The United States military has begun to publish its recent experience with the use of tourniquets, and the results are positive.1 Prior literature has already advocated for EMS use of tourniquets for civilian injuries,2 but last three years have seen the publication of studies that confirm their utility. The author members of the 31st Combat Support Hospital Research Group, led by Dr. Alec Beekley, have summarized the results of their work:1
"Prehospital tourniquet use is an effective means of establishing extremity hemorrhage control in military casualties. Tourniquet use is associated with low risk of ischemia-related complications or neurologic injury."
"Liberalized use of prehospital tourniquets as a first-line treatment for extremity hemorrhage should continue."
"Prehospital providers and treating surgeons should be cognizant of the possibility of failure of the tourniquet to control hemorrhage, particularly at the above-knee level."
"To avoid rebleeding or bleeding through a prehospital tourniquet, hospital physicians should replace those tourniquets with pneumatic tourniquets as soon as possible after patient arrival to the medical center."
In the civilian trauma population, tourniquet use has been viewed cautiously. Civilian injuries occur in a wide population range—not the young, healthy population of military personnel. Most trauma injuries have bleeding that is easy to control with direct pressure. First aid classes have historically contained a section on tourniquet use, and it is common for EMS providers to remove tourniquets placed by members of the public on extremities that have relatively minor injuries. But there are certain extremity injuries that produce rapid bleeding that will be difficult for EMS providers to control, and a tourniquet is an excellent tool to utilize for a short time.
Applying a tourniquet causes pain in the conscious patient. More pain occurs when the tourniquet band is thin or places uneven pressure. Pain control is beneficial in the conscious patient, especially one who has a major injury isolated to the single extremity and no distracting factors. Pain control for EMS providers typically is provided through narcotic medications. Medical control may be helpful in directing pain control medications in the patient with multiple injuries and when the patient is perfusing poorly. Early contact will allow the hospital to mobilize trauma resources and any equipment needed for immediate care on arrival.
An 18-year-old male in acute distress. His arm has been amputated in a very irregular fashion. Bystanders have fashioned a trouniquet to control bleeding.
- Airway: Uncompromised.
Breathing: No respiratory distress
- Circulation: Adequate perfusion, brisk capillary refill. Significant bleeding from the amputated arm.
- Disability: Patient reports severe pain in the arm.
Exposure of Other Major Problems:
The young man's girlfriend is extremely upset, as are a number of bystanders.
|1810||140||28||98% on L. index finger|
- Allergies: None
- Medications: None
- Past Medical History: No significant medical problems
- Last Intake: Just prior to the accident
- Event: A low-speed auto accident results in a traumatic amputation of a victim's arm
Customer Service Opportunity
This incident brought a range of bystanders to assist a severely injured patient with an unusual injury. The bystanders performed a critical intervention and worked with law enforcement to provide as much care as possible prior to EMS arrival. There are situations where bystanders make a significant investment in the care of victims, and will benefit from feedback on how well they performed and victims' outcomes. Considering the significant privacy protections owed to EMS patients, there are still ways for EMS personnel to assist in connecting rescuers to victims. In this situation, "family knows family," so there was an easy way to establish a communications bridge.
There are also incidents where bystanders will be overwhelmed by the sights, sounds and/or smells of the emergency. This incident had essentially all of those elements, and brought enough distress to the witnesses, rescuers and even law enforcement to cause a multiple-casualty incident. In the midst of providing critical patient care, it is important for EMS crew leaders to be prepared to mitigate the effects on other witnesses, so they don't also become victims.