Emergency Tourniquets Military and Pre-Hospital Tourniquets

There are two types emergency tourniquets used in military and pre-hospital settings:

While both types of tourniquets can be used to stop bleeding in military and pre-hospital settings to save a life, pneumatic tourniquets provide greater safety to the limb because they can occlude arterial blood flow at lower pressures, thus increasing the probability of saving the limb and recovering full limb function. Lower pressures are safer because it is well established by evidence in the clinical literature that higher tourniquet pressures are associated with higher probabilities of tourniquet-related injuries [1].

Emergency Tourniquets: Pneumatic tourniquets

Pneumatic tourniquets are commonly used in surgery to safely establish a bloodless surgical field in a portion of a limb over a time period suitably long for the performance of a surgical procedure. It is estimated that at least 15,000 surgical procedures are performed each day on limbs with the benefit of pneumatic tourniquet systems. The introduction and widespread use of automatic tourniquet systems, with microcomputer control and improved pneumatic cuff designs, has greatly reduced the reported severity and number of tourniquet-related hazards and injuries [2, 3]. It is well established in the medical literature that the probability of tourniquet-related injuries increases as tourniquet pressure increases, and as the pressure gradients near the edges of tourniquet cuffs increase [3-10].

Pneumatic tourniquets have recently been developed for military and emergency use, based on surgical designs proven to be safe and effective over many years. Such pneumatic devices are deployed in Afghanistan and Iraq and in other pre-surgical emergency settings. Pneumatic military tourniquets are more commonly used by medics than by individual soldiers in combat, but both types are designed to be suitable for rapid, one-handed self-application in the field.

Emergency Tourniquets wide pneumatic cuff

Figure 1: Wide, pneumatic tourniquet cuff with hand bulb pump.

Emergency Tourniquets: Non-pneumatic tourniquets

In a recent study, the early use of both types of military tourniquets (pneumatic and non-pneumatic) when shock was absent was strongly associated with saved lives; pre-hospital use was also strongly associated with lifesaving, and no limbs were lost due to use of these military tourniquets [11]. In another paper reporting on the same study, pneumatic military tourniquets were rated 92% effective and non-pneumatic tourniquets were rated 79% effective [12].

Comparatively narrow, non-pneumatic tourniquet straps were developed to be very small in size and light in weight so they could be carried in backpacks by all soldiers, and were developed to be suitable for rapid one-handed self-application by wounded soldiers in combat situations. While effective in helping to stop potentially fatal arterial blood flow in combat, such narrow non-pneumatic tourniquet straps may produce hazardously high, inconsistent and uncontrolled pressures around limbs and may further produce high pressure gradients near the strap edges. Click here to learn more about how high pressures and pressure gradients may lead to nerve injuries.

Emergency Tourniquets - non-pneumatic

Figure 2: Narrow, non-pneumatic strap tourniquet designed for one-handed self-application in certain military settings

Very recently, it has been suggested by some that non-pneumatic tourniquets, including elastic bandages, elastic rings and non-elastic straps might be employed in pre-hospital civilian use and even in surgery, as they were in the 19th century. The uncritical acceptance and use of such non-pneumatic tourniquets in non-military settings and in surgery for extended periods, without investigation of applied pressure levels and applied pressure gradients and with limited evidence of their safety, may unnecessarily increase the incidence of tourniquet-related injuries in surgical patients to earlier unacceptable levels, and may expose users in civilian settings to potential legal liability.

Non-pneumatic tourniquet devices for stopping arterial bleeding may not be as safe as pneumatic tourniquets in civilian settings, where pneumatic tourniquets with proven safety and efficacy are readily available and where one-handed self-application is not an essential consideration. A recent study confirmed that non-pneumatic tourniquet straps and non-pneumatic elastic rings produce substantially higher applied pressures and higher pressure gradients when selected and used to stop arterial blood flow according to manufacturer’s instructions (see Figure 3 below) [13].

