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Thu Dec 14 18:43:45 GMT 2006

Dear Karim et al,
Two tourniquets (SATS) sit in my kit bag and we still actively teach their use, so I suppose that I should raise a few more questions before removing them! Let's stir the discussion up a little.

Firstly your case, there are clearly a number of issues.
time to theatre (and tourniquet removal) was significantly longer than ideal
you suggest that little if any direct or indirect pressure was applied before resorting to tourniquet
after such a long tourniquet time did you consider employing a crush protocol for renal protection, once haemostasis was achieved?
I fully agree that the tourniquet should be the last option in massive limb haemorrhage and that most can be controlled by simpler measures, but this is not always the case for all sorts of reasons.
We teach 'D.D.I.T.' - as in 'did it' to our medics and docs. They try direct pressure (aggressively) twice, before moving on to indirect pressure, if control still remains impossible and the haemorrhage remains considerable, then they are taught to move onto tourniquet. The patients get an obvious safety label or are marked with TIME and LOCATION and our labels have a short explanation for clincians.
We teach that if transfer time will be prolonged then the tourniquet should be realeased at 30 minutes for 30 seconds (this may pop the clot, but will hopefully reduce limb iscahemia). If bleeding stops then we leave the tourniquet. If bleeding resumes then the tourniquet is re-applied for 3 minutes then a further 30 secs release, this is repeated three times every 30 minutes (sticking to all the '3's reduces confusion to a degree!!)

This pattern of release and re-application is also used in the 'staged release' protocol for crush syndrome and suspension trauma mentioned by Mark Hellaby. 

(Staged relelase: Apply tourniquets to both limbs before crush release: after extrication then release one leg for 30 secs, if no problems then reapply for 3 mins then repeat twice more (6 times for two legs). 
Any instability then re-apply tourniquet or if prior to another release, wait a further minute and re-assess.)

Reviewing the recent literature, the main issues with tourniquets appear to be poor effect (especially on  the thigh versus the arm) and the recommendation of lower pressures in wider cuffs. There is not a wealth of work on crush syndrome and renal damage after short periods of tourniquet use (under 2 hours).

Similarly, if this is a real problem, then other than the cuff width, I cannot understand why a 2-3 hour cuff application during the trauma for elective surgery would not produce huge numbers of such cases. I have little doubt that they will have elevated CKs, limb oedema and probably even moderately deranged renal function but they are not all coming to critical care for renal support. Why is this different? Total limb ischaemia is limb ischaemia.

Dissmissing combat versus civilian practice is also not so easy. Many pre-hospital scenarios are in isolated or difficult locations and the trauma carer may be managing serious polytrauma alone, for some time. A tourniquet frees you up to move onto other issues. Another example where I have use touniquets for short periods is  during difficult extications form RTCs where patient access amy be minimal for significant periods. Obvious maasive haemorrhage cannot be controlled by pressure in some of these situtations, becasue you have to move out of the way, to allow continuous activity duing the extrication. 
I am also a little suprised by the Mine workers evidence that they can maintian quality direct pressure during transfers. Now that we scoop and run, there is often a considerable amount to do during a high speed transfer of polytrauma victims eg airway/resp support, cannulation, traction or pelvic splints, analgesia etc(we can debate again how much of it is life saving another day eg cannulation and fluid). Once again, there may not be enough hands to go around!

Surely the issue is not that we should abandon tourniquets but emphasise that they should be used  when all else fails or is impossible and that they should be left on for the shortest possible period. In addition, there are numerous other potential indications as mentioned by myself and others.

DON'T CROSS THEM OFF THE CHRISTMAS LIST JUST YET!

Regards
Mark Forrest
ATACC MD

----- Original Message ----
From: Karim Brohi <karim at trauma.org>
To: trauma-list at trauma.org
Sent: Sunday, 10 December, 2006 1:55:21 PM
Subject: The case against tourniquets

Recently, the US and UK military have "rediscovered" tourniquets.  Their use
has been published in meetings around the world and is now spreading to
civilian practice.  ATLS and other groups have spent years campaigning to
remove tourniquets from civilian practice, for good reasons, and now they
are back - with not a shred of evidence to support this reversion.

Maybe we need reminding of why tourniquets were abandoned in civilian
practice - so here's a case from a couple of weeks ago.  A young man is
brought to another hospital after a multiple stabbing incident.  Most are
superficial but he has arterial haemorrhage from a wound in the distal
medial thigh.  A tourniquet is placed in the upper thigh and he is
transferred to us.  On arrival he is taken straight to the operating room
for revascularisation but total time with the tourniquet is 2.5 hours.

The popliteal artery injury is small and only requires direct suture repair.
However the distal limb shows signs of swelling and a 4-compartment lower
leg fasciotomy is performed.  The patient is transferred to the ward but
despite the early fasciotomy has a large rise in his Creatine Kinase and
develops renal impairment.  Further he has a complete foot drop from
ischemic injury which may or may not recover.

The patient's haemorrhage would have been easily controllable by pressure
either at the site of injury or by digital pressure over the common femoral
artery at the femoral head.  2.5 hours is not a particularly long ischemic
time and there was no associated vein injury.  Venous congestion,
fasciotomy, ischemia to calf and thigh misculature, ischemic nerve damage
and renal failure were all contributed to, or arguably entirely the result
of tourniquet use.

The military operate under entirely different conditions.  A second pair of
hands to provide manual pressure may not be available and hence a
self-applied tourniquet may indeed be life-saving.  These are blast injuries
and often control haemorrhage from distal amputation.  But they may well not
be limb saving - indeed the amputation rate is twice that of previous wars.
(Yes more lives are being saved and yes there is improved torso armour etc
etc).   Further anecdotal UK experience suggests that soldiers are often
applying them with too little force and therefore causing venous obstruction
and increasing blood loss from the limb.  Watching 3 marines walking down
the street in San Diego with one leg between them was sobering.

And for all the talk of not having a second pair of hands, there is a wealth
of evidence from landmine victims that non-medical, in fact uneducated
villagers in remote, rural settings can control haemorrhage with digital
pressure and transport victims long distances for medical therapy (using
donkeys, not CCAT military transports) - and villagers can teach other
villagers to do it). The Tromsoe Mine Victim Resource Centre
(http://www.traumacare.no/) has been doing this in Cambodia, Afghanistan,
North Iraq, Burma and Afghanistan for years.  Read what they have to say
about tourniquets and the cases and images of increased haemorrhage
following their use.

To use a military term, we are suffering from severe mission creep as
tourniquets seep back into civilian practice.  Their use was banned for a
reason, which we are in danger of forgetting - and relearning.  The military
have their own reasons for using them, but we need to see real data about
their effectiveness for limb salvage.  For the military, tourniquet use
should be a last resort, in the knowledge that morbidity, disability and
amputation are increased with their use. They should not be advocated in
civilian practice at all.

Karim

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The case against tourniquets