By Dr. Ken Lavelle, MD, NREMT-P
You are standing by at a fire in an abandoned building when you and the Rapid Intervention Team are activated for a firefighter down. He reportedly fell into a hole in the floor. He is brought out awake, but yelling in pain, with head and chest trauma. He also has a severe laceration to his right leg midway between his hip and knee. Another firefighter is holding pressure to the area but there is still a lot of blood on the leg. He states it is "squirting pretty bad" and that he injured it on sharp metal that was in the hole.
What are your first actions?
If you have been following this column for a while, this is a bit of a trick question. All trauma patients start with the ABCs, right? Of course, but what is the primary threat to this patient? He is awake and yelling, so his airway is likely open and not threatened. If he is able to yell, then he is breathing (to some degree). He has chest trauma that could affect this, however. Finally he has a severe wound on the leg that is bleeding, possibly from an arterial source.
When we put everything together there are two immediate threats that could cause death in the next 10 minutes: a tension pneumothorax and the arterial bleed. The best approach with this patient is to rapidly evaluate the airway — look in the mouth for blood or anything else that could threaten the airway. Suction if necessary. Place high-flow oxygen via a non-rebreather mask. Listen to the lungs for unequal sounds, while considering the possibility of a tension pneumothorax. If there are decreased lung sounds and severe respiratory distress, then needle decompression is the treatment of choice for the paramedic. For a basic crew, rapid transport is indicated.
What about the leg wound?
Get the bunker gear off and get a look at the wound. In this case, let's say when you do there is pulsating bleeding that continues from the medial thigh. Pressure is immediately applied, but he continues to lose blood. Classical bleeding control has been direct pressure, elevation and occluding the blood vessel at the pressure point. The problem is this doesn't always get the bleeding under control, and it takes some manpower to accomplish. What about a tourniquet?
The use of the tourniquet dates to the Roman times. Its use increased during the Civil War, particularly to control bleeding during a therapeutic amputation. However this is also about the time that its complications were starting to be more recognized and its use questioned. Until recently, the use of the tourniquet by civilian EMS personnel was thought to be a last resort, to be used only when more conventional methods (direct pressure, elevation, pressure point and pressure dressing) were unsuccessful. This was due to the complications of its indiscriminate use.
Despite the complications discussed below, the tourniquet has experienced a resurgence in the military. Current conflicts are generating a large number of patients that are alive, but have massive extremity trauma. This is due to the use of protective body armor, and the role of IEDs (Improvised Explosive Devices) as a cause of trauma. Soldiers are more likely to survive due to protective equipment, but their extremities are still vulnerable.
There are several reasons why the first use of the tourniquet has been found to save numerous lives.
In the event of an IED or other explosive cause of injury, it is common to have multiple victims. These victims may be cared for by a single medic, or soldiers with a minimal amount of training. It is necessary to control life-threatening bleeding quickly, without tying up the provider on a single patient by applying constant direct pressure. The tourniquet allows this. The medical provider can place the tourniquet and then more on to the next patient.
Victims in a military theatre of operations often must be evacuated to a medical facility. The ability to maintain direct pressure on a wound during an evacuation is also limited. Thus, it is an advantage to place the tourniquet and allow the patient to be transported either in a helicopter or other vehicle to a forward aid station.
Finally, many of the wounds an explosive device causes are not amenable to direct pressure, and are difficult to control. The limbs may be partially or completely amputated, and bleeding may continue. In these cases a tourniquet may be the only option to control the bleeding.
How does the tourniquet work?
The tourniquet is designed to compress the muscle and other tissues to collapse the lumen of the artery. Larger extremities will need more pressure than a smaller extremity. Also, a wider tourniquet has been found to be more effective than a narrower one.
There are a number of complications that formerly led to tourniquet use to be a last resort. The common one is the local effect to the extremity distal to the tourniquet. Most studies have found that while there is some temporary nerve damage that can occur after 30 minutes, in general there is no evidence of permanent injury if less than one to one and a half hours of placement is used. After six hours, there can be irreversible ischemic damage.
- Post tourniquet syndrome: This includes weakness, paresthesias, pallor and stiffness that can remain for several weeks after a tourniquet has been placed.
- Tourniquet palsy or paralysis: Temporary nerve injury after a tourniquet has been removed.
- Ischemic reperfusion injury: This results after a tourniquet has been removed, and the toxins and free radicals present distal to the tourniquet re-enter the blood stream. This is the concept behind crush injury as well.