Use of Tourniquets - 2024 Updates

2nd October 2017 updated 4th May 2018, 27th December 2019, 18th May 2021 and 2nd April 2024

The following practices are suggested for use by those with relevant training and experience.  As with all of our articles, reading alone does not make anyone proficient in any practical skill.

Never has any one subject caused so much debate in First Aid than the use of tourniquets: Whilst it is widely accepted that tourniquets have saved countless lives in a military setting, their use - especially among civilians - is misunderstood and frequently bad practices are still taught.

The Royal College of Surgeons Faculty of Pre-Hospital Care Position statement on the application of Tourniquets (2017) for the first time brings civilian protocols in line with established and proven military protocols.(1)

The Dilemma

There is no doubt that tourniquets provide an effective means to stop 'catastrophic haemorrhage' - serious bleeding wounds to the extent that death is imminent due to blood loss.  There is also evidence to support the negative consequences of inappropriate or prolonged use of tourniquets, including  nerve damage, tissue death and circulatory complications.

Ischemia
The obvious concern is tissue damage due to a loss of circulation.  Continuous application for longer than 2 hours can result in permanent nerve injury, muscle injury, vascular injury and skin necrosis.  Muscle damage is nearly complete by 6 hours (2-6).

Compartment syndrome
The more sinister - and less known - issue is compartment syndrome; a serious condition which can affect both life and limb.   Raised pressure within the compartment such as the arm, leg or any enclosed space within the body and leads to nerve damage because of the lack of blood supply.  Prolonged or inappropriate use of a tourniquet can lead to compartment syndrome, especially if venous blood flow is impeded but not arterial, thereby allowing arterial blood into an area but not allowing venous return. (7-12)

Further Reading - Crush Injury

Reperfusion Injury
Reperfusion injury is tissue damage caused when blood supply returns to the tissue after a period of ischemia or lack of oxygen. The absence of oxygen and nutrients from blood during the ischemic period creates a condition in which the restoration of circulation results in inflammation and oxidative damage through the induction of oxygen rather than restoration of normal function.  (13-14) 

Slow-release
A policy of periodic loosening of a tourniquet in an attempt to reduce limb ischaemia has often led to incremental exsanguination and death. (15)

Pain
A properly applied tourniquet is painful; a casualty may require significant pain relief to apply the tourniquet to the appropriate pressure.

And this is the crux of the argument; tourniquets are effective and appropriate but only if their use is warranted and the person applying the tourniquets understands what they are doing, how to do it and why.

Related article:  Duty of Care and The Law

Rationale for Tourniquet use in a civilian setting

Despite the relative low incidence of catastrophic haemorrhage from limb injury in a civilian setting there are occasions where the use of a tourniquet is warranted:

Amputation
The risks of hypovolaemic shock greatly outweigh the potential damage to the limb beyond the point of tourniquet application in the case of an amputation. (1)

High-Hazard setting
High-hazard settings such as industrial environments experience similar injuries to those seen in hostile environment; principally traumatic amputation and blast injuries.

Multiple casualties
Mass casualty incidents such as industrial accidents and terrorist attacks result in multiple casualties with serious limb injuries without the resources to treat all casualties with direct pressure.

Multiple Injuries
A casualty with multiple injuries, including serious bleeding limb injuries may be effectively managed by the immediate application of a tourniquet as a temporary measure to stop bleeding whilst Airway and Breathing are assessed and managed.   Following successful management of the Airway and Breathing, the tourniquet may be removed under the assessment of Circulation where the bleeding wounds may be more appropriately treated with more basic measures. (1)

Entrapment
Where a casualty is trapped and direct pressure may not be applied to the limb injury because of lack of access a tourniquet may be appropriate as the only remaining method of controlling the bleed. (16)

A 2011-2016 study of civilians treated with tourniquets pre-hospital showed an increased survival rate compared to those without tourniquet applied with no increased likelihood of amputation as a result of tourniquet application (17)

Principles of Tourniquet Application

If it is deemed necessary to apply a tourniquet either because the necessity of the situation dictates or because the simple measures are not sufficient; it is imperative that the tourniquet is applied appropriately.

• Use a dedicated tourniquet if one is available - if not, improvise:
  Improvised tourniquets have been proven to be as effective if not more so than some prefabricated devices. The issue with improvised tourniquets is that, by definition, there are variations in their constructions, application and overall effectiveness. (18-20)

• The design of any tourniquet improvised or otherwise requires a broad band to provide adequate compression. (21, 22)

• The tourniquet should be applied onto bare skin to prevent slipping.

