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Fri Dec 15 13:32:58 GMT 2006

And for the sake of decency- I have no relationship with 'first care 
products".

>From: "oded private" <tangentcarrot at hotmail.com>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: trauma-list at trauma.org
>Subject: Re: The case against tourniquets
>Date: Fri, 15 Dec 2006 15:30:38 +0200
>
>
>When there are not enough hands, there is still an alternative to 
>tourniquets. Modern pressure dressings such as the "emergency bandage" by 
>"first care products" can be adjusted to provide sufficient direct pressure 
>to the wound without a hand holding it and without cuasing global limb 
>ischemia. It takes an even shorter time to aplly it then to apply a 
>tourniquet.
>
>>From: MARK FORREST <atacc.doc at btinternet.com>
>>Reply-To: "Trauma &amp; Critical Care mailing list" 
>><trauma-list at trauma.org>
>>To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
>>Subject: Re: The case against tourniquets
>>Date: Thu, 14 Dec 2006 18:43:45 +0000 (GMT)
>>
>>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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