CAT tourniquet Inservice Honolulu EMS Joseph Lewis, M.D. Medical Director

1. CAT tourniquet InserviceHonolulu EMS Joseph Lewis, M.D.Medical Director

2. Tourniquets Honolulu EMS Tourniquet Protocol Background and Indications Tourniquets have been used intermittently, for years in a life over limb response to life threatening arterial bleeding. It is considered life over limb, as traditionally the use of a tourniquet was followed by a limb amputation. Modern surgical techniques and trauma triage have made automatic limb amputation a thing of the past, but improvised tourniquets or misuse of modern tourniquets can still result in permanent injury or amputation. As you are aware two wars have increased dramatically the number of extremity injuries that Army Medics, Nurses and Physicians care for, with multiple deaths due to hemorrhagic shock, due to traumatic amputations, mangled limbs and penetrating wounds to limbs. The Army has established protocols for life saving application of tourniquets. Since they havethe most experience with both successful tourniquet application and tourniquet application complications, we are using their guidelines to provide the safest application guidelines. This in-service is to refresh your knowledge of a tool, which could be life-saving, if used appropriately, but could cause permanent injury, including limb amputation if misused. Joseph Lewis, M.D. Medical Director, Honolulu Emergency Services Department June, 2012

3. Pressure Dressings First • The first principle regarding tourniquets is that a tourniquet is Plan “B”. It is applied if pressure dressings fail, except in certain situations like amputations and mangled limbs with multiple bleeding sites where a tourniquet is Plan “A”. • Most civilian injuries should respond to pressure dressings, but exceptions exist.

4. Tourniquets Always use real a tourniquet. Field improvised tourniquets should not be used because they are often ineffective, they cause more tissue damage and they increase the risk of post-tourniquet complications. Apply ours and remove these.

5. Tourniquets Tourniquet placement: Historically tourniquets were applied as distal as possible to minimize the amount of the limb which was amputated later. Now that we have safer design and limited tourniquet time, proximal placement over the largest portion of the extremity is recommended due to speed of application, minimizing pressure injury to tissues (nerves and blood vessels) and the possible multiple bleeding sites.

6. Tourniquets Tourniquet placement: Examples: • Thigh wound place tourniquet at least 5 cm proximal over a thick well padded section in proximal thigh to minimize risk of injury to nerves and blood vessels and a second should be applied proximal to the first. • Lower leg wound: apply tourniquet at least 5 cm proximal to the wound over a thick padded part of the calf to minimize risk of injury to nerves and blood vessels and a second above the first, if indicated or avoid the knee joint area. • Forearm wound; apply tourniquet 5 cm above wound in thickest portion of the forearm to minimize risk of injury to nerves and blood vessels , avoid the elbow area and apply second above the first, still below elbow or above elbow in lower arm. • Upper arm, apply 5 cm above wound over thickest portion of the arm to minimize risk of injury to nerves and blood vessels, below deltoid, apply second if needed.

7. Tourniquets Tourniquet safety theme; to minimize risk of injury to nerves and blood vessels place it over the thick portion of a limb and the use of two is OK.

8. Tourniquets Tourniquet tightness- the lowest possible pressure should be used to minimize subsequent ischemic injury, i.e. damaged nerves and blood vessels. The tourniquet should be just tight enough to stop the bright red bleeding, no more. Pulse checks not recommended, as pulses don’t kill, bleeding does, so focus on the bleeding not pulses.

9. Tourniquets Tourniquet Number- Apply the first tourniquet and tighten until bright red bleeding stops, If clinically indicated, i.e. bleeding continues, apply a second tourniquet more proximal if possible then the first and if indicated apply a third.