• The tourniquet can be applied on single or double-bone compartments.
  
  Traditional teaching has avoided placement of a tourniquet over a double bone compartment (lower leg or lower arm) as the twin bones in these areas may protect the blood vessels from adequate compression from a tourniquet. Although there is little evidence to contradict this theory, recent anecdotal evidence from Iraq and Afghanistan challenge it. (1, 23-25)

• The tourniquet should be applied just above the injury. (1)
  

• The tourniquet can be applied ‘high and tight’ as an interim measure.
  
  In a multi-casualty, time-critical setting it is reasonable to apply the first tourniquet 'high and tight' over clothing until a more considered assessment and reapplication may be considered. In these cases, review of the placement should be considered when possible with a view to re applying a tourniquet closer to the wound prior to releasing the initial higher placed one to ensure haemorrhage control is maintained. (1)
  

• Tighten the strap as much as possible before tightening the windlass. (26, 27)
  

• The tourniquet should be tightened until bleeding stops. (1)
  

• If it is ineffective the tourniquet should be tightened or repositioned.
  

• The application of a second tourniquet (applied above the first) may be required
  

• Slight oozing at the wound site may occur due to some blood flow from the exposed medullary bone end. (1)
  

• Write the Time and Date on the tourniquet and mark the casualty with a T on their cheek (easier to see than on the forehead if they are wearing a helmet and more likely to remain clear because of less sweat).
  

• The time and date of the tourniquet application should be mentioned in the communication and handover. Any casualty with a tourniquet applied is classed a "1 - Immediate" on any triage sieve.

Which Tourniquet?

In December 2019 the Journal of Special Operations Medicine published the Montgomery review of commercially available tourniquets (28); the largest meta-analysis of tourniquets undertaken to date. Tourniquets were assessed on a number of criteria including, but not limited to, efficacy, ease of use, time required for application, size, failure incidence, cost and availability.

The outcomes (modified from scores out of 50 to percentages) of approved tourniquets are listed below:

• 88.0% CAT 7th Generation

• 83.7% RMT / TMT

• 83.5% CAT 6th Generation

• 82.8% SOFTT Wide 3rd Generation

• 81.6% SAM XT

• 80.6% TMT

• 76.0% Delfi EMT - pneumatic

• 69.% TPT2 -pneumatic
  
  

Other tourniquets assessed which failed to meet requirements for recommendation include, SOFTT, RATS, IEST, MAT, MET, RTK, SWAT-T, TPT3, TK4 / TK4L / TQ, NATO TQ, McMillan and Ramsey's

Further Reading - In Defence of the SWAT-T

In a recent, but limited study (22) the CAT was found to be as effective as the TMT and significantly more effective than the SOFTT-W. In addition, the CAT demonstrated shorter application times than either the TMT or SOFTT-W. However, there was no significant difference between the three tourniquets in their ability to maintain pulselessness after subject maneuvers.

When necessity dictates, improvised tourniquets should be used, and have been found to be as effective as prefabricated tourniquets.  (18-20).  The same principles of tourniquet application apply but consideration should be made to the materials used.

Width

The tourniquet should be at least 2cm wide (20).   Some would say more.  Cable ties and electrical cable is too thin and acts more like a cheese-wire.  

Pliability

The efficacy of the TQ is due to the twisting action, not the initial ‘wrap’.   If you examine a CAT of SOFT you will notice that within the wide exterior strap, there is a thin, supple ribbon which actually exerts the force, with pressure diffused by the broad strap encasing it.

We often think of a belt as an ideal TQ because of TV movies in the 80’s when a cowboy was bitten by a snake they would wrap a belt around their leg.  They died.   Belts make terrible tourniquets.   They are a decent width but too stiff.   The casualty’s limb would snap before enough pressure was exerted to constrict the limb.

Length

It must be long enough to encircle the limb as well as enough free end to tie the TQ off.

Windlass

The only evidence to support improvised TQ are those based around a windlass method (18-20) to apply pressure.  Something long enough to apply the torque and strong enough not to snap:  Cutlery, a screwdriver, a stick (at least as thick as your thumb).   If you are improvising, you will need more than you are used to; a Sharpie for example, whilst similar dimensions to the windlass of a TQ probably won’t work because of the materials you are using to improvise the strap.

