Tourniquets 101

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Unless trauma, emergency, operating room (OR), or pre-hospital nursing is your specialty, it is possible you may never encounter a tourniquet. And unless it is something you deal with on a daily basis, many may not feel comfortable when the time comes to properly apply one. Because of the time-sensitive nature of tourniquet application, there is room for user error and serious complications. This course is designed to educate and help with tourniquet application and management.  

Introduction 

Despite the varying opinions on tourniquets, they have developed a tight grip on society. The use of the first tourniquet dates back to 6th century B.C. when Hindu physicians utilized them to prevent the spread of snake venom in Greek soldiers as opposed to hemorrhage control, which we commonly associate them with (4). The Romans introduced tourniquet usage for bleeding management; however, one of their top surgeons Galen, criticized the tourniquet, believing it pushed more blood out of the wound (4).  

While the most common use of the tourniquet is for immediate bleeding control, civilians may utilize them as the Hindu physicians did or have heard of the method. Despite this, using tourniquets to prevent or slow the spread of venom has been disproven and is not encouraged by medical organizations (8). 

Unless trauma, emergency, operating room (OR), or pre-hospital nursing is your specialty, it is possible you may never encounter a tourniquet. And unless it is something you deal with daily, you may not feel comfortable when the time comes to apply one properly. Because of the tourniquet application’s time sensitive nature, there is ample room for user error and serious complications. This course is designed to educate and help with tourniquet application and management. 

What is a Tourniquet?

A tourniquet is a medical device used to control or stop the bleeding from a severe wound or amputation in the extremities. The name is derived from the French word tourner, meaning to turn (4). Tourniquets may be commercially manufactured devices or created using everyday objects such as belts, clothing, rope, or seat belts with sticks or polls to tighten them. The Committee for Tactical Emergency Casualty Care (C-TECC) has recommended the use of a commercially manufactured device over others due to a 40% ineffective rate in makeshift devices. (7).  

Because traumatic situations occur every day, the medical and civilian communities must be prepared to correctly apply a tourniquet. Depending on state and county regulations, EMS personnel, such as paramedics and emergency medical technicians (EMTs), are trained to apply them. While not country-wide, many law enforcement officers have seen the benefits of carrying them and have undergone training to develop this skill. The American College of Surgeons designed the “STOP THE BLEED“ program to educate civilians on the importance of proper tourniquet application and how to do so (2). 

Current Practice with Tourniquets 

In the trauma and emergency setting, nurses may be trained to apply a tourniquet if needed. It is best to follow hospital policy and state board of nursing guidelines to determine if you can apply a tourniquet. Even if it is outside your scope of practice, it is best to understand the procedure of application and know how you can assist the provider.  

Tourniquets should be quickly placed as soon as a major hemorrhagic event is noticed. The Emergency Nurses Association (ENA) and many other emergency medicine organizations have adjusted the primary trauma assessment, changing the standard airway, breathing, circulation portion to reflect the importance of immediate hemorrhage control (1). They now advocate for providers to perform an across-the-room assessment and determine if lifesaving bleeding management needs to be addressed first (1). The “MARCH“ pneumonic, which the U.S. Department of Defense utilizes to determine priority, consists of Massive hemorrhage, Airway, Respirations, Circulation, and Head injury/Hypothermia (1).  

Indications and Application of Tourniquets 

As mentioned previously, the only indication for tourniquets is severe bleeding due to a traumatic amputation or injury to one of the four extremities that cannot be controlled by direct pressure and elevation (1). While all tourniquets are not made equal and should be applied to manufacture instruction, there are a few general do‘s and do not‘s for applications.  

The ENA recommendations on application:  

• Tourniquets should be placed as close to the amputation or injury as possible but refrain from placing them over joints (1).  
• The tourniquet should be painful to the patient if applied correctly; this confirms that arterial bleeding is controlled (1).  
• Ensure that the time of application is written on the tourniquet and documented in the patient‘s electronic medical record (EMR) to keep track of the “ischemic time“ (1). 
• A time frame of two hours is the maximum limit a tourniquet be placed on a patient (5).  

It is important to note that these studies were done on elective surgical cases, and the data is derived from stable individuals in a controlled setting, as opposed to the multi-system trauma and potentially hypovolemic patients of the emergency room or pre-hospital setting (3).  

In the event that one properly applied tourniquet does not control the bleeding, it is recommended that a second one be placed two inches above the first one (1). Inappropriately applied tourniquets may increase bleeding instead of decreasing it, so be sure that the first tourniquet is applied per manufacture instruction before applying additional ones to decrease complication risks in patients (1). If the tourniquet needs to be released for any reason, do not do so unless a provider is at the bedside to control any bleeding that may occur.

