Taipan Magazine – by Brian Brzowski, MD
The history of the tourniquet dates at least as far back as 500 BC when the Romans designed a device to control bleeding during amputations. It was made mostly of bronze and was lined with a bit of leather for “comfort”
Primarily because of the practical need to control bleeding during surgical procedures, other tourniquet designs proliferated during the 18th, 19th, and 20th centuries. These were quite simplistic and culminated in the development of a pneumatic tourniquet that is currently used thousands of times/day across the world to permit the creation of a bloodless field during procedures on both the upper and lower extremities.
The Romans were probably the first to use a tourniquet in an emergency setting like one would encounter during a violent altercation (for our purposes, the only concern worthy of consideration). However, tourniquet use gradually fell upon disfavor around the time of the Civil War, presumably because of the significant number of injuries that resulted from prolonged TQ use prior to the performance of surgical amputations.
For many years lay people and uneducated emergency responders feared the damage that could be wrought by the use of a tourniquet despite their widespread safe use in operating rooms. Indeed, there are precautions that need to be followed in order to prevent injury in the elective surgical setting, but this record of successful use should comfort the timid when controlling massive hemorrhage in the non-hospital setting.
The tissues at risk for potential injury from use of a tourniquet are muscle and nerve. Damage to the muscle appears to come from the lack of oxygen while the TQ is in place, and nerve damage occurs from the direct pressure of the device. Wider, broader TQ’s are less risky to the nerves, and a shorter duration of use lessens the likelihood of muscle damage. Of course, in the situation of a life threatening injury, these concerns need to be kept in perspective.
Interestingly, the fear that even a properly applied tourniquet could endanger the limb while saving a life was confirmed in print in the 1988 Emergency War Surgery, Nato Handbook. The significant life-saving potential of this device was downplayed, and the combat medic was admonished that his main objective in the field was to avoid worsening the injury. The use of TQ’s by the medic was felt to be rare, preferably avoidable, and usually an unnecessary act. Nonetheless, from the Vietnam Conflict to our present Military actions in Iraq and Afghanistan, tourniquet use has increased and its great value has been realized. Many thousands of lives have been saved while injury to the extremities has been very limited. Both military and civilian surgeons, medical personnel and first responders finally understand the clear and convincing evidence for use of a tourniquet in managing extremity trauma.
In fact, while almost all Military Surgical literature up to this point has boldly stated that bleeding from an extremity wound is the most common cause of preventable battlefield death, the successful use of TQ’s has changed that paradigm. Interestingly, the challenge has now become to create a tourniquet that is able to staunch bleeding that comes at the junction of the extremities with the trunk: groin, neck. Devices to control this so called Junctional Hemorrhage are now appearing and are needed to deal what is now the most preventable cause of battlefield fatalities.
One of these devices is the Combat Ready Clamp:
The battle of Mogadishu and the death of Corporal Jamie Smith from a very high injury to his femoral artery prompted the development and pursuit of these types of devices. Many of you will remember the scene of his death in the movie Black Hawk Down: http://www.youtube.com/watch?v=gixRgsPFR7g
Another effort at controlling hemorrhage that is not manageable with a standard tourniquet is the Abdominal Aortic Tourniquet. This unit applies pressure on the lower abdomen and is designed to compress the large blood vessels within the lower abdomen/pelvis, stemming bleeding from injuries that are too high for a tourniquet and not within the abdomen itself.
And here’s the last one from North American Rescue, the Junctional Emergency Treatment Tool (JETT):
Stay tuned. This story hasn’t yet been completed……
Below is a brief introduction of the most widely used and available tourniquets. For further instruction on their use, it is strongly recommended that the user attend formal training such as is offered in the stable of SI Tactical Medicine Courses. In particular order, good choices to so-so choices:
I. SOF-T Tourniquet
- Special Operations Forces Tactical Tourniquet – favored by many Special Forces Teams
- Windlass is Aluminum
- Dual rings of molded plastic
- No Velcro
- One of the easiest to use one handed
- Safety set screw to prevent unintended release of strap
II. SOF-T Tourniquet, Wide
- 1 ½ inches wide
- 25% lighter than SOF-T
- No-thread buckle
- More drag when using one handed because of buckle design
III. CAT Tourniquet
- Adopted by the US Army
- Durable Nylon Windlass secured in place with Velcro loop
- Strap secured in place to itself with Velcro
- Velcro material on strap increases friction making one handed use difficult unless strap is not fully threaded through buckle
- Handy location to record time of tourniquet placement
IV. Cav Arms Tourniquet
- Nylon Windlass
- $28.00 for set of two from One Source Tactical
- Easy to apply one handed
- Less secure once placed
V. Ratcheting Medical Tourniquet
- Works well one handed
VI. Tourni-Kwik – TK4
- Elastic Latex band with metal end hooks
- $8 from One Source Tactical
- One handed application possible
- Somewhat easily dislodged
VII. Improvised Tourniquets (significant compromise over commercially available units)
i. Can be fairly effective
ii. If long enough, sucks less
iii. Best if you have key ring and sturdy rod/pen to secure (see Beating the Reaper for another slick trick)
iv. Doesn’t shock the Mugabe followers if it falls out of your pocket in line for your mochachino
ii. Nearly impossible to generate enough pressure to stop the bleeding because of its stiffness and lack of windlass
iii. Holes are never in the right spot to secure the belt in place
3. Shoe string/Paracord/other rope
i. Really sucks and hurts like hell
ii. Expect permanent nerve damage
WHY DON’T YOU HAVE YOUR TOURNIQUET WITH YOU???