A New "Old Squeeze"

Say the word “Tourniquet” around some people and you’ll see their heads spin around. This is unfortunate because even with a proven track record, there is still a lot of negativity and stigma surrounding the use of a tourniquet. Tourniquets, when I came in the military back in 1991, were the last resort. “Whatever you put it on will die”, I was told. “They’ll lose the limb for sure”, they said. Well, “they” were wrong.

Tourniquets have been used successfully, without complication, in operating rooms since the late 1800’s and the last several years of combat have given us new information and a new perspective on the use of a tourniquet, as well as the terrorist activity in Boston and natural disasters like the tornadoes in Oklahoma. In Iraq and Afghanistan, the much-maligned device has been credited with saving close to 2,000 lives. In the Boston bombing incident, makeshift/expedient TQ’s are credited with saving at least 50 lives. That’s over 50 families who will get to celebrate birthdays, anniversaries and holidays with their loved ones due to a tourniquet being used successfully and we're seeing an increasing number of TQ's being utilized by civilian law enforcement, fire fighters and EMS with excellent results.
Massive, life-threatening hemorrhage accounts for approximately 80% of all combat deaths with about half of those being compressible either with a TQ or hemostatic agent. The other half are non-compressible, unfortunately, but hopefully, with the advent and success of the Abdominal Aortic Junctional Tourniquet (AAJT), as well as other junctional devices, we will see that percentage decrease.
A TQ, as we'll call it, enables the medic, or person performing self-aid, to quickly and efficiently achieve hemostasis (stopping the flow of blood) from a compressible extremity injury. It can be done when there are multiple casualties or when the situation may not be suitable for taking the time to attempt placing a pressure dressing or hemostatic gauze. Once all the casualties have been treated or the threat has passed, the wounds can be re-evaluated to see if they are amenable to wound packing and pressure wrapping. If the TQ was put on for initial hemorrhage control of an injury which would be amenable to hemostatics and pressure dressing but time wouldn’t be packed or dressed due to an unsafe environment or multiple casualties and it's been more than a couple of hours, go ahead and leave it on. However, don’t be overly concerned about limb loss as the average TQ time in a study done in Iraq in 2006 was 1.3 hrs and no limb was lost due to TQ application. The limb may have been lost as a result of the injury which necessitated the TQ but not as a direct result of the TQ. Can there be nerve injuries? Sure, but even those were minimal in the study at a rate of <1.5% and they were transient, meaning they lasted a short time and then were gone. As a side note, there was a documented case of a TQ time of 16 hours and the injured party still kept the arm and was back on flight status in a year.
Rapid placement of the TQ is what we want because blood needs to stay in the body to carry oxygen, remove waste and bring clotting agents to the site of injury. Placing a TQ will hopefully, prevent shock and in the event of shock, hopefully prevent the shock from progressing to it's irreversible stages, provided the wounded hasn't lost too much blood initially.
The TQ works best when placed as high as possible on the affected limb on a single long bone (ie. the humerus in the upper arms or the femur in the upper legs). Think about what a military haircut is called; a “High and Tight”. That’s the way a TQ should go on. The rationale behind this is that as the windlass is turned to compress the TQ material, it is compressing all the vessels against the large surface area of those long bones and this aids greatly in stopping the loss of blood. It is much easier to occlude the flow of one vessel on one long bone vs two or more against two bones (lower leg or arm). Also, the “High and Tight” placement is called a “hasty” TQ due to placing it as quickly as possible in an easily recognized landmark in order to stop the bleeding. TCCC guidelines, as of October 2014, have added that if the “hasty” TQ is applied, that once the victim is in a safe area, the wound should be evaluated by the medical personnel to see where the injury is located and that an additional TQ should be placed ~4” above the wound and tightened down and the other TQ released. It further states that in the event of an injury where the site of bleeding is easily recognized, that the TQ should be placed ~4” above the wound initially. For the layperson, we still emphasize the “High and Tight”, “hasty” placement for ease of use.
Once the flow of blood has been stopped, it is imperative to monitor and reassess the casualty and site of injury at least every 5 minutes until the casualty has been delivered to a higher level of care. The reason for this is to ensure that they are not exhibiting nor experiencing any signs or symptoms of shock and that the blood flow to the affected limb remains stopped. If they have an altered mental status secondary to shock or head injury, they may loosen the TQ because a well-placed TQ will hurt due to the pressure it puts on the extremity as well as the tissue ischemia (low blood oxygen) and they may attempt to loosen it in an attempt to alleviate the pain, so watch their hands. Another consideration to this is if they are armed. Ensure all weapons are removed, cleared and secured from casualties with an altered mental status.
If the TQ isn't on tight enough to compress the arterial flow but cuts off the venous flow, not only does the casualty lose precious volume but also can build dangerously high pressure in the extremity and what may not have been a "loss of limb" situation with a properly placed TQ, now is due to compartment syndrome damaging the nerves, tissue and vessels. This is why the limb may require an additional tourniquet. The old saying of “Two is one and one is none” comes to mind. The TQ acts not just on the force of compression but also by the surface area being compressed so if your TQ is 1.5” wide and you add another TQ just above or below it (wherever you can place it), you’ve essentially doubled your surface area being compressed and will hopefully achieve hemostasis. This is one of several reasons that many first aid courses don’t teach tourniquet use. However, with anything medical or firearms related, getting proper training and practice are of the utmost importance. So, make sure that the type of TQ that you use will work with a variety of limb sizes or buy some different types of proven TQ’s that are commercially available and buy more than one. “Two is one and one is none.”
If you practice with placing your TQ, use a dedicated “practice” TQ as you decrease the tensile strength of the unit with each application and it could fail when you need it most. Also, be on the lookout for counterfeit TQ’s and only buy them from a reputable source. Don’t “bargain basement” shop for items which may mean the difference between life and death. Utilize TQ drills where you are on a timer in a low-light or no-light situation in a motor vehicle or other environment. Practice applying them with one hand (primary hand and support hand). Practice applying them to your spouse. Have your kids practice applying them to you and each other. Learn how to improvise TQ’s and remember that the band needs to be at least 1” wide, so no strings, paracord or wires. That just cuts and damages tissue. These are just a couple of things to think about.
Remember, the TQ is not the last resort any longer and they can stay on safely and effectively for up to 2 hours and in some rare cases, even longer, per recent studies. We’ve had many successes on and off the battlefield with the TQ and simply refusing to utilize one based on hearsay when there are scientific studies out there which refute that hearsay is both dangerous and irresponsible.
Put the TQ on like a military haircut; high and tight.
Get trained. Reassess your casualty at least every 5 minutes. Obtain good equipment. Know your equipment. Practice with your equipment. Win and come home alive.

-Pocket Doc