- Email: [email protected]
The Tourniquet Debate
TRAUMA NOTEBOOK
The Tourniquet Debate
Authors: Denise M. Langley, RN, BSN, CEN, and Laura M. Criddle, MS, RN, CEN, Portland, Ore Section Editor: Maureen Harrahill, RN, MS, ACNP-CS
Denise M. Langley, is Emergency Department Nurse Practice Education Coordinator, Oregon Health & Science University, Portland, Ore. Laura M. Criddle, is Doctoral Student, Oregon Health & Science University, Portland, Ore. For correspondence, write: Denise M. Langley, RN, BSN, CEN, 3181 SW Sam Jackson Park Road, Portland, OR 97239; E-mail: langleyd@ ohsu.edu. J Emerg Nurs 2006;32:354-6. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.04.016
Earn Up to 8 CE Hours. See page 363. Case 1
A
40-year-old man involved in a high-speed motor vehicle collision was f lown to a regional trauma center by medical helicopter. He had significant chest and abdominal injuries, hypotension, and an open fracture of his left proximal femur that was bleeding profusely. At the scene, the patient stated he was a Jehovah’s Witness and was vehemently opposed to blood transfusion. Hemorrhage from the leg could not be controlled with direct pressure in the field or during transport. The patient arrived in the emergency department in hypovolemic shock. Good alignment of the fractured femur was obtained using a Sager splint. However, brisk bleeding from the injured femoral artery continued. The application of an extremity tourniquet was brief ly discussed but dismissed in favor of expediting the patient’s transfer to the trauma intensive care unit, and then to the operating room. Despite surgical intervention, the patient continued to exsanguinate, went into cardiac arrest, and died.
Case 2
A 27-year-old man sustained a single, high velocity gunshot wound to the right, upper anterior thigh; he had no other injuries. In the field, paramedics were unable to staunch the hemorrhage with direct pressure. Due to the wound’s location a few inches from the groin, the standard practice of elevating the bleeding site was not practical. On arrival at the trauma center, the patient was hypotensive. Direct pressure over the femoral artery was continued and the massive transfusion protocol was initiated. Nevertheless, attempts at hemorrhage control with the use of manual pressure and vessel clamping were unsuccessful. A tourniquet was considered but deemed too risky. The 354
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patient exsanguinated in front of the entire trauma team and died.
NON-CLINICAL INDICATIONS FOR PRE-HOSPITAL TOURNIQUET USE
Hostile environments (e.g., war zones, unsecured scenes, collapsing buildings, impending explosions). . Total darkness. . Mass casualty events when the number of wounded or the severity of their injuries exceeds the abilities of medical personnel to render optimal care. In the hospital setting, indications for tourniquet application have not been well delineated. In fact, as our case studies illustrate, this intervention is rarely carried out, even in the face of lethal hemorrhage. Why? Because there are many serious complications associated with tourniqueting. .
Conventional measures sometimes fail [to prevent exsanguination] and tourniquets can be a potentially lifesaving bridge to definitive hemorrhage control. Tourniquet debate
For centuries, tourniquets have been used to manage bleeding. A modern pneumatic version of the tourniquet is routinely and safely employed thousands of times each year for orthopedic extremity surgery. However, tourniquet use for hemorrhage control now is considered generally an unsafe and antiquated practice because of the risk for substantial complications associated with ischemia and reperfusion. Because there is overwhelming agreement in the medical community that most extremity hemorrhage can be controlled with direct pressure and elevation, tourniquet application is no longer taught routinely in United States nursing, medical, or paramedic curricula. Likewise, references to tourniqueting have been removed from most basic first aid texts. Nevertheless, there are several pre-hospital circumstances in which tourniquet application is acknowledged to be an acceptable intervention. The Israeli Defense Force,1 that has extensive experience with tourniquet use, has identified several clinical and non-clinical indications for their application. CLINICAL INDICATIONS FOR PRE-HOSPITAL TOURNIQUET USE . .
.
.
.
.
Hemorrhaging amputations. Failure to control bleeding with direct pressure bandaging. An injury site that does not allow the application of adequate direct pressure. Significant bleeding from multiple locations when there are not enough hands to maintain pressure. Hemorrhaging patients who need immediate airway or breathing management. Uncontrolled bleeding at the site of an impaled foreign object.
August 2006
32:4
COMPLICATIONS OF TOURNIQUET APPLICATION
Crush injury to the underlying tissues, particularly from tourniquets that are small or narrow. . Limb ischemia, that may necessitate amputation. In fact, amputation is recommended for any extremity that has experienced six or more hours of tourniquet time. . Reperfusion injuries. These cause massive destruction of the injured limb’s microcirculation. . Gas gangrene, that can occur after long-term placement (N12 hours). 2,3 . Significant pain. Given these serious complications, should tourniquet placement ever be considered in the emergency department? In a hospital setting, particularly in a designated trauma center, hemorrhage that cannot be controlled by conventional measures is an infrequent occurrence. Yet, as illustrated by these 2 cases, conventional measures sometimes fail and tourniquets can be a potentially lifesaving bridge to definitive hemorrhage control. Once the procedure is deemed necessary, there are no absolute contraindications to tourniqueting. There are several steps that can be taken to limit the extent of tourniquet damage.1 .
