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Tourniquet the Limbs, Pack the Junctions, Seal the Box

Tourniquet the Limbs, Pack the Junctions, Seal the Box

Posted by Kerry Davis on May 12th 2020

So, let’s talk a little bit about tourniquets, hemostatic agents and chest seals.

So much has changed in the last few years concerning tourniquet use, thankfully. Tourniquets were the

"last resort" for many years and still are in many civilian settings. However, thankfully times have

changed and as we learn more about the human body, our skills and tools have improved. Tourniquets,

once maligned, are now credited for saving many, many lives after being the first item placed in the

event of a life-threatening hemorrhage. To that end, we need to know the “how?”, the “when?” and the

“why?” when it comes to our first piece of info; “Tourniquet the Limbs”.

An old myth is, "Once you place the tourniquet, everything else below it is dead". False. Tourniquet

placement times up to 2 hours are common not only on the battlefield, but in the operating room. This

prevents blood loss. Blood needs to be in the body and a well-placed tourniquet helps it stay there. It

doesn’t matter whether it’s arterial or venous in nature, bleeding is still bleeding and needs to be

controlled. All bleeding is bad. Full stop. End of story.

There are many instances where the TQ has been in place longer than 2 hours and the victim has still

retained their limb. A nine-month study in Iraq described how there wasn’t a single loss of a limb was

attributed to TQ placement. The limb may have been lost as a result of the injury which necessitated the

application of the TQ, but the loss wasn't a direct result of the TQ placement. Also, the quicker the

bleeding is controlled, the greater the chances of survivability for the victim. Blood belongs in the body.

Period. If hemostasis can be achieved before the victim falls into Stage II Shock (750-1500ml of blood

loss), then the chances of survival are over 90%. If the victim falls into Stage II or greater shock, the

survival rate drops down to less than 20%. Blood carries oxygen, removes waste and has vital clotting

factors. All of those need to be in the body when it is wounded, not leaking out onto the ground. So, get

the bleeding stopped as quickly as possible, however possible. The better our tissues are perfused with

oxygen, the less downstream issues we have to deal with. A victim may survive the initial injury and

blood loss only to die of other related complications later. If they do survive, their organ function may

take a very long time to return to a baseline “normal”, if at all. So, stopping the bleeding and getting the

victim to a definitive care facility to get blood back onboard is going to increase survivability


Tourniquet use is now a widely accepted method of controlling hemorrhage and the majority of the up-

to-date bleeding control curriculum reflects that. They agree with the general consensus that pretty

much all bleeding is bad and that if hemostasis can't be achieved with direct pressure, then move onto a


For TQ placement, we teach “deliberate” and “hasty” placement. Basically, a “Deliberate” placement is

if you can see where the blood is coming from, you’ll want to place the TQ 2-3” above that wound,

unless there’s a joint involved, in which case, you’ll want to place it a couple of inches above that joint.

Now, let’s say the scene is chaotic, multiple victims, blood-soaked clothing, poor lighting, etc….and you

just can’t tell where the bleeding is coming from, that’s where you can apply a “Hasty” TQ. You’re going

to place the TQ as high up on the limb as you can and then secure it. This is also called the “High and

Tight” placement method used in CUF (Care Under Fire) scenarios. This type of TQ placement may stay

as it is until the victim is at a higher level of care or it could be “converted” to a “Deliberate” TQ

placement by the First Responders if the wound is easily identified. What they would do then is place a

second TQ 2-3” above the wound, secure it and then release the first “High and Tight” TQ to prevent

more tissue from being affected by no blood flow. This has to be done within the two-hour window we

talk about in class and why it is absolutely vital that we mark any TQ with the time of application. This

two-hour window is very important in that it lets First Responders know how long the TQ has been in


Securing the TQ is another big thing. If you secure it, stop ALL of the bleeding. Veins are lower pressure

and it’s typically easier to stop venous flow, so if you still have an ooze, you may have arteries (higher

pressure and harder to occlude) feeding the extremity and you won't have any return through the veins

as they are occluded. This can cause a dangerous amount of pressure to build up in the extremity and

lead to a life/limb-threatening situation called "Compartment Syndrome". A wound which may have

needed a TQ but wouldn't have resulted in an amputation now does due to a poorly secured TQ. So,

constantly reassess for any bleeding and ensure you can’t feel a pulse below the tourniquet on a pulse

point (ie. Radial artery in the wrist or dorsalis pedis/posterior tibial in lower leg). Once the TQ is secured

and all the bleeding is stopped, you’ll want to note the time and write that on the place provided on the

TQ. If all the bleeding isn’t stopped with one TQ, you can add a second one directly adjacent to the first

one, whether above or below (wherever you have the most room) and then secure and mark the time of

application. Individuals with larger limbs may need more than one TQ to successfully stop the bleeding

because not only does a TQ work on circumferential compressive force, it also acts on the surface area

which is being compressed. Therefore, if one TQ doesn’t work, you are doubling the surface area being

compressed by adding a second TQ and increasing your chances of successful hemostasis.

