In the olden days, the tourniquet got a bit of a bad name. Medics used the phrase “save a life, lose a limb,” which translates to “this thing will save my patient, but their limb is gonna go.” This mindset has led to the tourniquet being a weapon of last resort in the fight against exsanguination, but new research shows that tourniquets are far more useful than you think.
Combat Application Tourniquets are being added to the jump kits on my ambulance sometime this month, and you should put one in your range bag as well. Here’s why.
Even if you’re the safest shooter in the world, the possibility exists for an accident on the range. One malfunction or inattentive shooter and suddenly the day goes from a relaxed fun event to a race for your life. If that negligent discharge hits your head, neck or torso, the combination of a tampon, a pressure dressing, and diesel therapy (driving really fast) is about the only option available. If that round hits an extremity, however, the options are a lot better.
In the old mindset, a tourniquet was the option of last resort. As soon as that thing goes on it’s a fight against time to get into the operating room or else the patient is going to fit right in at the next pirate’s convention. New research based on experiences in the military has provided some insightful statistics about the use of tourniquets in real life situations and has changed the minds of my medical director enough to move them up in our algorithm. So what are the numbers?
When a tourniquet is used in the pre-hospital setting:
- 87% of patients with a tourniquet applied (in the study) survived
- 96% survival rate if applied before shock
- 4% survival rate if applied after shock presents
- 0.4% of patients underwent “limb shortening” (amputation), usually unassociated with the tourniquet
- Permanent nerve damage in 1.5% of patients. (Temporary in 98%)
From the numbers, it looks like (A) tourniquets are not a guarantee for amputation or nerve damage as previously thought, and (B) the survival rate when a tourniquet is applied is much higher when applied quickly. Hypovolaemic shock can set in very rapidly when a patient is leaking, and once it sets in it’s almost impossible to reverse.
The moral of the story seems to be that tourniquets need to be applied faster in the field, and are safe to use without fear of amputation or nerve death in the future. The fear is still there, but not as overwhelming as it used to be.
What does this have to do with guns? As shooters, the possibility of being injured is always present. One of the first articles I wrote for this site was about making an emergency medical kit for yourself, and while I discussed tourniquets I placed them pretty low on the list. Armed with this new information it seems that tourniquets should be more important than they have been in the past.
Further testing has shown that tourniquets are more effective when the band of material is 2 inches wide, rather than the shoestring size footprint of the standard EMS cravat. The increased importance of the tourniquet coupled with the need for a larger surface area created a demand in the military and EMS fields for a solution that’s easy to apply and effective against appendage wounds.
That’s where the Combat Application Tourniquet (CAT) comes into play. The CAT was designed to be applied quickly either by the injured person themselves or another rescuer, as well as provide that even 2 inch band of pressure required to properly cut off circulation. The company making the CAT has a couple videos showing how to apply the CAT on their website, and it looks pretty damned easy.
OK, so now we know that tourniquets are extremely effective in stopping bleeding and preserving life, they’re relatively safe to use, and have a low probability of causing amputations or nerve damage. So what’s the procedure?
According to the new protocols handed down from Medical Control on high, my indications for using a tourniquet on an extremity other than the head are (bold indicate the ones you’ll probably see):
- Amputation or traumatic extremity injury with extensive bleeding
- Unable to control bleeding with pressure dressing
- Significant bleeding with the need for other interventions (CPR, etc)
- Bleeding from multiple locations
- Impaled / foreign body with bleeding
- Under fire / dangerous situations
- Total darkness
- Mass casualty event
Basically, if the thing is bleeding a lot slap a tourniquet on it. Our Medical Control made a point to not dictate what “extensive bleeding” actually means, instead leaving up to the individual rescuer to determine. So use your judgement.
What’s the procedure for properly applying a tourniquet?
- Visualize the wound. Tear off the patient’s clothes if need be, but actually get a look at the wound. This is important for figuring out the proper placement of the tourniquet.
- Apply tourniquet 2-3 inches proximal to the wound. You want the tourniquet to cut off circulation to as little as possible of the limb. Increase the pressure until you can no longer feel a pulse in the extremity.
- Mark the patient with “TK: [Time Applied].” Even though tourniquets are safer than once believed, there still is a ticking clock element the second the tourniquet goes on. Note the time and write either on the tourniquet itself or the patient’s forehead “TK,” which is the abbreviation for tourniquet, and then the time it was applied.
- Add tourniquets, not pressure. If the bleeding doesn’t stop with the application of the first tourniquet apply a second. See the picture above, on the right? That soldier has two tourniquets on his leg. The medic didn’t simply tighten down the first one, as that would not work as well as adding another. Surface area is more important than pressure, it turns out.
One last pearl of wisdom: avoid using a tourniquet on the knee. There’s a structure in the knee through which the blood vessels pass and it is incompressible. Apply the tourniquet above the knee when required.
Remember, tourniquets are not always the best solution. Little cuts and bleeds are still probably better served by a pressure dressing and some gauze. But if you’re bleeding heavily and help is still a few minutes away, a tourniquet can be your best friend.
Stay safe, shooters.