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Fri Dec 15 00:09:19 GMT 2006

Hi Ron,
Fully agree with what you say and in support of this my tourniquets still look remarkably pristine, but I have gone through a fair few trauma dressings!!
Interesting that you mention Quickclot, as I have spent the night reading many of the miltary discussion boards to look at the various anecdotal experiences in the field., to compare with the literature.

What seems clear is there is huge variation in it's effect but as suggested by the manufacutrers, much of this can be explained by poor technique. Some things clearly come over from the discussions, which support does the literature:
- powder more likely to blow away, or contaminate the medic, although better than sponge/mesh for getting deep into wounds
- all types need support with a good direct pressure dressing
- best results when systolic pressure is very low (no surprise there, but follows the guidelines in the pig training video )
- lots of reported cases of tissue burns, although some irrigation may reduce this without  washing out the powder
- different review trials have demonstrated better results for Zeolite and other for Chitosan, the jury is still out.

I would also like to hear more about experiences with the new Quickclot, that is less exothermic.....anyone used it yet?

Regards
Mark F

----- Original Message ----
From: Ronald Gross <Rgross at harthosp.org>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Thursday, 14 December, 2006 11:36:55 PM
Subject: Re: The case against tourniquets

Mark,

I agree with most of what you have said.  The problem with the overall
theme is, however, that military is not civilian, and vis versa.  Your
discussion about rural polytrauma is cogent and indeed germain to the
present thread; however, it belies the fact that we are seeing a move
towards the use of new technologies such as civilian use of the highly
fashionable clotting bandages/substances such as Quick-Clot and
tourniquets in lieu of that which we know works most of the time,
without any true and trusted data to support their use - other than the
$$$ generated for the companies that champion their use.  

Yes, desperate times demand desperate measures, but most of the time we
just ain't so desperate - at least in the civilian trauma world!

Just MHO, for what that is worth.
Ron
>>> MARK FORREST <atacc.doc at btinternet.com> 12/14/2006 1:43 PM >>>
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