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Introduction

One reason for the high survival rate in the Global War on Terrorism for the past 17 years is early and aggressive tourniquet use to manage severe extremity hemorrhage as the main cause of preventable death on the battlefield. (Eastridge et al 2012; Kragh and Dubick 2017) Based on recommendations by the U.S. Department of Defense’s Committee on Tactical Combat Casualty Care (CoTCCC), tourniquet use has become the universally accepted first choice versus the historical “Last Resort” option. There have been clear benefits and successes from using CoTCCC-recommended tourniquets for extremity exsanguination as a cause of preventable death. (Walters et al 2005) Lessons learned have showed us that there are critical steps for proper tourniquet application to avoid hemorrhage control failure. One specific tourniquet failure is not converting it to another hemorrhage control technique within two hours after application as recommended by CoTCCC. (Shackelford et al 2015) Thus, it is our intent to emphasize how to optimize tourniquet use and how to convert a tourniquet for ongoing extremity hemorrhage control.

Background

The number of commercially available tourniquets on the consumer market has increased, resulting in tourniquet evaluation studies such as those performed at the U.S. Army Institute of Surgical Research. They reported that the Combat Application Tourniquet, known as the C-A-T, (North American Rescue Products, Inc.) and the Special Operations Forces Tactical Tourniquet, known as SOFTT (Tactical Medical Solutions, LLC) were both 100% effective in elimination of distal pulses in human volunteers. (Walters et al 2005) These two tourniquets were subsequently recommended by the CoTCCC and are widely used today in the U.S. military and NATO militaries worldwide. Other noteworthy studies established that early tourniquet use before the onset of shock was associated with a 90-96% survival rate versus 4-10% survival if the application was delayed until the casualty was in shock. (Kragh et al 2009; Kragh et al 2011)

Short- and long-term tourniquet-related morbidity has been assessed using available data; however, some gaps in knowledge still remain. Kragh et al found that approximately 3% of patients that had limb tourniquets applied had transient nerve palsies and there were no amputations caused by tourniquet use. (Kragh et al 2009) We are constantly reminded that in the face of exsanguination, it is better to accept the small risk of damage to the limb by a tourniquet than to have a patient bleed to death from not applying a tourniquet – thus the adage, “Life over Limb” still is very relevant today. It is estimated that approximately 1000-2000 lives have been saved from CoTCCC-recommended tourniquet application during the wars in Iraq and Afghanistan when they were used as a tool for self and buddy aid. (Blackbourne et al 2012)

Current tourniquet evidence indicates that most tourniquet applications are safe and effective in civilian settings as they are in military settings, with civilian success rates of 98.7%. (Kragh and Dubick 2017; Zietlow et al 2015) Though exsanguinating extremity hemorrhage is relatively uncommon in most civilian settings, tourniquets have undoubtedly gained acceptance in civilian tactical medicine and with emergency medical system (EMS) personnel. An analysis of EMS data shows an increase of prehospital tourniquet use from 0 to nearly 4,000 in the years between 2008 and 2016. (Goodwin et al 2019). The applicability of these findings of tourniquet success can be easily transitioned to civilian austere or wilderness settings. (Butler, Bennett, Wedmore, 2017)

Other successful examples showcasing the transition of military prehospital tourniquet use to the civilian sector are programs like Stop the Bleed and Tactical Emergency Casualty Care (TECC), where over 125,000 non-medically trained people and 150,000 law enforcement officer and paramedics have been trained on proper tourniquet application, respectively. (Goodwin et al 2019; Callaway 2017) The TECC curriculum represents the first broadly accepted set of civilian all-hazards, high-threat trauma care guidelines, that are based on the CoTCCC Guidelines, geared toward civilian medical providers and other first responders.

Tourniquet Optimization

Knowledge and practice of effective tourniquet use is essential. There are several points of performance in applying tourniquets, and later optimizing them, that can help to minimize potential application failures – see Table 1 (Shakelford et al 2015): 

Table 1 – Tourniquet Mistakes to Avoid

CoTCCC Guidelines suggest that the provider place the tourniquet “high and tight” during Care Under Fire (“hasty” tourniquet placement on the extremity), and then later optimizing placement after both the provider and casualty are well away from combat action or during threats in the wilderness from wild animal attacks, rock slides, avalanche, etc. See a short video on tourniquet placement during Care Under Fire that discusses this concept at deployedmedicine.com/market/11/content/80.

