is training all emergency responders on the proper application of tourniquets and equipping those personnel with at least one tourniquet they always carry.

References

1. MAJ Robert L. Mabry, et al. (2000) United States Army Rangers in Somalia: An analysis of combat casualties on an urban battlefield. Journal of Trauma, 515–528.

2. Gregory C. Risk, MD, MPH, FACEP. (2012) Civilian EMS Should Consider Tourniquets. Journal of Emergency Medical Services.

3. D. G. Burris, et al. (2004) Emergency War Surgery, 3rd edition. U.S. Department of Defense.

4. J. F. Kragh, et al. (2011) Battle casualty survival with emergency tourniquet use to stop limb bleeding. Journal of Emergency Medicine, 590-597.

5. J. F. Kragh, et al. (2009) Survival with Emergency Tourniquet Use to Stop Bleeding in Major Limb Trauma. Annals of Surgery, 249.

6. Stobbe, Mike. (2014) Once-doubted tourniquet now seen as Boston lifesaver. The Boston Globe.

7. (2015). Medics credit tourniquet training in saving cop's life. EMS1.com

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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