Tourniquets for Treating Open Fractures and Traumatic Injuries: Contraindicated or Not?

Overview:

A current overview of the use of tourniquets in surgery and traumatic injury is provided elsewhere [1].

Open fractures:

The use of a tourniquet is contraindicated in the surgical treatment of open limb injuries because it is necessary to make an assessment of the devascularized zone of injury for the purpose of wound management (debridement).  This cannot be achieved under tourniquet conditions and may lead to an underestimation of the injury zone size [2].  The anoxia that is produced by a tourniquet also interferes with the assessment of the viability of muscle and may add to a pre-existing ischemic injury [3].  However a tourniquet may be inflated if unexpected bleeding is encountered when it is necessary to control bleeding to allow a clear view or to limit blood loss during surgery [3].

Traumatic injury:

The European guideline on management of major bleeding and coagulopathy following trauma [4] includes the following statements:

When uncontrolled arterial bleeding occurs from mangled extremity injuries, including penetrating or blast injuries or traumatic amputations, a tourniquet is a simple and efficient method with which to acutely control haemorrhage. Tourniquet application has become standard of care for the control of severe external haemorrhage following military combat injuries, and several publications report the effectiveness of tourniquets in this specific setting in adults and children … Tourniquets should be left in place until surgical control of bleeding is achieved; however, this time span should be kept as short as possible. Improper or prolonged placement of a tourniquet can lead to complications such as nerve paralysis and limb ischaemia ​… Bleeding from most civilian wounds can be controlled by local pressure, however uncontrolled external bleeding from either blunt or penetrating limb injury should be controlled with a tourniquet.

Some types of pneumatic tourniquets specifically designed for treating traumatic injuries have been shown to be more effective and safer by requiring lower pressures and by applying lower pressure gradients to consistently and reliably stop arterial blood flow [5-7].

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] Khan AL, Gray A. Tourniquet uses and precautions. Surgery (Oxford). 2014 Mar 31;32(3):131-3.

[3] Klenerman L. The tourniquet manual—Principles and practice. Springer Science & Business Media; 2003 Jul 30.

[4] Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EA. The European guideline on management of major bleeding and coagulopathy following trauma. Critical care. 2016 Apr 12;20(1):100.

[5] 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.

[6] 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.

[7] 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.