There's tons of info on how to apply a Tourniquet, but I'm having a hard time finding imformation on when/how to use a tourniquet.  Anybody care to offer some information of sources?  At what point would one want to use a tourniqeut?  Does it result in limb loss?  Removal?  Etc.............

It is probably good there is not random information for how to use a TQ readily available on the net.

A TQ is a very valuable tool in the right hands.  You really should seek out hands on training in its use.

If done correctly and quickly treated, the use of a TQ does not condemn one to limb loss.  With that said, improper use could mean the difference between, for instance, a above the knee amputation or a below the knee amputation.  There is MAJOR functional end differences for the patient in that case.

Either way, it is life before limb, but with correct use you may be able to have both.

It is along the lines of when to use Quick Clot.  If you have not been trained, you probably should not carry it.

Apply direct pressure and get help.

The quick answer is a tourniquet is a last resort treatment when direct pressure, pressure points, elevation will not be effective or the wound is obviously going to bleed out, like in an amputation type injury.  Apply the tourniquet above the area of the wound over an artery near the area affected and make it tight.  Use some type of assistance tool like a stick for example to twist the tourniquet tight enough to stop the blood loss. Note the time that the tourniquet was applied.  You may place a T with the time on a person's forehead T-1831 to indicate to higher medical authority when the tourniquet was applied.  It should not be removed except by more advanced medical personnel (hospital setting).

Thanks for the responses so far!

Mostly agreed, but a good rule is that if there's a lot of bleeding just tourniquet it right away. You can bleed out VERY quickly(minutes) and don't want to waste time trying other measures to stop the bleeding only to end up using a TQ in the end. Like was said before, using a tourniquet does not condemn you to limb loss. If I remember correctly you have around 7-8hrs before losing a limb is a serious possibility.



Place a TQ about two inches above the wound, but not on a joint. If a joint is there, move it higher(closer to the heart). Tighten down until the bleeding stops.



 

place on the upper arm or thigh above wound and knee/elbow, twist until bleeding stops, mark casualty forehead with time, check for secondary wounds, treat for shock

ETA not a doctor, just what i was trained do

http://www.au.af.mil/au/awc/awcgate/army/fm4_25x11.pdf

This is what I was always taught. We were taught how to apply a tourniquet in the military but every First Aid Class I've had in the civilian world refuses to teach it because in the civilized world good care is usually not that far away and if the person applying the tourniquet does not know what they are doing the end results will usually not be good.

If the blood is bright red and you can shoot someone in the eye with it, go straight to the tourniquet.

Thanks again guys!  I'm far from an expert on the whole medical thing, but I did take the EMT-B but they never covered anything about tor. or gunshot wounds.

Care under fire says to apply the touriquet is there is bleeding of the serious sort. Our medic said to just stick it as high on the leg near the groin as possible. Once you have a little time you can also place pressure on the wound. If you know a medic or somebody in the medical profession it would be worth your while to get them to train you on the proper use of a TQ.

That's what we were taught, too. Tourniquet goes on for most any extremity hit.



 

Sure heres the answer and im not trying to be a jerk but its simply a fact. Unless your are a Corpsman or a Tac Medic or someone else who needs to apply care under fire or triage, you have no need to ever use a tq. They are dangerous, require training and there are a handful of excellent alternatives available that will function as pressure bandages, pressure bandages with a torque bar and then only a tq if absolutely neccessary. If anything thats what you should consider.

Ill be happy to reopen the arguement regarding the use of tq's and exactly how dangerous and stupid they are for anyone with the distinct exception to those who are .mil, tac medics or provide care in a major trauma response since I still have all the links to the case studies of tq patients dying on the table in an OR while under direct care of a doctor during routine surgery.

Direct pressure, keep packing the wound, elevate, move up to a pressure point if neccessary. Bottom line tq's are dangerous and can lead to permanent injury, which is why you don't see them available unless your recieving training.