Complications of Tourniquets 

Over the centuries, tourniquets have received their fair share of criticism. You may recall that the Roman surgeon Galen did not like the use of tourniquets (4). During the US Civil War, tourniquets received a bad reputation due to the lack of antibiotics, inexperienced application, and delays in transporting to the field hospitals (4). This led to increased cases of amputation, causing many to believe that tourniquets were the cause (4). World War I brought similar opinions; however, World War II introduced a new view, citing that when properly applied tourniquets helped save lives by decreasing blood loss and decreased overall complications (4).  

With the proper training and education, tourniquet application can be a benefit to society. However, with everything in life, there are risks of developing complications. Modern medicine and technology have certainly brought about a change when it comes to how tourniquets are made, applied, and managed. Despite those advancements, patients who have tourniquets applied can be at risk of severe ailments.  

Nerve injury, pressure sores, necrosis, and thrombosis are a few of the potential problems that can arise (5). Decreasing the time a tourniquet remains in place can help decrease the chances of these complications from occurring. Compartment syndrome is a rare occurrence that accompanies severe injury and swelling (5). Without the ability to remove the extra fluid, the pressure grows and presses on the veins, nerves, and arteries. This eventually causes complete occlusion and total loss of limb if not treated.  

Rhabdomyolysis can be a secondary complication to compartment syndrome or a primary complication due to the tourniquet (5). Because of decreased blood flow to any cell past the tourniquet, they become oxygen–deprived and lead to cell death. Muscle cells release, creatine kinase (C.K.), myoglobin, electrolytes, lactate dehydrogenase, and aldolase into the circulatory system, eventually making their way to the kidneys and cause acute renal failure. (9).  

Despite these risks, those who received tourniquets’ mortality rate was significantly lower than those who did not per a study conducted by the American College of Surgeons in 2016 (10). 

Parts and Troubleshooting

There are various manufacturers that produce tourniquets. Therefore, it would be difficult to go through each type and list all the parts. In general, there are a few essential components that apply to every tourniquet on the market. They all have a strap, usually two inches in width, designed to fit around the limb (7). Some of these are adjustable to fit either arm or leg, while others come premade to fit one or the other (7). The next part is what makes the tourniquet. Whether it be a windlass/stick, pneumatic/air, buckle, or dial, each type has a mechanism used for tightening the tourniquet (7). 

Being able to quickly troubleshoot any complications that may arise while using a tourniquet is imperative. A patient could bleed out in a matter of minutes if an issue is not resolved promptly. Before you are in a situation where a patient needs a tourniquet, it is essential to know how to apply and remove a tourniquet. Ensure you obtain proper hands-on training from your facility or from the manufacture of the particular device used. It is also essential to know what to do if the device fails or the bleeding continues.  

As mentioned above, tourniquets should not be removed unless there is a proper team at the bedside to manage the blood loss mechanically or surgically (1). If the bleeding continues despite initial tourniquet application, the device may need to be tightened or reassessed to ensure proper applied per manufacturer instruction (1). The next step would be to apply a second tourniquet two inches above the first (1). If all methods fail—including direct pressure and elevation—immediate surgical intervention or beside cauterization is needed.  

Conclusion

Tourniquets have unfortunately become a staple in today‘s society. With the growing war on terror, the home front has become the battlefield in unexpected ways. Concerts, movie theater, and schools are now the targets of unsolicited attacks, leaving everyday civilians and medical providers to act as army medics. Because of the severity of injury or loss of life that can occur, everyone must be educated on proper tourniquet application. Nurses in the emergency, trauma, or pre-hospital setting should advocate for having tourniquets in their workplace and receive proper education on them. 

While most of the tourniquets placed are done so in the pre-hospital setting, it is always a possibility that they may need to be placed in the initial resuscitation phase in the emergency room. If the patient undergoes an elective surgery, a tourniquet may be used by the surgeon and their team under a controlled environment.  

Any patient that is actively hemorrhaging in one or more of their extremities is a candidate for a tourniquet. If possible, patients should be educated on potential risks of the device; however, this may be a decision made by providers due to the other injuries a patient may have that prevent them from giving informed consent.  

Nurses need to ensure that in addition to the correct application, they know the proper place to document the time when the tourniquet was placed and several troubleshooting methods. They should ensure they have adequate support from the team and suggest and provide additional methods of decreasing blood loss if the tourniquet fails, such a surgery or bedside cauterization.

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