When do I not use a TQ?? Simple…. if it's not life-threatening. What’s life-threatening? Any of the

following could be viewed as life-threatening:

-Blood pouring out of a pitcher

-Blood-soaked clothing

-Bright red arterial spray

-The victim is lying in a large pool of blood

-The bleeding won’t stop with direct pressure

If the bleeding doesn’t look like the aforementioned, then, more than likely, good old fashioned direct

pressure is going to do the trick. Don’t go “full guns” if your kid gets a minor laceration and you try to

put a tourniquet on their limb. Even small arterial punctures and lacerations can be controlled with

direct manual pressure.

If you have to utilize a hemostatic or pressure dressing to ensure the wound stops bleeding, then go for

it. It matters not whether it’s arterial or venous in nature, it’s still bleeding and blood belongs in the

body. It’s science. Do all you can to keep it there.

Some wounds may need the TQ initially due to an unsafe scene and then can be dressed with a

hemostatic gauze and pressure bandage or may just need the pressure bandage; this is called a

“tourniquet conversion”. Also, some wounds may not be amenable to tourniquet placement and the

only way to control the bleed is through the placement of a roll of hemostatic gauze. Those areas of the

body we can’t apply a tourniquet to are where we are looking at; the “junctions” like where the neck

meets the shoulders, the arms meet the armpits and the legs meet the groin. So, we “Pack the

Junctions”. The key to success when using a hemostatic agent is to get the agent down to the source of

the bleed through constant, consistent pressure and keep applying it until no more can be placed and

then holding pressure for the prescribed amount of time, observing for any re-bleed and then

reinforcing it with a pressure bandage. You’re trying to put as much of the agent in the wound as

possible while the gauze is conforming to the wound and applying compression. If it begins to re-bleed

you’ll have to pull that gauze and place a fresh one in. If you have only one, just pack more standard

gauze (or whatever type of packing material you have on hand) in behind that and continue to hold

pressure and then wrap it and secure it with a pressure bandage.

The hemostatic gauze we utilize in our kits have two different compounds; Chitosan (ChitoGauze) and

Kaolin (QuikClot Combat Gauze and Bleeding Control Dressing). The Combat Gauze helps with the body's

own clotting capability to assist in forming a clot while the ChitoGauze acts completely independent of

the body’s “clotting cascade”. The QuikClot Combat Gauze has absolutely no heat at all associated with

it and won’t burn, while the ChitoGauze breaks down into glucosamine and causes no issues with folks

who are allergic to shellfish, iodine or CT dye as the proteins (what we’re allergic to) are absent. They

are both solid, proven hemostatics. They are impregnated into the gauze to get to the source of the

bleed for better delivery and to start building the clot. The gauze is there as a framework for the clot and

to add compression into the wound.

"But it has to be washed out"....every wound, whether it has the old granules or the newer gauze or

nothing, will be irrigated copiously and debrided in the OR.

“What about sterility?....Sterility is also another big question and that completely goes out the window

when someone is injured. Plus, you'll be getting an equine-sized dose of broad spectrum antibiotics in

the ER anyway. The packaging has to be sterile per FDA requirements but unless the outer wrapper is

sterilized and you open it utilizing sterile technique with sterile gloves in a sterile environment, the

moment you break the seal on the package in the outside environment, while using non-sterile gloves,

sterility is now gone. The least of your concerns at the time someone is bleeding to death is whether or

not something is sterile. It’s a good idea to keep it as clean as possible but we have to know that it’ll

never be sterile after it’s opened. All of the hemostatics we utilize in our kits are solid performers and

have been proven to work in austere environments time and again.

What about packing a penetrating wound to the chest? Nope. We call anything from the collarbone to

the pelvis and allll the way around the trunk, “The Box”. One, we don’t pack anything into a penetrating

injury to the chest, two, we can’t tourniquet it off, three, there’s a lot of ways there that air can get into

the pleural spaces and collapse a lung. So, if we can’t tourniquet it off or pack it, what do we do? We

“Seal the Box” with a non-porous occlusive dressing. The first choice is one which is “vented”. This

means it allows any pressure building up inside the chest to be released passively so that it doesn’t

continue to build and cause an excess of pressure. That said, we must know the signs and symptoms of

a tension pneumothorax because just because you have a vented seal in place over a penetrating chest

injury does not mean that it will be working. There are many things which can occur with this type of

injury which can cause the wound to occlude and not “vent”. So, know your signs and symptoms and

constantly reassess the victim for any increased difficulty breathing and other indicators of this

dangerous build up of pressure. There are many types of chest seals out there and we utilize the HALO

or Hyfin as they are excellent performers and pack easily into our kits and other stand-alone kits.

The key with any of the aforementioned items is learning how and when to use them. Get the training

and be prepared. We offer these products in our kits and the training on how to use them and other

items in the event that you don’t have them with you. The time chooses you. Will you be ready?

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