TO MINIMIZE TOURNIQUET-INDUCED COMPLICATIONS .
. .
Place the tourniquet as distally as possible, but at least 5 cm proximal to the wound. Avoid application over a joint. Apply the tourniquet directly to exposed skin. This will prevent unnecessary movement or slipping.
JOURNAL OF EMERGENCY NURSING
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TRAUMA NOTEBOOK/Langley and Criddle
Release the tourniquet as soon as it is medically safe to do so. Tourniquet times of 2 hours or less rarely are associated with serious complications. . Never apply the tourniquet directly over a protruding foreign object.1 Tourniquet application is considered effective when bleeding ceases and the peripheral pulse is obliterated.1 Most hospitals with surgical services have a variety of pneumatic tourniquets that can be made available to the emergency department in emergent situations. Silicone tourniquets are commercially available and are carried by some prehospital providers, including all members of the Israeli Defense Force. .
Release the tourniquet as soon as it is medically safe to do so. Tourniquet times of 2 hours or less rarely are associated with serious complications. As part of the ABCs of trauma patient care, bleeding must be halted. Whether in the hospital or in the field, early recognition of the failure of standard techniques to control external hemorrhage is essential. In these unusual circumstances, tourniquets must be considered a potentially lifesaving intervention to prevent fatal exsanguination. REFERENCES 1. Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M. Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 2003;54:S221-5. 2. Navein J, Coupland R, Dunn R. The tourniquet controversy. J Trauma 2003;54:S219-20. 3. Husum H, Gilbert M, Wisborg T, Pillgram-Larsen J. Prehospital tourniquets: there should be no controversy. J Trauma 2004;56:214-5.
Contributions for this column are welcomed and encouraged. Submissions should be sent to: Maureen Harrahill, RN, MS, ACNP-CS 1404 SE Malden, Portland, OR 97202 503 494-6007 . [email protected]
356
JOURNAL OF EMERGENCY NURSING
32:4
August 2006
The Tourniquet Debate
Authors: Denise M. Langley, RN, BSN, CEN, and Laura M. Criddle, MS, RN, CEN, Portland, Ore Section Editor: Maureen Harrahill, RN, MS, ACNP-CS
Denise M. Langley, is Emergency Department Nurse Practice Education Coordinator, Oregon Health & Science University, Portland, Ore. Laura M. Criddle, is Doctoral Student, Oregon Health & Science University, Portland, Ore. For correspondence, write: Denise M. Langley, RN, BSN, CEN, 3181 SW Sam Jackson Park Road, Portland, OR 97239; E-mail: langleyd@ ohsu.edu. J Emerg Nurs 2006;32:354-6. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.04.016
Earn Up to 8 CE Hours. See page 363. Case 1
A
40-year-old man involved in a high-speed motor vehicle collision was f lown to a regional trauma center by medical helicopter. He had significant chest and abdominal injuries, hypotension, and an open fracture of his left proximal femur that was bleeding profusely. At the scene, the patient stated he was a Jehovah’s Witness and was vehemently opposed to blood transfusion. Hemorrhage from the leg could not be controlled with direct pressure in the field or during transport. The patient arrived in the emergency department in hypovolemic shock. Good alignment of the fractured femur was obtained using a Sager splint. However, brisk bleeding from the injured femoral artery continued. The application of an extremity tourniquet was brief ly discussed but dismissed in favor of expediting the patient’s transfer to the trauma intensive care unit, and then to the operating room. Despite surgical intervention, the patient continued to exsanguinate, went into cardiac arrest, and died.
Case 2
A 27-year-old man sustained a single, high velocity gunshot wound to the right, upper anterior thigh; he had no other injuries. In the field, paramedics were unable to staunch the hemorrhage with direct pressure. Due to the wound’s location a few inches from the groin, the standard practice of elevating the bleeding site was not practical. On arrival at the trauma center, the patient was hypotensive. Direct pressure over the femoral artery was continued and the massive transfusion protocol was initiated. Nevertheless, attempts at hemorrhage control with the use of manual pressure and vessel clamping were unsuccessful. A tourniquet was considered but deemed too risky. The 354
JOURNAL OF EMERGENCY NURSING
32:4
August 2006
TRAUMA NOTEBOOK/Langley and Criddle
patient exsanguinated in front of the entire trauma team and died.