Ok pal what you are saying is outdated. The use of TQ's in war zones has been proven as an effective means of preventing major blood loss and has saved lives. Due to this it is now taught to EMT-B as the next step after direct pressure. I don't know what your background is, and I'm not an expert but I am an EMT-B and volunteer fire fighter and as of last year the protocol is to employ a TQ if direct pressure is not stopping the bleeding. I'm not saying that using a TQ is routine or something that happens very often, just that because of its successful use in the military it has been carried over to civilian EMT curriculum. Packing the wound is something taught to military but not civilian medical treatment. Going for a pressure point during severe blood loss has been shown to waste time and be ineffective as people have had a hard time successfully finding the pressure point and a TQ is quicker and more effective. If you see serious arterial bleeding, such as a femoral then apply direct pressure then put a TQ on. I do think people asking about these types of questions should take a BLS class at least, and really EMT would be better. When you do put a TQ on someone you want to write down the time on the TQ because you have roughly 6 hrs for a doctor to safely remove it before you will lose the limb.

I'd love to see what you have.  Honestly, also not trying to be a jerk.
In 2006 the TCCC Committee reviewed every tourniquet application in all of OIF and OEF, which numbers well into the thousands.  They found three patients with symptoms of nerve damage, two of which had already resolved.  The third was improving at the time- he was the Chinook pilot that was shot down on Takur Ghar that had a tourniquet on for an unprecedented 16 hours*.  They think the combination of the PJ occasionally loosening the tourniquet and the fact that he was laying in snow most of the time explains the fact that he still has his hand.  Anyway, like was said, attitudes have turned around quite a bit in the last ten years based on the fact that no one is losing limbs in OIF and OEF.  If you have any publications on the topic I'd love to look them up.

*Extended (16-Hour) Tourniquet Application After
Combat Wounds: A Case Report and Review of the
Current Literature
John F. Kragh, Jr, MD, David G. Baer, PhD, and Thomas J. Walters, PhD

Respectfully,

you obviously didnt read what I wrote and secondly you are still mistaken.

I am a 9 year vet of active  EMS starting back August 2001 in NYC. I was an NR-EMT (EMT-b while working in NY since -i isn't recognized in my area and then workd as an EMT-i while living in Atlanta.

I am also BLS/ACLS-ep  as well as PALS certified and currently work as  a Lead Instructor in both BLS and ACLS. I am also a member of the NYMRC, NCPD Police Surg. CERT and a handful of other groups in the past mainly relating to swift water and rescue diving. as a result of my involvment through Med reserve, I have recieved training in a variety of Mas Cas situations, NBC, as well as Disaster Triage and a variety of other specialties as a result.   I am also attending Med school.
I am very familar with the transition of both .mil and .civ trauma care over the years especially TCCC.

But most importantly, I just had to sit for my EMS refresher about 14 days ago and happen to have all my notes right here by my computer.


I am very familar with TCCC and combat medicine. This is why a made a major point to preface each of my statements with a giant disclaimer stating that the absolute exception to this is in the event of Combat Medicine. I said it about 500 times. ATLS is the method used to treat civillian trauma victimes., in a controlled environment and prescribed manner. (scene safety, BSI, CPR, C-spine, primary, advanced airway, volume, etc. etc.)

The failure of this system was seen most clearly in Somalia, and the lessons needed to correct it were paid for in blood. In Vietnam about 60 percent of wounded were expectant even if they were somehow transported magically directly to an OR.
The other 40 percent however were a different story, 6 out of 10 of those men died from massive blood loss, and 3 of the ten from tension pneumo..

Hence the begining of TCCC. the first step and most important step for a wounded solider in combat if the ability to regain fire supiorority. The absolute very next thing of utmost importance is hypoperfusion and blood loss. Hes got an airway. The number 1 cause of preventalble combat death is bleeding period. the TQ is not the better option because its more effective and certainly not because its safer, its effective because A. it can be self applied, it doesnt require losing an additional shooter to come render aid and most likely come out from cover, and B. It often allows teh casualty himself to start putting rounds downrage.

In a combat scenario, just like I said above over and over Corpsman, Tac Medic, Care under fire or Triage the name of the game is BATS, BLEEDING, AIRWAY, TENSION PNEUMO AND THEN SHOCK.



now on to what you said and why you are wrong, im not trying ot break your balls here but these facts you put out there are just false
STATEWIDE BASIC LIFE SUPPORT ADULT AND PEDIATRIC TREATMENT PROTOCOLS EMT-B AND AEMT


II.  Control bleeding by:
A.  Immediately applying pressure directly on the wound with a sterile dressing, and
B.  Elevating the injured part above the level of the patient’s heart (when possible),
and
C.  Applying a pressure dressing to the wound.   If bleeding soaks through the
dressing, apply additional dressings and reapply pressure.  Do not remove
dressings from the injured site! Continue to pack the wound as neccessary
D.  Cover the dressed site with a bandage.
 III.  If severe bleeding persists, locate and apply pressure on the appropriate arterial pressure points.  Splints
and pressure splints may also be used to control bleeding.
The Use a tourniquet is reserved strictly as a last resort and only if the
uncontrollable bleeding persists to the point of becoming life threatening.