Figure 3: Applied pressures and pressure gradients typically produced by (a) a modern pneumatic surgical tourniquet cuff, (b) a non-pneumatic, non-surgical military tourniquet designed for self-application on the battlefield, and (c) a non-pneumatic elastic ring designed in an attempt to combine exsanguination and tourniquet functions.

Such higher pressure levels and higher pressure gradients are associated in the clinical literature with higher probabilities of patient injuries. Additional caution is suggested by a 2009 anecdotal report of possible nerve, muscle, and soft tissue injuries associated with a commercial, non-pneumatic elastic ring recently developed for use as a surgical tourniquet and exsanguinator [14].

Figure 4: Narrow, non-pneumatic elastic ring tourniquets produce substantially higher applied pressures and higher pressure gradients.

Recommendations

Pneumatic military tourniquets have proven to be effective in stopping arterial bleeding in combat situations, as have narrow, light-weight non-pneumatic tourniquet straps [11].

For both of these types of military tourniquets, small size, light weight and the requirement that they be suitable for one-handed self-application are essential considerations where saving a life is the primary consideration and where saving the limb and returning it to full functionality is a secondary consideration. However, for civilian pre-hospital applications and civilian surgical applications these are not considerations. Thus for greatest patient safety and to minimize potential legal liability, much further investigation is warranted before there is uncritical acceptance and use of non-pneumatic tourniquet straps, or non-pneumatic elastic tourniquet rings, when pneumatic tourniquets with proven safety, lower pressures and lower pressure gradients are available.

Sources

[1] Noordin S, McEwen JA, Kragh Jr CJ, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. JBJS. 2009 Dec 1;91(12):2958-67.

[2] McEwen JA. Complications of and improvements in pneumatic tourniquets used in surgery. Med Instrum. 1981 Jul;15(4):253-7.

[3] McGraw RW, McEwen JA, McFarlane RM. The tourniquet. Unsatisfactory results in hand surgery. New York: Churchill Livingstone. 1987:5-13.

[4] Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in peripheral nerves compressed by a pneumatic tourniquet. Journal of Anatomy. 1972 Dec;113(Pt 3):433.

[5] Gilliatt RW, Ochoa J, Rudge P, Neary D. The cause of nerve damage in acute compression. Trans Am Neurol Assoc. 1974;99:71-4.

[6] Shaw JA, Murray DG. The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh. J Bone Joint Surg Am. 1982 Oct 1;64(8):1148-52.

[7] Graham B, Breault MJ, McEwen JA, McGraw RW. Perineural pressures under the pneumatic tourniquet in the upper extremity. The Journal of Hand Surgery: British & European Volume. 1992 Jun 1;17(3):262-6.

[8] Crenshaw AG, Hargens AR, Gershuni DH, Rydevik B. Wide tourniquet cuffs more effective at lower inflation pressures. Acta orthopaedica Scandinavica. 1988 Jan 1;59(4):447-51.

[9] Younger AS, McEwen JA, Inkpen K. Wide contoured thigh cuffs and automated limb occlusion measurement allow lower tourniquet pressures. Clinical orthopaedics and related research. 2004 Nov 1;428:286-93.

[10] Ochoa J, Danta G, Fowler TJ, Gilliatt RW. Nature of the nerve lesion caused by a pneumatic tourniquet. Nature. 1971 Sept;233:265-6.

[11] Kragh Jr JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of surgery. 2009 Jan 1;249(1):1-7.

[12] Kragh Jr JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Practical use of emergency tourniquets to stop bleeding in major limb trauma. Journal of Trauma and Acute Care Surgery. 2008 Feb 1;64(2):S38-50.

[13] McEwen J, Casey V. Measurement of hazardous pressure levels and gradients produced on human limbs by non-pneumatic tourniquets. In: Proceedings of the 32nd Conference of the Canadian Medical and Biological Engineering Society 2009. Calgary, Canada; 2009 May 20-22. p 1-4.

[14] Reported personal experience with an elastic ring used as a non-pneumatic tourniquet.