Return of the tourniquet
By Dan White

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Tourniquets have been used on the battlefield since 1674. The earliest known usage of a tourniquet dates back to 199 BCE-500 CE. The Romans used them to control bleeding, especially during amputations. These early tourniquets were narrow straps made of leather and bronze.

INDUSTRY PULSE

Have you used tourniquets in emergency situations?
  • 1. Yes
  • 2. No

My first exposure to tourniquets was in the Boy Scouts, where we learned how to fashion one from readily available parts like our kerchief. In EMT school, I was taught that tourniquets are a solution of last resort. Not that you should never use them, but that using one came with a terrible price.

Back then we were taught the price of cutting off arterial blood flows was loss of the distal limb. It made intuitive sense that for a tourniquet to stop hemorrhage, it had to block atrial blood flow. With loss of blood flow, tissue necrosis and death seemed an inevitable conclusion. Like many things I was taught when I was young, this one is apparently not entirely true either.

Recent combat medical military experience has taught us something different. Tourniquets both save lives and often do not cause limb loss. Tourniquets have been applied for hours and many limbs still saved. As in any conflict of war, our EMS systems learn invaluable lessons from the horrible price our soldiers pay. One of the lessons learned in Iraq is that when elevation and direct pressure fail, a tourniquet can work.

Today, many soldiers, combat medics and paramilitary types carry one. It has become accepted in EMS, too. This has resulted in a number of commercially manufactured tourniquets entering the civilian market. Many of these were originally built to military demand. The tourniquet is now so popular that it is being built into pant belts or even clothing.

The EMS professional usually has more medical training than the average soldier or corpsman. EMTs and paramedics understand each therapy has a place in context. The place for the tourniquet is when direct pressure and elevation fail. It is for when the potential for loss of life outweighs the risk of losing a limb. It is not a therapy competition; all three treatments along with hemostatic agents each have a place in the control of bleeding.

The reality is injuries requiring the use of a tourniquet are much more common in combat. The kind of bleeding that direct pressure can't always stop are injuries from large projectiles and explosive devices that tear arteries down their length, or create massive wound channels.

The easiest way to make a tourniquet is with a triangular bandage. Roll it long ways into a one-to-two-inch-wide band, encircle the limb and tie in a firm square knot. Then, find a windlass to tighten it. A stick or even an oxygen wrench will work fine.

Slide the windlass under the bandage and twist until arterial blood flow to the distal extremity is occluded. Tape the windlass down into a secure position and document the time is was applied. It's really pretty simple. For those who want a ready-to-use version, there are several good ones on the market.

Most commercially available tourniquets come ready to use and take up very little space. Those clinicians in the emergency department and aeromedicine can expect to see more frequent use of tourniquets by first responders. Everyone should become familiar with the different types and applications. These are few of the better-known and latest models.

The SOF Tactical Tourniquet, or SOFTT, features a black nylon-webbing strap with an integrated windlass. There is a retainer to secure the windlass "stick" once correct pressure is achieved. The SOFTT is constructed of quality, high-strength materials. The tourniquet handle is machined from a solid piece of aircraft aluminum.

The MAT, or Mechanical Advantage Tourniquet, features a rotary dial. You twist an innovative dial-type mechanism to tighten them. Initially developed for the U.S. Department of Defense, the newer EMAT is available to the EMS market in a new safety orange color.

One of the most popular windless-style tourniquets is the CAT, or Combat Application Tourniquet. It is a one-handed tourniquet used extensively by the U.S. Army.


One of the most popular windless-style tourniquets is the CAT, or Combat Application Tourniquet. It is a one-handed tourniquet used extensively by the U.S. Army. It utilizes a durable windlass with a patented internal bad that applies true circumferential pressure to the extremity. A hook-and-loop windlass retainer secures the windlass to maintain constant pressure during transportation. The CAT also features a bright red tip that makes seeing and threading the strap easy. It also has a ready to use time label boldly displayed on the front.

A more recent tourniquet is the RMT or Ratcheting Medical Tourniquet. The RMT buckle features a two-piece mechanism. The outer frame is your tightening lever. You simply raise and lower the outer frame and, with each motion, the tourniquet gets tighter. The action uses mechanical leverage to apply incredible tension.

The inner portion of the buckle is the release mechanism. To use it, the receiving clinician simply pulls the inner tab up once bleeding is controlled. What I really like about it is how the release is recessed below the frame. That makes it almost impossible to accidently release pressure inadvertently.

You can hear the clicks as the buckles ratchets the strap tight. The buckle looks tough as nails. It has been tested down to 29 degrees below freezing and you can operate it with gloves on. The RMT comes fully assembled and can also be self-applied with one hand. They even have a pediatric model.

The latest type of tourniquet is the Junctional Tourniquet. They use direct arterial pressure points to stop bleeding from large arteries at the junction of the torso and limbs. There are two different models available. These devices are mainly used to treat blast injuries where legs or arms are amputated.

The Combat Ready Clamp or CRoC looks like a bench clamp. The CRoC has a vise-like compression disk that provides the distinct life-saving advantage of creating bilateral pressure exactly where it is needed most — stopping collateral flow and controlling hemorrhage. The CRoC is lightweight and can be assembled and applied quickly. It can put direct point pressure on the femoral artery.

The SAM Junctional Tourniquet or SJT occludes the femoral artery in the inguinal area at the junction of the torso and legs. When blast injuries take off legs like in Boston and every day in combat zones, it can easily be fatal. It is frequently difficult if not impossible to stop the bleeding in time. Sometimes there is just not enough leg left to get a tourniquet around.

The SAM Junctional Tourniquet puts pressure on the arteries feeding the legs. It does this with a sophisticated mechanism of action that is easy to use and fast to deploy. You can put it on in under 25 seconds with a little practice.

It is also a pelvic splint. It is not unusual for a bomb blast to also fracture the pelvis when it takes off a leg. When you are confronted by severe bleeding, the kind you can't control with direct pressure, tourniquets can prove to be indispensable. If you carry one, practice with it until you can use it in the dark. Always mark the time of application and monitor distal pulses and the bleeding site frequently.

For receiving clinicians, always leave the tourniquet on until bleeding is surgically controlled. Then remove it very slowly and monitor for bleeding as perfusion is gradually restored.

What was once rarely used has once again become a first-line therapy. Tourniquets work and save lives. This was proven recently in Boston just like is has been in the combat zone. If you would like to learn more see this excellent article — Tourniquets for the control of traumatic hemorrhage: a review of the literature by Stephen L. Richey.

Dan White, EMT-P, runs Arasan LLC, a company dedicated to commercializing innovative emergency products. He was previously the national sales and marketing director for Truphatek, Inc. He has been certified as an emergency paramedic since 1977 and an EMS and ACLS instructor since 1981.