I don't know what your background is, and I'm not an expert but I am an EMT-B and volunteer fire fighter and as of last year the protocol is to employ a TQ if direct pressure is not stopping the bleeding. No see above. There are a full four alternative techniques that all should be applied before you reach the point of TQ application, which again is an absolute last resort. you are simply jsut wrong.


I'm not saying that using a TQ is routine or something that happens very often, just that because of its successful use in the military it has been carried over to civilian EMT curriculum. Packing the wound is something taught to military but not civilian medical treatment. Again see above you are wrong
If you were riding on my bus and you had someone on thinners with a laceration and you began to treat the bleed with pressure and then failed to continue to pack the wound, elevate and apply a pressure point at the nearest location. your but would be out of my dept that day out of a job ASAP and I would not trust you to ride alone again until you completely recycled through basic EMS.

Going for a pressure point during severe blood loss has been shown to waste time and be ineffective as people have had a hard time successfully finding the pressure point.... Ok now your serioulsy starting to scare me, are you honestly an acitive duty EMT? People have a hard time finding pressure points??? take your thumb, find your brachial pulse located under your bicep. now squeeze. feel for the femoral artery, the massive artery along the patients groin, again squeeze like hell, the popliteal artery which is located behind the knee. elevate if at all possible, and then definately be prepped and ready to treat for shock.. Please tell me you know this stuff, this is day one how not ot let somoene die type medicine, either that or tell me that your on the FF side and have been out of the EMS side of the house for years.


If you see serious arterial bleeding, such as a femoral then apply direct pressure then put a TQ on.
Where do you suggest I apply my TQ to treat a femoral bleed.

I do think people asking about these types of questions should take a BLS class at least,

A BLS class either original or refresher covers the following exactly Scene Safety and BSI, CPR 1 and 2 rescuer adult child infant, AED, AED special situaitons compression only CPR, BVM use, rescue breathing. REscue breathing in a code situation with and without an advanced airway, with or without sup O2. Witnessed vs unwitnessed response. signs and symptoms of a stroke, concioous choking in an adult child and infant, as well as uncioncious choking. and choking hazards while alone as well as drowning. good samaritan laws, duty to act and fall prevention. In a hospital setting I also make sure to cover specific hospital protocols, call a code get a crash cart, smash the button, RRT response etc. That is it

BLS in no way shape or form covers one single iota of trauma or anything remotely trauma related, its strictly medical from the word go. Again are you sure you've even taken BLS cause you seem to know almost nothign about it.

I hope you reevaluate your positions and training for your sake  and that of your potential patients.

State of Michigan EMS protocols now go from direct pressure to tourniquet use.  No more pressure points or elevation for bleeding control.  This is new and some medical controls are just getting it adopted, but it's now the standard of care in Michigan for licensed EMTs.

Yes attitudes have changed with regards to tourniquets but only in relation to combat. You brought up the Army's TCCC Committee. Let's remind everyone what the first word in that organization stands for "Tactical" and the second "Combat". If you have a moderate gash in your limbs they do not recommend you immediately go to a tourniquet. As for amputations, the rules still apply to stepping up levels of treatment prior to using the tourniquet.If you're being shot at and you can treat your wounded, yes remember the first step in TCCC is to subdue the enemy/secure the casualty, then you use the tourniquet because its quicker. Also keep in mind that EVERY Soldier and Marine are educated and know how to use tourniquets, the average civilian who attends a first aid course may not be so knowledgeable. You mention a "PJ" (which stands for pararescue jumper) which is an elite Air Force medic who often supports America's Special Operations Forces. You need to separate the two worlds: civilian & military.

Pwr2al4 is right in that for most wounds and even severe wounds direct pressure and layering the pressure will suffice. Slapping a tourniquet on it right away may do more harm than good as most people will have a tendency to overtighten the device and cut through nerves as well as the wounded vessel. For most people, if you can't stop bleeding at that point or its a gushing main artery then you might want slap a tourniquet on it immediately but for the average range/class shooter you won't have to deal with that.