NON-CLINICAL INDICATIONS FOR PRE-HOSPITAL TOURNIQUET USE
Hostile environments (e.g., war zones, unsecured scenes, collapsing buildings, impending explosions). . Total darkness. . Mass casualty events when the number of wounded or the severity of their injuries exceeds the abilities of medical personnel to render optimal care. In the hospital setting, indications for tourniquet application have not been well delineated. In fact, as our case studies illustrate, this intervention is rarely carried out, even in the face of lethal hemorrhage. Why? Because there are many serious complications associated with tourniqueting. .
Conventional measures sometimes fail [to prevent exsanguination] and tourniquets can be a potentially lifesaving bridge to definitive hemorrhage control. Tourniquet debate
For centuries, tourniquets have been used to manage bleeding. A modern pneumatic version of the tourniquet is routinely and safely employed thousands of times each year for orthopedic extremity surgery. However, tourniquet use for hemorrhage control now is considered generally an unsafe and antiquated practice because of the risk for substantial complications associated with ischemia and reperfusion. Because there is overwhelming agreement in the medical community that most extremity hemorrhage can be controlled with direct pressure and elevation, tourniquet application is no longer taught routinely in United States nursing, medical, or paramedic curricula. Likewise, references to tourniqueting have been removed from most basic first aid texts. Nevertheless, there are several pre-hospital circumstances in which tourniquet application is acknowledged to be an acceptable intervention. The Israeli Defense Force,1 that has extensive experience with tourniquet use, has identified several clinical and non-clinical indications for their application. CLINICAL INDICATIONS FOR PRE-HOSPITAL TOURNIQUET USE . .
.
.
.
.
Hemorrhaging amputations. Failure to control bleeding with direct pressure bandaging. An injury site that does not allow the application of adequate direct pressure. Significant bleeding from multiple locations when there are not enough hands to maintain pressure. Hemorrhaging patients who need immediate airway or breathing management. Uncontrolled bleeding at the site of an impaled foreign object.
August 2006
32:4
COMPLICATIONS OF TOURNIQUET APPLICATION
Crush injury to the underlying tissues, particularly from tourniquets that are small or narrow. . Limb ischemia, that may necessitate amputation. In fact, amputation is recommended for any extremity that has experienced six or more hours of tourniquet time. . Reperfusion injuries. These cause massive destruction of the injured limb’s microcirculation. . Gas gangrene, that can occur after long-term placement (N12 hours). 2,3 . Significant pain. Given these serious complications, should tourniquet placement ever be considered in the emergency department? In a hospital setting, particularly in a designated trauma center, hemorrhage that cannot be controlled by conventional measures is an infrequent occurrence. Yet, as illustrated by these 2 cases, conventional measures sometimes fail and tourniquets can be a potentially lifesaving bridge to definitive hemorrhage control. Once the procedure is deemed necessary, there are no absolute contraindications to tourniqueting. There are several steps that can be taken to limit the extent of tourniquet damage.1 .
TO MINIMIZE TOURNIQUET-INDUCED COMPLICATIONS .
. .
Place the tourniquet as distally as possible, but at least 5 cm proximal to the wound. Avoid application over a joint. Apply the tourniquet directly to exposed skin. This will prevent unnecessary movement or slipping.
JOURNAL OF EMERGENCY NURSING
355
TRAUMA NOTEBOOK/Langley and Criddle
Release the tourniquet as soon as it is medically safe to do so. Tourniquet times of 2 hours or less rarely are associated with serious complications. . Never apply the tourniquet directly over a protruding foreign object.1 Tourniquet application is considered effective when bleeding ceases and the peripheral pulse is obliterated.1 Most hospitals with surgical services have a variety of pneumatic tourniquets that can be made available to the emergency department in emergent situations. Silicone tourniquets are commercially available and are carried by some prehospital providers, including all members of the Israeli Defense Force. .
Release the tourniquet as soon as it is medically safe to do so. Tourniquet times of 2 hours or less rarely are associated with serious complications. As part of the ABCs of trauma patient care, bleeding must be halted. Whether in the hospital or in the field, early recognition of the failure of standard techniques to control external hemorrhage is essential. In these unusual circumstances, tourniquets must be considered a potentially lifesaving intervention to prevent fatal exsanguination. REFERENCES 1. Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M. Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 2003;54:S221-5. 2. Navein J, Coupland R, Dunn R. The tourniquet controversy. J Trauma 2003;54:S219-20. 3. Husum H, Gilbert M, Wisborg T, Pillgram-Larsen J. Prehospital tourniquets: there should be no controversy. J Trauma 2004;56:214-5.
Contributions for this column are welcomed and encouraged. Submissions should be sent to: Maureen Harrahill, RN, MS, ACNP-CS 1404 SE Malden, Portland, OR 97202 503 494-6007 . [email protected]
356
JOURNAL OF EMERGENCY NURSING
32:4
August 2006