Transcript CAT tourniquet - Emergency medicine

CAT tourniquet Inservice
Honolulu EMS
Joseph Lewis, M.D.
Medical Director
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 have the 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
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.
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.
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.
Tourniquets
Tourniquet placement: Examples:
A. 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.
B. 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.
C. 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.
D. 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.
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.
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.
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.
Tourniquets
Tourniquet time
4-8 hours for Pre-Hospital Use
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
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.
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.
4. 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. 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!
Complications of improperly applied
tourniquet nerve damage
Tourniquet Precautions
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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.
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
Anatomy of a
TM
C-A-T
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.
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.
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.
Two-Handed Application to a Leg
Step 3: Pull the Self-Adhering Band Tight
•And securely fasten the band back on itself.
Two-Handed Application to a Leg
Step 4: Twist the Rod
•Until bright red bleeding has stopped
Two-Handed Application to a Leg
Step 5: Lock the Rod in Place
•With the Windlass ClipTM
Two-Handed Application to a Leg
Hemorrhaging is Now Controlled.
•You can attend to other injuries or casualties.
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
Two-Handed Application to a Leg
The C-A-TTM Is Ready For Transport