Dude you are really coming off as a pompous dick who likes to hear himself talk. You blab on and on about a bunch of irrelevant shit and I still say you are wrong. No point in lecturing about Vietnam and TCCC. My EMT instructors had years experience as paramedics and were long time career fire fighter Captains who knew what they were talking about. I believe that national protocols changed last year, and if not they did in NE as they are teaching use of TQ and not employing pressure points, just as the person above me said they did in Michigan. Yes, my instructors gave examples of someone bleeding out while trying to find the femoral artery. That wasn't a spot on the body we really practiced applying pressure to each other and if direct pressure wasn't stopping the bleeding then we were instructed to apply a TQ. Direct pressure and elevation for an extremity wound and if that is not successful then TQ. Obviously if there is a bullet directly through the femoral you wont be applying a TQ, but if someone is shot in the thigh and the femoral is pumping that blood out of the leg you would apply a TQ above the wound site. Not sure if you are trying to play games with that comment or what but my comment was pretty obvious. No, I was not instructed on packing wounds meaning inside the cavity. I only really hear about that from the military side of the house. Civilian EMS training has been to apply sterile dressings, pressure bandage if necessary and apply direct pressure. Also, after I was an EMT I went through a BLS class for a govt job and it did cover basic trauma including treating a wound, direct pressure, etc so I figured that was a part of all BLS classes. Again, going through EMT-B would be the most beneficial for people if they have the time. I'd also add that going through the training is great, but it means SOOO much more when you are employing those skills and what you learned on a regular basis as part of an EMS team on a fire dept or whatever.

Minnesota too. While pwr2al4 sounds like he does and should know what he's talking about, what he's saying is simply incorrect where I am. Direct pressure, straight to tourniquet (well, after 20mins..) if that was ineffective.

You were told to wait 20 min before employing a TQ? If you wait 20 min on a patient that needs a TQ then they very well may have bled out by then. I wasn't told to wait a certain amount of time. If the bleeding is severe enough that direct pressure is not sufficient then step it up to a TQ.

TCCC isn't Army, it started out NSW, then NOMI, then moved to BUMED, and now belongs to the Defense Health Board.  I'm aware of the context of TCCC, as I spent four years researching it to develop a training program for the Coast Guard.  This included classes for special operations medics, TCCC Committee meetings, and SOMA conferences.  So I get that even though military members' femoral arteries are no different from civilian ones, there are still aspects of "tactical" medicine that civilians shouldn't just jump into without training and adult supervision (which in the military means a non-Combat Life Saver is shown how to use it, not how to recognize signs and symptoms of neuropraxis, rhabdomyolysis, and compartment syndrome).  
I'm not here to argue who should use it or when.

I'm just asking for some literature showing how dangerous tourniquets are.  I still talk to my former Senior Chief and CDR who are voting members of the TCCC Committee.  I have yet to hear about any lethal outcomes secondary to tourniquet application.  Now what I will point out is that a tourniquet applied in a conscious patient without painkillers is maddeningly painful.  After a while, it starts to hurt REALLY goddamn bad.  Most people aren't aware of that, and it would likely cause difficulty in maintaining hemostasis when the patient is flailing around and trying to take it off.  So it's important to learn to convert a tourniquet to a pressure dressing.

But that people are dropping over in ORs from tourniquet application would be news to many in DoD, and I can tell you from my own personal experience that a tourniquet constructed of anything but bailing wire will break bone before it cuts through anything.  Thousands of enormous amped-up-on-adrenalin badasses have applied tourniquets during combat.  If they're not applying them "too tight" I don't know who possibly could.  

I have never seen a tourniquet applied too tight, in fact mostly the opposite.

Absolutely right, in fact at the April 2008 TCCC meeting I sat next to a Navy trauma surgeon who had done two tours in Iraq, and he said that the cases of compartment syndrome he saw were all attributable to that very thing.

Specifically, people see a bad venous bleed, apply a tourniquet, and then tighten it until the bleeding stops.  The problem is there's still arterial flow.  
That discussion was what prompted the requirement to check for a distal pulse.

Fast and effective TQ application has been the difference between life and death in dozens of cases here over the last year. Triple and quadruple amputees are so common in dismounted IED strikes that you'll see soldiers patrolling with as many as four TQs on their gear.

ETA: Am I likely to lose both legs at the knee and my right arm at the elbow while at the range? Probably not. I still carry one in my range bag.

