IN RESPONSE TO MY QUESTIONS ABOUT “REMOVING THE TOURNIQUETS” TO THE TCCC COMMITTEE.
“FRANK” IS DR. BUTLER:
COL Keenan Thanks for this feedback. The material is there (see below), but I think we all can agree at this juncture
that it needs to be better communicated. The JTS will be looking at ways to help make that happen as an
action item from this casualty scenario once we have a little better understanding of all of the aspects of
these casualties' injuries and their care.
Best Frank
*********
TCCC Guidelines
Tactical Field Care
4. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a
CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically
amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3
inches above wound.
b. For compressible hemorrhage not amenable to tourniquet use or
as an adjunct to tourniquet removal (if evacuation time is
anticipated to be longer than two hours), use Combat Gauze as
the hemostatic agent of choice. Combat Gauze should be applied
with at least 3 minutes of direct pressure. Before releasing any
tourniquet on a casualty who has been resuscitated for
hemorrhagic shock, ensure a positive response to resuscitation
efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain
injury (TBI). If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply
a CoTCCC-recommended junctional tourniquet. Do not delay in
the application of the junctional tourniquet once it is ready for use.
Combat Gauze applied with direct pressure should be used if a
junctional tourniquet is not available or while the junctional
tourniquet is being readied for use.
c. Reassess prior tourniquet application. Expose wound and determine if
tourniquet is needed. If so, move tourniquet from over uniform and
apply directly to skin 2-3 inches above wound. If a tourniquet is not
needed, use other techniques to control bleeding.
d. When time and the tactical situation permit, a distal pulse check
should be accomplished. If a distal pulse is still present, consider
additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to
the first, to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of
tourniquet application. Use an indelible marker.
PHTLS Manual – TFC Chapter
Tourniquet Tips
Points to Remember
1.
Damage to the arm or leg is rare if the tourniquet is left on less than 2 hours.
2.
Tourniquets are often left in place for several hours during surgical procedures.
3.
In the face of massive extremity hemorrhage, it is better to accept the small risk of damage to
the limb than to allow a casualty bleed to death.
Six Major Tourniquet Mistakes
1.
2.
3.
4.
5.
6.
Not using a tourniquet when it should be used.
Using a tourniquet when it should not be used.
Putting the tourniquet on too proximally.
Not tightening the tourniquet well enough.
Not taking the tourniquet off when possible.
Periodically loosening the tourniquet to allow intermittent blood flow.
Tourniquet Application
1.
Apply without delay for life-threatening extremity bleeding during Care Under Fire.
Both the casualty and the person providing care are in serious danger while a tourniquet is being
applied during Care Under Fire.
The decision regarding the relative risk of further injury versus that of bleeding to death must be
made by the person rendering care
Note: The life-saving benefit of a tourniquet is far greater when the tourniquet is applied BEFORE
the casualty has gone into shock from his wound.
2.
Non–life-threatening bleeding should be ignored until the Tactical Field Care phase.
3.
Apply proximal to the site of hemorrhage over the uniform during Care under Fire.
4.
Tighten tourniquet until bleeding stops.
5.
During Tactical Field Care, expose the wound and reapply the tourniquet directly on the skin 2 to
3 inches above the bleeding site.
6.
Check for a distal pulse.
7.
Tighten the tourniquet or apply a second tourniquet side-by-side and just proximal to the first as
needed to eliminate the distal pulse.
8.
Note the time of tourniquet application.
Removing the Tourniquet
1.
Remove the tourniquet when direct pressure or hemostatic dressings become feasible and
effective, unless the casualty is in shock or the tourniquet has been on for more than 6 hours.
2.
Only a combat medic, a physician’s assistant, or a physician should remove tourniquets.
3.
Do not remove tourniquet if the distal extremity is gone.
4.
Do not attempt to remove the tourniquet if the casualty will arrive at a hospital in 2 hours or
less after application.
Technique for Removal
1.
Apply Combat Gauze™ as per instructions.
2.
Loosen the tourniquet.
3.
Apply direct pressure to the bleeding site for 3 minutes.
4.
Check for bleeding.
5.
If no bleeding, apply pressure dressing over the Combat Gauze™.
6.
Leave the tourniquet in place but loose.
7.
Monitor for bleeding from underneath the pressure dressings.
8.
If bleeding does not remain controlled, retighten the tourniquet, remove dressings, and
expedite evacuation.