Are There Any Guidelines on Best Practices for Hospital Admission of a Patient with a Pre-Applied Tourniquet?

How should a patient be assessed and managed if a tourniquet has been applied to establish hemostasis prior to admission? What is the best practice? Do guidelines exist?

The use of tourniquets in pre-hospital settings is increasing to prevent life-threatening blood loss, based on fundamental changes in doctrine regarding early use of tourniquets [1], and based on improved designs of tourniquets for such applications [2-5].

However, such tourniquets are intended for short-term use in the field to stop life-threatening blood loss prior to admission [6]. Within hospitals, in addition to preventing blood loss, additional goals involving the use of tourniquets are to preserve limb function to the greatest extent possible, and to minimize tourniquet-related limb injuries.

It is well established in the clinical literature that higher tourniquet pressure levels, higher tourniquet pressure gradients and longer periods of application of tourniquets are associated with higher probabilities of injuries to nerves, muscle and other tissues [3, 7-9]. Therefore, in a hospital setting, the best practice is to minimize tourniquet pressure levels and pressure gradients, and to minimize tourniquet application times.

Unlike hospital tourniquets, tourniquets applied in the field to prevent death from exsanguination do not automatically monitor tourniquet application time, they do not allow tourniquet pressure levels to be monitored, controlled and minimized, and they do not minimize applied pressure gradients [6,10]. Additionally, there are wide variations in the relative safety and effectiveness of devices proposed for pre-hospital use [5,11]. Thus in admitting a patient with a pre-applied tourniquet, the following protocol is recommended.

  1. For patient safety, the objective should be to replace the applied tourniquet with a pneumatic hospital tourniquet instrument and tourniquet cuff as soon as is practicable, so that tourniquet time can be monitored and minimized, so that the tourniquet pressure level can be measured, regulated and minimized, and so that applied tourniquet pressure gradients can be minimized.
  2. Before such replacement, the patient’s primary injuries and hemodynamic status, should be carefully assessed, and a determination made as to if and when the replacement may be safely accomplished.
  3. For best practice and to minimize any potential legal liability, staff should assure that the nature and extent of the primary injuries that led to pre-hospital application of a tourniquet is thoroughly documented, so that any possible secondary tourniquet-related injuries can be differentiated.
  4. Also for best practice, an effort should be made to determine and record the approximate duration of tourniquet application prior to admission, the name and qualifications of the individual applying the tourniquet, the location of tourniquet application on the limb, whether the tourniquet was applied over clothing, zippers, buttons or other objects, and the specific type (manufacturer, model) of tourniquet applied.
  5. Also for best practice and to allow for any later study and investigation, the removed tourniquet should be saved, labelled and sequestered.

In view of the widespread adoption and use of tourniquets prior to admission to hospital, there is a corresponding need for guidelines to establish best practices for admitting to hospital individuals with pre-applied tourniquets. It is hoped that the above protocol will provide a sound evidence-based framework.

Sources:

[1] 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.

[2] 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.

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

[4] McEwen JA, Inkpen K. Surgical tourniquet technology adapted for military and prehospital use. BRITISH COLUMBIA UNIV VANCOUVER; 2004 Sep 1.

[5] Taylor DM, Vater GM, Parker PJ. An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage. Journal of Trauma and Acute Care Surgery. 2011 Sep 1;71(3):591-5.

[6] Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emergency Medicine Journal. 2007;24(8):584-587.

[7] 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.

[8] 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.

[9] 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.

[10] Bogdan Y, Helfet DL. Use of Tourniquets in Limb Trauma Surgery. Orthopedic Clinics of North America. 2018;49(2):157-165.

[11] Ross EM, Mapp JG, Redman TT, Brown DJ, Kharod CU, Wampler DA. The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons. The Journal of Emergency Medicine. 2018;54(3):307-314.

2018-09-04T11:08:49+00:00