All Bleeding Eventually Stops (Tourniquet Talk)

We in healthcare often think we're pretty funny, and one of the sayings we like is "all bleeding eventually stops," because, well, it does. Bleeding stops because the wound naturally starts the clotting process along with blood vessel constriction, or bleeding stops because the body simply runs out of blood. The goal is to help the former and prevent the latter.

Our SafeTrails First Aid programs currently offer Stop The Bleed certifications, through the American College of Surgeons/Committee on Trauma. We talk about using direct pressure and packing for wounds, but the course also covers a bleeding control tool that's been quite controversial: tourniquets.

Admittedly, life-threatening bleeding will be uncommon from trail injuries, but not impossible, and let's face it, bleeding injuries can occur anywhere. 

Some examples of injuries possibly requiring advanced and aggressive bleeding control are;

• Penetrating trauma from firearms and stabbings. Home Office figures (England and Wales) show a 16% increase in firearms offences resulting in serious injury in 2005/06 compared to 2004/05.15
• Firearms police officers working in tactical environments who may benefit from a self‐applied tourniquet for “care under fire”.
• Terrorist incidents with penetrating and/or blast injury to limbs.
• Rural incidents or wilderness medicine where there are limited resources and delayed, often unconventional, transport to definitive care.
• Industrial accidents. From personal communication there are a number of examples of tourniquet use to prevent haemorrhage from limbs following entrapment or shredding by industrial or farming machinery (http://www.marsbasics.co.uk/)

I mentioned that tourniquets have been controversial, and at one point they were considered "an instrument of the devil that sometimes saves a life." Over the years though, and *thanks* to research in battlefield medicine, tourniquets have been found to be safe (when used appropriately), and beneficial.

So what is appropriate tourniquet use? This video is great on how to apply one, but in summary:

• Tourniquets are used on life-threatening bleeding in extremities when pressure and packing have not worked. 
• A tourniquet should be applied about two inches above the wound, but not over a joint. If the joint is too close, go above the joint (meaning closer to the torso). 
• The tourniquet should be tight--tight enough to stop both arterial and venous blood flow. When it's that tight, it's going to hurt.
• If possible, clothing should be removed so the tourniquet is applied directly to the skin.
• Once applied, tourniquets should not be loosened until definitive care is available (such as in the hospital). Loosening a tourniquet can lead to "reperfusion injury."
• If an appropriately applied and tightened tourniquet has not stopped the bleeding, a second one may need to be applied above the first one.
• The time that a tourniquet is applied should be noted. Maybe the easiest way would be to take a quick photo with your phone, but writing on the tourniquet (or the patient) will work too.

Some of the common questions we've had in our classes are:

• What about improvised tourniquets? Yeah, what about them? They may work, and if life-threatening bleeding is present, it would be important to try anything. I think in a high-stress situation like that, it would be easier just to grab a device designed for that purpose, but straps, belts, and other options could work. Width is important, and it's been advised that improvised tourniquets be about 2-4 inches wide.
• How long can a tourniquet stay on? Ultimately, the least amount of time is best. It's been generally accepted that two hours is time window that should be safe. There may still be some nerve damage, but nerve damage is better than death. There been studies with longer time (up to 16hrs), with good outcomes, but 

While they are safe when used the right way, they won't be your first approach. The majority of external haemorrhage can be controlled by direct pressure, but some injuries need more. It's important to know when and how to use them.

If you want to learn more, check out one of our courses or take an online course.

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