An ideal material may be a triangular bandage, a silk scarf or the ribbon from an extendable barrier, often found at large public events and airports.

Method

If tourniquet has been applied as an interim measure due to multiple injuries or because of limited resources, there may be merit in 'downgrading' the treatment for serious bleeding under Circulation of the ABC protocol or once the situation has been managed, other injuries have been stabilised or after additional resources have been sourced.

The tourniquet may be downgraded if it was hastily applied ‘High and tight’. (1)

The above images show the effects of a tourniquet which has been hastily applied “high & tight” and left in situ for 4 days. The consequence was amputation of the leg.

Releasing the tourniquet once the casualty has been stabilised will, theoretically, avoid or limit the complications of prolonged use of a tourniquet, listed above.  Alternatively, after a period of time of reduced arterial flow from tourniquet use, clotting may have occurred sufficiently, allowing simpler methods of haemorrhage control to be effective

1. Visualise the whole limb to assess for additional bleeding wounds.

2. Place the new, distal, tourniquet 5 cm from the highest wound.

3. Apply the tourniquet tightly.

4. Release the proximal tourniquet, observing the wound. If bleeding continues, tighten the distal tourniquet until bleeding stops.

5. Continue to release the proximal tourniquet, observing the wound for bleeding.

The tourniquet should remain in place if (24-25):

• The transit time to definitive care is less than one hour.

• The casualty has other life-threatening injuries.

• The casualty has unstable vital signs.

Before release of the tourniquet secure wound packing / haemostatic and application of direct pressure.

If careful release of the tourniquet then results in a return of uncontrollable external haemorrhage, the tourniquet should be replaced and not removed until the patient is in the operating theatre. 

Military medics and Emergency Services personnel should follow their current protocols regarding the release of tourniquets.

Preparing the Tourniquet

Tourniquets should be removed from their original packaging and stowed in a manner that facilitates prompt application:

Conclusions:

Tourniquets are an effective method of controlling serious bleeding which may not otherwise be controlled by simple measures but only if applied effectively.

The greatest risk of serious complications are due to inappropriately or incorrectly applied tourniquets, not the tourniquet per se.

Tourniquets can be removed or relocated if:

• The casualty DOES NOT have an amputation and

• Dangers at the scene have been stabilised and

• Bleeding has stopped and

• The casualty’s vital signs are normal and stable and

• Transfer time to definitive care is greater than one hour

Both Tourniquets and Haemostatics are demonstrated and applied on our Remote, Forestry and First Responder courses.

References

1. Royal College of Surgeons of Edinburgh, Faculty of Pre Hospital Care (2015)  “Position statement on the application of Tourniquets”.

2. Bellamy RF. "Combat trauma overview". In: Zajtchuk R, Grande CM, eds. (2005)  Textbook of military medicine part IV: surgical combat casualty care. Office of the Surgeon General, US Army.

3. Lakstein D, Blumenfield A, Sokolov T, et al.  (2003)  "Tourniquets for hemorrhage control on the battlefield: a 4 year accumulated experience."  Journal of Trauma.  54(5 Suppl):S221–5.

4. Reikeras O, Clementson T.  (2009)  “Time course of thrombosis and fibrinolysis in total knee arthroplasty with tourniquet application. Local versus systemic activations”.  Journal of Thrombosis and Thrombolysis.  28(4): 425-428.

5. Blaisdell FW.  (2002)  “The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review”. Cardiovascular Surgery.  10(6): 620-630.

6. Lee YG, Park W, Kim SH, Yun SP, Jeong H, Kim HJ, Yang DH.  (2010)  “A case of rhabdomyolysis associated with use of a pneumatic tourniquet during arthroscopic knee surgery”.  The Korean Journal of Internal Medicine. 25(1) 105-109.

7. Farrow C, Bodenham A, Troxler M.  (2011)  “Acute limb compartment syndromes”.  Continuing Education in Anesthesia, Critical Care & Pain.  11(1).

8. Altizer L.  (2004)  “Compartment syndrome”.  Orthopaedic Nursing.  23(6).

9. Frink M, Krettek C, Hankemeier S.  (2010)  “Compartment syndrome of the lower leg and foot”.  Clinical Orthopedics and Related Research.  468: 940–950.

