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Torniquet use and Haemostasis in Wilderness & Outdoor First Aid

Unless you live in a cave it cannot have escaped you that for most of the new century we have been in armed conflict with someone, somewhere in the world – the one that always hits the headlines is Operation Herrick – The war in Afghanistan. Whilst war should not be encouraged or celebrated one thing it does do is push forward the boundaries in battlefield medicine – which in turn filters down into current practice and policy in civillian healthcare particularly on the frontline in emergency care.

Celox gauze Haemostat

The use of haemostatic agents (bleeding stoppers) like Celox and Quikclot has become prevalent, the torniquet has made a spectacular return to immidiate care and it has even affected the basic building blocks of the primary survey leading to the addition of an extra ‘C’ in the DRABC algorithm, most  surprisingly this ‘C’ standing for ‘Catastrophic Bleeding’ comes before ‘Airway’ in the sequence of actions – particularly in Hostile Environment First Aid – the thinking behind this of course is that if you have someone bleeding severely from several locations (as you would find common with an IED strike) its pointless opening airways and ventillating the casualty as the life giving oxygen isnt being transported due to the casualty being haemodynamically unstable – they are losing fluid faster than it can be put in.

So if they have catastrophic bleeding what’s the best course of action? Well for years there was controversy about the use of tourniquets but the above experience in Iraq and Afghanistan has taught they are in fact life savers…..if correctly used

CAT in use

One of the most common types is the CAT tourniquet that is now used by the military. It is small and simple to use….so much so that a friend of mine who is a tree surgeon always takes one up into the tree with him as well as a packet of Celox – getting him down following a saw injury could take a while and that could be long enough to bleed to death. The C.A.T., offers a wide band that can be applied and secured with one hand, and a large, pre-attached windlass that’s rotated three times for hemorrhage control, secured in a ˙U-shaped holder and locked safely in place by a Velcro tab. It is designed to be self applied.

Now I’m not suggesting for a minute that folks should rush to the local branch of Boots and pick up a torniquet for each limb…. but it should not be entirely discounted as an addition to your basic precautions given the nature of the sharps used by some outdoor enthusiasts, and generally the distance from help in which we place ourselves – intentionally I may add. In fact some eminent medical professionals  “believe that properly applied tourniquets can safely, rapidly and effectively control life-threatening bleeding from a penetrating extremity injury. Further, to this they consider this intervention should be more routinely considered, especially in prehospital systems that have appropriate quality control procedures.” Kalish/Burke JEMS August 2008.

Further, the U.S. military has kept the pendulum swinging in favour of tourniquet use because of its recent mandate to issue a Combat Application Tourniquet (C.A.T.) to all field troops in Afghanistan as have the British Armed Forces. Although no data has been published, anecdotal reports indicate these self-applied tourniquets are beneficial for extremity injuries.

So  what if there is serious bleeding in an emergency such that applying direct pressure cannot stop it ?

First try to get immediate assistance. Only decide to try to use a tourniquet to save a life, and then if you decide that you have adequate materials and reasonably think that you know how to do it. Call for help and do not leave the victim unless you are alone and haven’t been able to call for emergency services.

Try to use other methods — to do everything to avoid loss of a limb (leg or arm) caused by the tourniquet stopping circulation for too long — be sure that all other ways of stopping bleeding have failed, and never use a tourniquet until it is determined to be really necessary!

Expect the loss of the limb or loss of use of the limb because a tourniquet causes severe damage of or killing tissues from stopping circulation for too long in that arm or leg but it may be necessary to keep the injured person alive until it is possible to get help, i.e.: when alone, or in a rural location. Remember to apply the tourniquet only on an arm or leg and only apply above the bleeding (never on any other part of the body other than an arm or leg.)

The most critical point in the application of any tourniquet is that it be tightened with enough pressure to impede both arterial inflow and venous outflow. The lower leg usually doesn’t provide a good location for tourniquet application because the tibia and fibula preclude adequate arterial compression; therefore it is suggested that a torniquet should be applied to single bones only such as the upper arm or thigh but still as close to the injury as possible.

Other points:

  • If you do not have a specially designed tourniquet, find a length of strong, pliable cloth like gauze, muslin, or clothing such as a shirt or a skirt. Never use wire, string or similar narrow material that may cause new bleeding injuries when tightened
  • Consider using a strong belt as a tourniquet, if it can be tightened sufficiently and kept from slipping loose.
  • Be sure to mark a “T” on the victims forehead so any medical personnel who encounters the patient will immediately realize there is a tourniquet. Always document the time the tourniquet is applied on any casualty record. Without the time, doctors anticipate the onset of muscle tissue necrosis on everything below the tourniquet and amputate. (after two hours)
  • Since the tourniquet is only to save a life, then it makes no sense to release it after securing it, if it were necessary to apply it. So it should stay in place to save the life. If released it might be difficult to re-tighten it, and then the bleeding which was unstoppable will evidently resume.
  • Be sure to get professional medical aid as soon as possible.

They work for the military and there is no reason they are not applicable to our daily lives.  You may be able to control bleeding with other techniques, but when those fail then you have lost much time and blood…and you dont have much to spare of either. You need to recognise what injuries may indicate potentially using a torniquet. Failing to recognise it will lead to death much faster than trying to control life threatening bleeding with pressure, elevation and the like. Plus………… wouldnt it be better to be less one limb, than dead.

This article and its steps, tips and warnings are intended as considerations to promote discussion and only as suggestions to help you decide what to do, and should not be a replacement for common sense, and proper training.

The great First Aid Kit debate…..
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