Don't forget that, if you have a civilian style aid kit along, a BP cuff makes a dandy improvised tourniquette.

Well 'dude' pompous no. People like you piss me off cause you love to claim experience that you obviously do not have. those who know what they are doing see right through it and I guess the only way to show someone that they are just poking around in the dark is to show them that at every fact they spew they are wrong and then put out the proof.

Speaking of being wrong..

EMT-Basic: National Standard Curriculum
Appendix H
––––––––––––––––––––––––––––––––––––-
BLEEDING CONTROL/SHOCK MANAGEMENT Points                  Points
Possible               Awarded
Takes or verbalizes body substance isolation precautions 1
Applies direct pressure to the wound 1
Elevates the extremity 1
Applies a dressing to the wound 1
Bandages the wound 1
Note: The examiner must now inform the candidate that the wound is still continuing to bleed.        
Applies an additional dressing to the wound 1
Note: The examiner must now inform the candidate that the wound is still continuing to bleed. The    
second dressing does not control the bleeding.                                                                      
Locates and applies pressure to appropriate arterial pressure point 1
Note: The examiner must now inform the candidate that the bleeding is controlled and the patient is in
compensatory shock.    
________
From this years NR (national) EMS standard Curiculum.


I am wrong all the time, but I will happily own it, wont take it personal and hopefully become a better caregiver as a result. Thats the difference I guess, instead of looking at the facts I put up, you just choose to attack me personally. Whatever at the end of the day your talkin out of your ass and its shows,

Guys like Prime and a bunch of other people here know a shitload more than I do, and if they correct me than there almost definately right and im wrong. local protocols... no doubt I'm sure they are right and im wrong.

ill pull some for you give me a minute. do you have access to pubmed or ovid?

The need to realize though that were coming from two totally seperate ends of the spectrum. Which is why I try to mention the very large exception which is you and the .mil when it comes to TQ's they save lives period, tons of lives I think I made that clear earlier, but on the civillian side he stakes are a lot different mostly just a ton lower and people naturally have a tendency to adopt the high speed response to their normal problem.nowhere is this more common than in the transition from combat med to trauma med in the years following major conflicts, where med tech and techniques explodes forward through neccessity. The problem comes when people forget to stop and think about whether or not they combat solution is really the best course of action for the trauma solution.

The golden hour, you bet. Triage, forward aid, 'medevac vs casevac' 'stay and play or grab and go'.. Mast pants etc. etc. 95% of these new techniques or technologies trickle down and do incredible good for the trauma med, ER community. But some things just dont translate well at all, but people continue to try to incorporate them cause we all naturally assume if its used by the .mil its what we should be using. Hence ever member on this site, myself included building thousand dollar m4gerys with all kinds of high speed type shit on them.

Couple examples of things that simply dont translate from the combat side to the trauma side... I'm sure you already know the obvious ones im gonna name. quickclot, what everyone thought was gona be the coolest revolution ever in EMS, myself included now realize how terribly and how much of a huge pain in the ass the stuff is. the recent crackdowns at least in the northeast regarding lifeflight and patient stability. in a casevac situation is doesnt matter what the guys vials are, he either dies in the sand of maybe maybe gets to a forward aid station in time. in the civillian world we have a bunch of different options if they are to unstable for a chopper.

Tq's are very similar, do they work, you bet, not only do they work but they also happen to compliment a combat environment perfectly, but the fact is the mechanism of injuries are way different, the needs of the responders are different etc. etc. They are just not a good fit in the civillian world. Unless you are trained on them

whoever was asking about tq risks... here this should get you started, theres more but im not in the mood to do work.

If you have access to pubmed or medline feel free to read through all of these, i'm not gonna turn this discussion into a thesis.

The tourniquet. Instrument or weapon?
Sanders R.

PMID: 4715692 [PubMed - indexed for MEDLINE]




Pneumatic tourniquet paralysis. Case report.
Aho K, Sainio K, Kianta M, Varpanen E.

Abstract
We describe a 31-year-old man in whom a paresis and sensory defect of the left arm developed after amputation of the index finger. The operation was performed in a bloodless field, using a pneumatic tourniquet. The sensory defect resolved in two months and the paresis in five and a half months. We consider that direct pressure produced by the tourniquet caused the nerve lesion.