10. Barendse MG, Steenvoorde P, van Doorn L, Zeillemaker A.  (2009)  “Compartment syndrome of the arm after cable-wakeboard accident”.  European Journal of Trauma and Emergency Surgery.  1.

11. Burkhart KJ, Mueller LP, Prommersberger KJ, Rommend PM.  (2007)  “Acute compartment syndrome of the upper extremity”.  European Journal of Trauma and Emergency Surgery.  33(6) 584–588.

12. Starnes B W, Beekley A C, Sebesta J A. et al(2006)  “Extremity vascular injuries on the battlefield: tips for surgeons deploying to war”.  Journal of Trauma, Injury, Infection and Critical Care.  60;432–442

13. Wakai A, Wang JH, Winter DC, Street JT, O’Sullivan RG, Redmond HP.  (2001)  “Tourniquet-induced systemic inflammatory response in extremity surgery”.  J Journal of Trauma, Injury, Infection and Critical Care.  51(5) 922-926.

14. Townsend HS, Goodman SB, Schurman DJ, Hackel A, Brock-Utne JG.  (1996)  “Tourniquet release: systemic and metabolic effects”.  Acta AnaesthesiologyScandinavica.  40(10) 1234-1237.

15. Clifford CC.  (2004)  "Treating traumatic bleeding in a combat setting."  Military Medicine.  169 (12 Suppl):8–10.

16. Royal College of Surgeons of Edinburgh, Faculty of Pre Hospital Care (2015)  “Consensus Statement On The Early Management Of Crush Injury And Prevention Of Crush Syndrome”

17. Teixeira PGR, Brown CVR et al.  (2018) "Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury".  Journal of the American College of Surgeons.  226(5), 769 - 776.e1

18. Stewart SK, Duchesne JC, Kahn MA(2015)  "Improvised tourniquets: Obsolete or obligatory?"  Journal of Trauma and Acute Care Surgery.  (78)1;  178-183

19. Cremonini C, Nee N, Demarest M, Piccinini A, Minneti M, Canamar CP, Benjami ER, Demetriades D, Inaba K. (2021) “Evaluation of the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model”. Journal of Trauma and Acute Care Surgery. 90(3):522-526

20. Rohrich C, Plackett TP, Scholz BM, Hetzler MR. (2019) “Proficiency in Improvised Tourniquets for Extremities: A Review”. Journal of Specialised Operational Medicine. Fall;19(3):123-127.

21. Wall, P. L., Duevel, D. C., Hassan, M. B., Welander, J. D., Sahr, S. M., & Buising, C. M. (2013). Tourniquets and occlusion: the pressure of design. Military Medicine, 178(5), 578–587.

22. Treager C, Lopachin T, Mandichak S, et al. (2021) “A Comparison of Efficacy, Efficiency, and Durability in Novel Tourniquet Designs”. Journal of Trauma and Acute Care Surgery. 90 (6).

23. Brodie S, Hodgetts TJ, Ollerton J, et al. (2007)  “Tourniquet Use In Combat Trauma: UK Military Experience”.  Journal of the Royal Army Medical Corps 153(4): 310-313

24. Lee, C.  Porter, K.M. and Hodgetts, T.J.  (2007)  "Tourniquet use in the civilian prehospital setting".  Emergency Medical Journal.  24:8 584-587

25. Joint Royal Colleges Ambulance Liaison Committee. (2015). UK Ambulance Service Clinical Practice Guidelines. Warwick: JRCALC

26. Baruch EN, Kragh JF Jr, Berg AL, Aden JK Rd, Benov A, Shina A, Shlaifer A, Ahimor A, Glassberg E, Yitzhak A.  (2017)  "Confidence-Competence Mismatch and Reasons for Failure of Non-Medical Tourniquet Users."  Prehospital Emergency Care.  Jan-Feb;21(1):39-45

27. Polston RW, Clumpner BR, Kragh JF Jr, Jones JA, Dubick MA, Baer DG.  (2013)  "No Slackers in Tourniquet Use to Stop Bleeding".  Journal of Special Operational Medicine.  Summer; 13(2):12-9.

28. Montgomery HR, Hammesfahr R, Fisher AD, Cain J, Greydanus DJ, Butler Jr FK, Goolsby C, Eastman AL. (2019) “2019 Recommended Limb Tourniquets in Tactical Combat Casualty Care“, Journal of Special Operations Medicine, 36(3)