10. Tourniquets Tourniquet time 4-8 hours for Pre-Hospital Use

11. Tourniquets Immediate application of a tourniquet is justifiable in the following examples: Extreme life threatening limb hemorrhage with Failure to stop bleeding with pressure dressings or Injury does not allow control of bleeding with pressure dressings or Limb amputation / mangled limb with multiple bleeding points, to allow immediate management of airway and Breathing problems. (Following treatment of any airway or breathing problems the need for a tourniquet can be reassessed in the circulatory assessment and may be converted to a simple method of hemorrhage control.)or

12. Tourniquets Immediate application of a tourniquet is justifiable in the following examples: Point of significant hemorrhage from limb is not peripherally accessible due to entrapment (and therefore it is not possible to initiate simple methods of hemorrhage control such as direct pressure).Or Major incident or multiple casualties with extremity hemorrhage and lack of resources to maintain simple methods of hemorrhage control.And Benefits of preventing death from hypovolemic shock by cessation of ongoing external hemorrhage are greater than the risk of limb damage or loss from ischemia caused by tourniquet use.

13. Tourniquets Principles of tourniquet application include 1. placement of the tourniquet over thick part of limb, at least 5 cm proximal to injury. 2. Sparing joints as much as possible; and ideally applied directly onto exposed skin to avoid slipping. 3. Effectiveness of tourniquet use will be determined by stopping the bright red bleeding and not by the presence or absence of a distal pulse. Pulse absence is important, but stopping the bright red of bleeding is the goal. • If it is ineffective the tourniquet should be tightened or repositioned. If the tourniquet is still ineffective place a second tourniquet placed just proximal to the first. • 5. Slight oozing may still occur in a limb amputation despite effective application if there is medullary bone blood flow. 6. The time of application should be recorded and handed over to the receiving emergency department staff. 7. Write a “T” and the tourniquet application time on the forehead, it’s that important and losing a limb is that serious!

14. Complications of improperly applied tourniquet nerve damage

15. Tourniquet Precautions • Precautions • Never cover over or bandage a tourniquet • Write plainly on the emergency tag “tourniquet” • Tell every healthcare provider you turnover the patient to that he has a tourniquet. • Wrap proximal to impaled objects, never over an impaled object. • Write the letter “T” and tourniquet application time on the forehead of the patient. • Never cover the tourniqueted limb with a blanket. • Never triage a victim in a mass casualty incident with a tourniquet lower then a yellow.

16. Tourniquet Alternatives • Pressure Dressings adequate for most cases • Large amounts of gauze and an ace wrap • Topical Hemostatic agents not as simple or effective as pressure dressing: Hemcon gauze dressing impregnated with chitosan has been shown to work well with venous bleeeding, but not well with arterial bleeding; Quickclot was shown to cause burns and other soft tissue complications

17. Anatomy of a C-A-TTM The Combat Application TourniquetTM (C-A-TTM) (Patent Pending) is a small and lightweight one-handed tourniquet that completely occludes arterial blood flow in an extremity. The C-A-TTM uses a Self-Adhering Band and a Friction Adaptor Buckle to fit a wide range of extremities combined with a one-handed windlass system. The windlass uses a free moving internal band to provide true circumferential pressure to an extremity. The windlass is then locked in place; this requires only one hand, with the Windlass ClipTM. The C-A-TTM also has a Hook-and-Loop Windlass StrapTM for further securing of the windlass during patient transport.

18. Two-Handed Application to a Leg • Step 1: Route the Self-Adhering Band Around the Leg • And pass the free-running end of the band through the inside slit of the friction adaptor buckle.

19. Two-Handed Application to a Leg • Step 2: Pass the Band Through the Outside Slit of the Buckle • Utilizing the Friction Adaptor Buckle which will lock the band in place.

20. Two-Handed Application to a Leg • Step 3: Pull the Self-Adhering Band Tight • And securely fasten the band back on itself.

21. Two-Handed Application to a Leg • Step 4: Twist the Rod • Until bright red bleeding has stopped

22. Two-Handed Application to a Leg • Step 5: Lock the Rod in Place • With the Windlass ClipTM

23. Two-Handed Application to a Leg • Hemorrhaging is Now Controlled. • You can attend to other injuries or casualties.

24. Two-Handed Application to a Leg • Step 6: Secure the Rod With the Strap • Grasp the Windlass StrapTM, pull it tight, and adhere it to the opposite hook on the Windlass ClipTM

25. Two-Handed Application to a Leg The C-A-TTM Is Ready For Transport