The incidence of large venous emboli during total knee arthroplasty without pneumatic tourniquet use.
Parmet JL, Horrow JC, Berman AT, Miller F, Pharo G, Collins L.

Department of Anesthesiology, Allegheny University of the Health Sciences, Hahnemann Division, Philadelphia, Pennsylvania, USA

"Compared with previous investigations of large venous emboli during total knee arthroplasty with a pneumatic tourniquet, multiple logistic regression analysis discloses a 5.33-fold greater risk of large venous embolism accompanied the use of a tourniquet during total knee arthroplasty. Implications: One third of knee replacements performed without a tourniquet demonstrated large emboli. Reducing marrow cavity invasion did not decrease the release of large emboli. Compared with knee replacement without tourniquet, tourniquet use places patients at a 5.33-fold greater risk of having a large emboli."


Complications are sometimes associated with use of a tourniquet. Among these the most feared, (although very infrequent) is death caused by pulmonary embolism from leg vein thrombi before tourniquet inflation (1) or after tourniquet deflation (2,3). Frequently, hemodynamic alterations are observed after tourniquet release, including hypotension, bradycardia, or even asystole (4). Neurologic deficits (“tourniquet paralysis”), caused usually by high tourniquet pressure and/or prolonged ischemic times, are sometimes observed (5,6).

Lower limb exsanguination and embolism.
Boogaerts JG.

Department of Anaesthesiology, Charleroi University Hospital Centre, Belgium.

Abstract
We report a case of fatal pulmonary embolism during lower limb exsanguination in orthopaedic surgery. A 76-year-old woman underwent an open fixation of an external femoral condyle fracture one day after injury. Subarachnoidal anaesthesia was performed and Esmarch compression bandages were applied in preparation for tourniquet ischaemia. At this time, the patient lost consciousness, became apneic and collapsed. Resuscitation procedures were instituted and transoesophageal echocardiography revealed pulmonary embolism. In spite of haemodynamic support and thrombolytic therapy, the patient died. Postmortem examination revealed multiple thromboemboli of recent origin in the right heart cavities, in the pulmonary arteries and in the popliteal and tibial veins of the injured leg. Preventive, diagnostic and therapeutic options of this catastrophic event and indications of pulmonary embolectomy are discussed.


Rhabdomyolysis-myoglobinurea: consequences of prolonged tourniquet.
Williams JE Jr, Tucker DB, Read JM 3rd.

Abstract
The authors review the literature on rhabdomyolysis and myoglobinuria and relate these phenomena to prolonged intraoperative tourniquet time in a case report. They alert the practitioner to the clinical manifestations, diagnosis, and treatment of such problems and emphasize the importance of early recognition.




Tourniquets for Surgery: Safety Aspects
Authors: K. B. Cartera; A. Shawa; A. B. M. Telferb
Affiliations: a Department of Clinical Physics and Bioengineering, Glasgow, UK

b Division of Anaesthesia, Glasgow Royal Infirmary, UK
DOI: 10.3109/03091908309032577


The list goes on and on, these are all TQ related major complications that occurred in a controlled hospital setting.

99% of combat med leads to tremendous advances in trauma med. TQ use is an exception and it is a major one, and I wish non combat medics/.civ lay persons would stop thinking that the application of a TQ is a safe and commmonly appropriate treatment, because its simply not. Convential methods are not only safer, but also can be much more effective as well.

You can boil all of the above down to this-



It should be no shock to anyone that you can't cut circulation off to an appendage without taking a few risks.  There's debate about embolus formation, but I'm willing to give that the benefit of the doubt if you'll concede that it's "extremely rare".  The hemodynamic alterations/asystole is probably from reintroduction of all the metabolic byproducts that build up behind a tourniquet over a few hours, or a surgeon forgetting there's a bunch of local anesthethic stored up in a limb.  Saying that the outcome of something as complicated as surgery can be blamed on one piece of equipment is tricky, though.  I'd be more interested in seeing studies on individuals who aren't loaded with anesthesia, IVs, and a surgeon hammering and sawing on their femur, since a lot can go wrong and it's hard to pinpoint the culprit sometimes.  But I guess beggars can't be choosers.  As for the nerve damage, well I guarantee that happens, but I'll also tell you every time I've seen it come up in the literature, it resolved.  Shrug.