Tourniquets should also be consistently reassessed for placement and efficacy during patient evacuation, especially during nighttime and while navigating uneven terrain in backcountry and in tactical environments. During ongoing patient assessment, complete exposure and removing footwear to check (absent) pulses distal to the tourniquet may be delayed; in such cases, visibly confirming control of wound hemorrhage suffices. (Shackelford et al 2015) However, in dark conditions, palpation for a distal pulse to the tourniquet may prove more useful than observing for hemorrhage. When tactically or situationally feasible in the combat setting or backcountry, if wounds do require a tourniquet after closer inspection, replace any limb tourniquet placed over clothing with another one applied directly on the skin 2-3 inches above the bleeding site, but not on a joint. After tightening the distal tourniquet then slowly release the proximal tourniquet, leaving it loosely in place in case it is needed for two tourniquets placed side-by-side since this widens the area of compression. A short video of this tourniquet replacement technique can be viewed at deployedmedicine.com/market/11/content/44.

Tourniquet Conversion

Tourniquet conversion is a vitally important procedure especially while in the backcountry where evacuation times may be several hours to days in duration. (Drew, Bennett, and Littlejohn 2015) Following reassessment of prior tourniquet application and assessment of scene safety, conversion should be attempted if three criteria are met– see Table 2.  

CoTCCC'
Table 2. Tourniquet Conversion Criteria. * Shackelford et al 2015. See TCCC Guidelines for all hemorrhage control recommendations. See: deployedmedicine.com/market/11/content/40

See Figure 1 for step by step methods for tourniquet conversion. (Shackelford et al 2015 

1. With high-and-tight tourniquet applied in the groin region, expose the wound.

2. Apply hemostatic gauze (i.e., Combat Gauze; Celox Gauze or Chitogauze) and a pressure dressing.

3. Loosen high-and-tight tourniquet and move it down to just above the pressure dressing.
*Leave tourniquet in place and loosened in case bleeding recurs.

4. Monitor for re-bleeding.

Figure 1. Four tourniquet conversion steps.

 

It is recommended to utilize an additional “Plus-1” tourniquet during conversion by adding a loosened proximal tourniquet to an extremity, which has already had an effective tourniquet applied. (Drew et al 2015) Both tourniquets may already be in place due to the tourniquet replacement technique described earlier with a high and tight initial tourniquet. The reasoning for the use of a Plus-1 tourniquet is two-fold: 1) if the initial tourniquet breaks during the conversion process, there will be a backup in place ready to be tightened if needed; and 2) it can be difficult to accurately gauge where the patient is along the resuscitation spectrum. The well-intentioned administration of fluids (crystalloids, colloids, or blood products) and/or ketamine has the potential to increase blood pressure beyond the hypotensive resuscitation systolic BP target of 90mmHg. This additional prepositioned tourniquet reduces bleeding time considerably if bleeding suddenly recurs. (Drew et al 2015) An overview of hemorrhage control and tourniquet conversion steps during Tactical Field Care and for backcountry care can be viewed at deployedmedicine.com/market/11/content/81.

TCCC Guidelines suggest the following algorithm (Figure 2) for managing massive extremity hemorrhage throughout the continuum of care, and these same considerations can be applied in the wilderness setting. (Shackelford et al 2015)

Figure 2. Algorithm for tourniquet placement during Care Under Fire and reassessment during tactical field care and tactical evacuation care.

The CoTCCC recently reviewed many commercially available tourniquets to determine their effectiveness based on a predetermined set of criteria. (Montgomery et al 2019) The outcome of this evaluation resulted in eight recommended non-pneumatic and two pneumatic extremity tourniquets (See Table 3); this was recently summarized by Bennett and Christensen 2019. 

Table 3. New CoTCCC Recommended Tourniquets Options Approved in 2019.

Final Thoughts

The increased use of tourniquets for severe and complex extremity wounds has made an indelible mark on preventable death by improving casualty survivability and decreasing morbidity. Tourniquet application, release, replacement, and conversion done improperly can ultimately increase hemorrhage, morbidity, and mortality rates. Training proficiency, both in controlled and stressful environments, in addition to pre-planned contingency measures can prevent additional hemorrhage from becoming clinically significant. Early tourniquet optimization should be attempted as soon as feasible to minimize complications and reduce morbidity. Within the wilderness setting, CoTCCC-recommended tourniquets and hemostatic gauzes should undoubtedly be included in one’s backcountry aid kit, readily accessible, and the provider should be well-trained in their use before any emergent need.

