Rethinking tourniquets

The use of tourniquets to stop massive bleeding and save lives goes back centuries. But in modern times, their use has been a bit controversial — mainly because of some reports that they can damage nerves and tissue.

In the military, however, tourniquets saw increased use in Iraq and Afghanistan — with studies demonstrating their effectiveness on the battlefield. And while civilian use has lagged because of those lingering concerns, interest has grown — particularly in the wake of mass-casualty events such as the Boston Marathon bombing.

“The controversy regarding their use in the civilian realm lies in the degree of training that the people applying the tourniquets have,” said Dr. John Myers, chief of trauma and emergency surgery at University Hospital, and professor of surgery at the UT Health Science Center. “In the military, everyone gets the right training for proper tourniquet use.”

A new national study that included University Hospital patients — described as the largest study of prehospital tourniquet use on civilians — has found that their benefits exceed those found by the military, when used by trained first responders.

The study, published in the July issue of the Journal of Trauma and Acute Care Surgery, examined the medical records of 197 civilian adult trauma patients who had tourniquets placed on injured arms or legs by first responders at 10 centers across the country. Of those, 49 had been brought to University Hospital.

The study found that the tourniquets effectively controlled bleeding for 89 percent of the patients, and more than half saw a beneficial increase in blood pressure after the tourniquet was applied. Mortality and limb amputation rates among all the civilians were lower than those seen in the military studies — likely because battlefield injuries were typically more severe than those seen in civilian trauma patients, said Dr. Myers, who led the local arm of the study.

One in five patients in the study had a tourniquet placed by the patient or a bystander before first responders arrived. Outcomes for patients with those initial, improvised tourniquets were no different than for those who had only commercially made tourniquets placed by trained emergency personnel.

The study noted that in mass casualty events, it is often bystanders that are first to use tourniquets to slow bleeding before help arrives. Dr. Myers said with a little training, friends, family or bystanders can use tourniquets effectively. But many of the concerns that now exist about their use stem from people applying them incorrectly.

“The risk of these is tissue ischemia, which can lead to permanent disability or limb loss,” Dr. Myers said. “So without proper education on their use, tourniquets could become a source of unnecessary trauma morbidity.”

Dr. Myers said anyone attempting to use a tourniquet should keep these principles in mind:

  • Place the tourniquet between the heart and the site of bleeding (if the bleeding is at the knee, put tourniquet around the thigh).
  • The tourniquet needs to be tight enough to stop arterial blood flow.
  • Record the time that the tourniquet was applied and provide it to the first responder or at the emergency room.

“If anyone has any doubt or concern, they should just apply direct pressure to the site of bleeding until trained medical personnel arrive,” Dr. Myers said.

Image shows U.S. military personnel training in the use of tourniquets. Photo courtesy U.S. Navy.