Edited for clarity.

i know this

i have a good friend whos alive because of TQs but thats combat all i know is ill do what ive been trained to do. if i see a person firehosing im gonna put a TQ on him if he suffers nerve damage or dies. at least i did my best. you have to accept the fact you cant save everyone. but there is some great info in this thread, thanks to all the life savers out there

I'm done arguing with you. You made it personal and do not come on some internet board and question my ability to provide care. I never claimed experience that I don't have. I said I'm no expert but I am an EMT-B and have experience as a volunteer fire fighter and that is a fact. Other people have spoken up and said the same protocols that I said are in place are now in place in their state. I know that is what I was taught in my state and I can't find 2010 national EMS protocols which state the change but I can say that's what is being taught in NE. As for the benefits of TQ's, other people like Prime who do have more experience have also spoken up so in the midst of you trying to come off as a know it all dick, it looks like you are still wrong.

I pulled this off another board and the statements are the same as mine.  "The current thinking that I was taught in my EMT-B class (1 year ago) about bleeding control, is that tourniquets are much easier than using a pressure point, and get the job done faster and more effectively (no fumbling around to make sure you are grabbing the right spot)... so I guess it could also be part of the NREMT making the curriculum simpler... I don't know, but that is what it is now, and how my class taught it.
Here is a link to the NREMT skills testing for the bleeding control section
http://www.nremt.org/nremt/downloads/Bleeding%20Control.pdf
As you can see, pressure points are not mentioned in it at all. "

I don't believe anyone ever got around to answering your question other then a lot of chest beating on how trained some folks are on technical aspects on the subject.
Yes its complicated subject but as i learned in the boy scouts long ago and while in the USAF through many lifesaving refresher courses a tourniquet may have to be used
in severe circumstance to save someones life....to control or stop severe bleeding until medical personnel arrive to take over. As some mentioned applying pressure
should be done first but if its obvious that its not working and you think this person could die apply it.....
Read through this instruction i found and it also has some links for further info.The best thing would be to take a life saver course someplace... really.
Tourniquet

The gentleman from Texas raises a good point.  Two good points, actually.  I fucking hate chest-beating so if any of what I said came across that way, I'll apologize for it.  

I'll also say this-  I understand where pwr2al4 is coming from.  It is a very human trait to think you can buy skill.  In firearms terms, I can watch an IPSC match and then find myself thinking that if I dropped 5 grand on a race gun with a giant red dot that I'd turn into some badass pistolero.  It just ain't so.  Neither can you take a medical procedure and acquire proficiency at the low low price of $29.  In defensive shooting, medicine, and many other fields, the assumption that you can buy proficiency will get people killed, and not always just the person at fault.

However, given the following criteria are met, I would argue that a tourniquet is a safe intervention in the case of massive hemorrhage.

1.  A quality tourniquet is used.  Having a good one keeps you from having to improvise one out of something godawful like electrical cord.

2.  The patient is relatively young and healthy.  The 76 year old woman mentioned in one of the above studies was not only 76 years old but already under the care of a cardiologist.  The military is admittedly a VERY different population.

3.  The user has a basic understanding of human anatomy (as in "arteries go out under high pressure and veins come back under low pressure") and knows how to check a pulse on the wrist.  You should learn the legs too, but they can be tricky.  

4.  You also need to understand when to use a tourniquet.  This is where I always always always recommend getting the military edition of the PHTLS manual.  I don't trust First Aid courses to address tourniquet use beyond "if all else fails do it, but we're not going to show you how".  I doubt anyone's ever listened and actually gotten the book, but if they did they would learn not only how both NAEMT and the Committee on Trauma of the American College of Surgeons say when you should apply a tourniquet, but how they say you should treat trauma in general.  Chances are that the wound that you would trade every material possession to know how to treat will NOT be a gunshot wound to the femoral you got saving that schoolbus full of kids.  So it's all good information to have.  Try reading a chapter at night instead of watching TV (that is, by the way, the sound of a pot preaching to a kettle).

Even if the above criteria are not all met, in some situations it's just better to have.  I compare this to defensive firearm use.  
I can't guarantee everyone who's carrying one has been trained in how to safely use it, in fact I can guarantee that not everyone has.  I would just rather promote individual responsibility and hope that if you're carrying a tourniquet in your range bag and you're out in the middle of nowhere with your family that you've done the necessary homework so you don't have to live with the death or unnecessary disfigurement of a family member.