Recommended resources for up-to-date information on TCCC Guidelines: deployedmedicine.com/

deployedmedicine.com/

References:

Blackbourne LH, Baer DG, Eastridge BJ, et al. Military Medical Revolution: Prehospital Combat Casualty Care. J Trauma Acute Care Surg. 2012;73:S372–S377.

Bennett BL, Christensen R. Committee on Tactical Combat Casualty Care Updates and Expands Recommended Tourniquet List. Wilderness Medicine Magazine. Volume:36 Issue:3, Summer 2019. 

Blackbourne LH, Baer DG, Eastridge BJ, et al. Military Medical Revolution: Prehospital Combat Casualty Care. J Trauma Acute Care Surg. 2012;73:S372–S377.

Bennett BL, Christensen R. Committee on Tactical Combat Casualty Care Updates and Expands Recommended Tourniquet List. Wilderness Medicine Magazine. Volume:36 Issue:3, Summer 2019. wms.org/magazine/1245/tourniquet. Accessed 25 May 2020.

Butler FK, Bennett BL, Wedmore I. Tactical Combat Casualty Care and Wilderness Medicine. Emerg Clin N Am. 2017:35:391-407.

Callaway DW. Translating Combat Casualty Care Lessons Learned to the High-Threat Civilian Setting: Tactical Emergency Casualty Care and the Hartford Consensus. Wilderness & Environ Med (Special Edition). 2017;28:S140-S145.

Drew B, Bennett, BL, Littlejohn L. Application of Current Hemorrhage Control Techniques for Backcountry Care: Part One, Tourniquets and Hemorrhage Control Adjuncts. Wilderness Environ Med. 2015; 26: 236-45.

Drew B, Bird D, Matteucci M, Keenan S. Tourniquet Conversion: A Recommended Approach in the Prolonged Field Care Setting. J Spec Oper Med. 2015;15:81-85.

Eastridge BJ, Mabry R, Seguin P, et al. Death on the battlefield (2001-2011): Implications for future combat casualty care. J Trauma Acute Surg Care. 2012;73:S432-S437

Goodwin T, Moore K, Pasley J, et al. From the Battlefield to Main Street: Tourniquet Acceptance, Use, and Translation from the Military to Civilian Settings. J Trauma Acute Care Surg. 2019;87(1S):S35-S39. 

Kragh JF, Dubick MA. Bleeding Control with Limb Tourniquet Use in the Wilderness Setting: Review of Science. Wilderness & Environ Med (Special Edition). 2017;28:S25-S32.

Kragh JF Jr, Dubick MA, Aden JK 3rd, McKeague AL, Rasmussen TE, Baer DG, Blackbourne LH. U.S. Military Experience From 2001 to 2010 With Extremity Fasciotomy in War Surgery. Mil Med. 2016 May;181(5):463-8.

Kragh JF, Swan KG, Smith DC, et al. Historical Review of Emergency Tourniquet Use to Stop Bleeding. Am J Surg. 2012;203:242–252.

Kragh JF, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med. 2011;41:590-597.

Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249:1-7.

Montgomery HR, Hammesfahr R, Fisher AD, Cain JS, Greydanus DJ, Butler FK, Goolsby C, Eastman AL. 2019 Recommended Limb Tourniquets in Tactical Combat Casualty Care. J Spec Oper Med. Winter 2019;19(4):27-50.

Shackelford SA, Butler FK Jr, Kragh JF Jr, Stevens RA, Seery JM, Parsons DL, Montgomery HR, Kotwal RS, Mabry RL, Bailey JA. Optimizing the Use of Limb Tourniquets in Tactical Combat Casualty Care: TCCC Guidelines Change 14-02. J Spec Oper Med. 2015;15(1):17-31.

Walters TJ, Wenke JC, Kauvar DS, et al. Effectiveness of Self-Applied Tourniquets in Human Volunteers. Prehosp Emerg Care. 2005;9:416–422.

Zietlow JM, Zietlow SP, Morris DS, Berns KS, Jenkins DH. Prehospital Use of Hemostatic Bandages and Tourniquets: Translation From Military Experience to Implementation in Civilian Trauma Care. J Spec Ops Med. 2015;15:48-53.

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