Norman McSwain MD Medical director PHTLS Tourniquets Do they belong in civilian EMS ?

Norman McSwain MD Medical director PHTLS Tourniquets Do they belong in civilian EMS ? If Yes How and When

Hemorrhage Control in the Field Non-combat patient care Direct hand pressure Pressure Bandage Torso Extremity Hemostatic Agent Tourniquet Hospital Yes No Hospital

Tourniquets PHTLS Scientific Panel 2008 Were we wrong? Why? Do they work? What is their place in modern EMS – Civilian – Military Guidelines for their use

Tourniquets Why were we wrong? – Don’t confuse me with no data, my mind is made up? – The data does not support their use – Data? What data? – Medical – Well if you put them on, that determines the level of the amputation. They distal extremity will die. – If they are too tight, the artery will be damaged. – If they are too tight, the nerve will be damaged.

Albert Sidney Johnston General, Confederate Army Gun shot would to thigh Blood ran down into boot Directed medic to another solder Exsanguinated Tourniquet would have saved his life Reportedly in his pocket.

Tourniquets Clinical experience Kandahar AFB - 4 months (2006) 134 patients treated 6 patients – 8 tourniquets Lives saved = 4 patients – 5 tourniquets Misuse = 1 venous tight only => Bleeding Prolonged use = 1 (4 hours) no complications Tien et al JACS ‘08

Tourniquet s Clinical application Combat operations => delay in transport 16 hours = no complications Patient life saved Kragh et al J Ortho Trauma ‘07

Tourniquets Clinical Experience UK Joint Trauma Registry 66 months 1375 patients Tourniquets = 70 (5%) patients Tourniquets used = or > = 24% 87% survival Brodie et al JR Army Med corps ‘07

Tourniquets Clinical Experience Vietnam KIA exsanguination = 9% OTF 31 st Combat Support Hospital 12 months = 3444 patients Major vascular, traumatic amputation, tourniquet 165 patients Prehospital tourniquet = 67 (TK) Severe extremity injury no tourniquet = 98 (No TK) Bleeding control = TK=83% vs No TK-60% Secondary amputation = TK=6% vs No TK=9% Potentially preventable deaths = 57% Beekley et al J Trauma ‘08

Military Tourniquet Design Criteria Self applied to arm – On handed Elimination of arterial blood flow 3 tourniquets met the requirements – CATT – SOFT-T – EMT Walters ISR Technical Report

Special Operation Forces Tactical Tourniquet SOFT-T

Combat Applied Tactical Tourniquet CATT

Application of CATT

Emergency Medical Tourniquet EMT

Tourniquets Clinical Experience Israeli Defense Forces 550 patients 91 prehospital tourniquets (16%) Injury to application 15 minutes Ischemia time = 83 minutes 78% effective Lakstein et al J Trauma ‘03

Hemorrhage Control in the Field Non-combat patient care Direct hand pressure Pressure Bandage Torso Extremity Hemostatic Agent Tourniquet Hospital Yes No Hospital