And in the spirit of that, I'll get you started.  Here, in my opinion, is what you should do aside from cracking a book every now and then.

The HOW-

Get three (3) CATs from a reputable source ($29 at North American Rescue).  One of these is for training, so if you want to get the orange or blue one, go for it.

Two of them go into your range bag/first aid bag/whatever.  Don't even open the package.

Get out the training CAT.  First, read the directions.  I know, you're probably a man and thus averse to doing so, but it's important.  There is an important procedural difference between application on an arm vs. a leg.  

Put your hand through it until the tourniquet is a couple inches past your wrist and pull TIGHT.  The most common cause of failure in the CAT is that people put it on loose and then end up cranking the windlass way too many times and it rips that little piece of fabric loose.  If you start out good and snug you won't have this problem.

Crank it down tight and then secure the windlass.  There should be a piece of velcro that goes over the top.

Now- VERY IMPORTANT-  check your wrist for a pulse.  If it's still there, it's not tight enough.  In the case of an amputation, obviously this isn't an issue- you'll SEE when it's not tight enough.  But any other time you want to make sure there's no pulse past the tourniquet.  It'll be easy to forget, which is why it's important to practice.  In the case of legs, as I said, they're tricky.  When in doubt go a little tighter, and if you can spare the extra tourniquet use both (see below).  This will assure there's no arterial blood getting into the limb and overpressurizing the tissues (not getting back out because of the tourniquet), which is one of the bad things that can happen with tourniquet use.

In actual use, if the tourniquet's as tight as you can get it and the bleeding hasn't stopped, get out the second one and put it above and right next to the first one.  Crank that one down good too and that should do it.  

The WHEN-

As I said in the beginning of this thread, if the blood is bright red and shooting out a couple of feet, then go straight to the tourniquet.  This is especially true if you're way out in the middle of nowhere or the patient is bleeding from multiple sources.  "There is no such thing as minor bleeding in multisystem trauma"- when someone's bleeding a lot from many different places, every little bit helps.  

Also, a slow but heavy venous bleed (dark red) is a perfectly valid reason to use a tourniquet.  Language in medical literature shifted from "arterial hemorrhage" to "uncontrolled hemorrhage" to reflect this.  Usually a venous bleed is controllable by direct pressure alone, but if there's a LOT of it, especially in someone with multiple wounds, get a tourniquet on it.  This is when it is extremely important to make sure the pulse is gone and not just tighten until the bleeding stops, since arteries are under higher pressure than veins.

And then remember that in someone who's awake it's going to start hurting BAD, so learn how to wrap a good pressure dressing.  
When it comes to a good pressure dressing there is no substitute for seeing one firsthand, or at least it's beyond my capacity to adequately describe.  In short, you take a tightly wadded ball of gauze, place it in or on the wound, and without letting that ball expand you wrap it tightly with something to keep the pressure on.  And it is far easier described than effectively executed.  If you have friends who are emergency medicine types or prior military they would be good to practice with.  

Ideally, you'll put the tourniquet on, giving yourself just enough room on the limb to work.  You'll then put on a really good, tight pressure dressing and only after a couple of minutes, slowly release the tourniquet.  If the patient doesn't look really deathly/about to pass out and/or you don't see blood soaking through the bandage, you should be okay.  Just leave the tourniquet loose around the limb just in case.  It's important to note that if there's any doubt at all, LEAVE THE TOURNIQUET ON.  

You should also treat for shock.  Keep them warm.  Once they're cold and bleeding, all is lost.  There are sections of the Joint Theater Hospital at Bagram that are kept at 100 degrees all year around for exactly this reason.  And try to write down somewhere what time the tourniquet was applied.  Releasing a tourniquet that's been on for more than two hours or so gets really dicey, and the hospital will want to know.


A lot can go wrong with all of this, but in the worse case scenario- I'm alone in the wilderness, can't do a decent pressure dressing one-handed and I end up passing out from the pain and crawl back into town with a blackened stump, the chances I'll be around to bitch about it are a lot better than if I bled to death.  

So there you go.  That's my humble opinion.  Please for the love of God do some reading and training, and don't just buy a tourniquet, try it on once or twice and then call it good.  Especially if you have a family.  Make sure every one knows some basic first aid and what to expect if Mom or Dad gets out the tourniquet.



May you never need it.


http://www.amazon.com/PHTLS-Prehospital-Trauma-Life-Support/dp/0323039863