Proper Tourniquet Application
- Thread starter JANES
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Great stuff Janes as usual. The biggest problem I have with all these tidbits of info you pass on is folks look @ me sideways when I use Army.ca as my reference when I regurgitate this stuff @ work!
Keep it up, you may drag CFMS into the lifesaving business.
Keep it up, you may drag CFMS into the lifesaving business.
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JANES said:
I say...Pardon Me? You wanna qualify that statement a bit? Take that statement out and you would have one of the best posts on the site.
I also say almost everything you said is exactly how I teach the use of a TK.
I used hand measurement for placement....no closer the a handwith of the wound, and not closer then 2 fingers above or below the joints.
I teach this in my theory lecture. Direct pressure mean pressure directly on where the bleeding is. That means pushing material right into the wound, fill the wound with the white part of the old fd dressing or gauze, and then cover over with the Israeli dressing. It is not sufficient to put the pressure dressing flat over large gaping wounds. I enjoy watching everyones eyes widen in surprise when I say that...
One thing for everyone:
No. Do it. If you do not have a pen or marker, use the casualty's blood and mark a T or at least a "T" like cross on the forehead.
edit to add:
No. In Care under Fire, a TK is applied immediately to all penetrating trauma to the arms and legs, regardless of the severity. You may have quite literally minutes left to live if you do not. And this has been proven in cbt. Once it is applied, return to the fight if able.
JANES,
Great post. Please refrain from the broad statements that may get you into trouble, esp as MM and I and others are really trying to enlighten people. I am more tolerent of insult then most
"Isn’t the standard to loosen it q10min?"
"My understanding from the docs in ER is it is on 10min and then off and a short time (based on the status of the bleed) and then back for another 10min...is it not necrosis that sets in after an extended period of lose of blood flow? Which kind of defeats the purpose of the tourniquet if you are supposed to be preserving life and limb.
Although if you have to choose life over limb you know how that story goes...
As well a complete amp (as per St. John Ambulance) is not supposed to bleed in excess..."
It was these statements that caused me to write that. I didnt mean to stereotype, my point was that there is still a lot of resistance and misunderstandings. I applaud your efforts to educate the CF on this topic. It is desperately needed. You said it yourself. Its trying to enlighten everyone. There is no doubt that there are a lot of compitent medics out there that know all about tourniquets. But when there are still medics that are asking if you should ventilate tourniqueted limb every 10 minutes then there still exists a problem. I'll say the controlversial statement again, because I stand by it, and maybe try to clarify it. I am amazed at the [lack of education] in the CF and specifically the medical field [meaning those that resist teaching everyone, not just deploying troops] all the information that exists on tourniquets. There are medics out there, and of course not you AM and MM and who ever else, that believe the old St Johns heave ho that tourniquets bad and do not use, and when you put on a tourniquet you have lost that limb and the soaking up the blood is "controling the bleeding", and if the dressing bleeds through just place another on top, an another and another. What I am saying is keep teaching, because we are in a paradym shift. And all truth will go through the phases. We want everyone to accept the information as self evident, and we are not there yet.
"My understanding from the docs in ER is it is on 10min and then off and a short time (based on the status of the bleed) and then back for another 10min...is it not necrosis that sets in after an extended period of lose of blood flow? Which kind of defeats the purpose of the tourniquet if you are supposed to be preserving life and limb.
Although if you have to choose life over limb you know how that story goes...
As well a complete amp (as per St. John Ambulance) is not supposed to bleed in excess..."
It was these statements that caused me to write that. I didnt mean to stereotype, my point was that there is still a lot of resistance and misunderstandings. I applaud your efforts to educate the CF on this topic. It is desperately needed. You said it yourself. Its trying to enlighten everyone. There is no doubt that there are a lot of compitent medics out there that know all about tourniquets. But when there are still medics that are asking if you should ventilate tourniqueted limb every 10 minutes then there still exists a problem. I'll say the controlversial statement again, because I stand by it, and maybe try to clarify it. I am amazed at the [lack of education] in the CF and specifically the medical field [meaning those that resist teaching everyone, not just deploying troops] all the information that exists on tourniquets. There are medics out there, and of course not you AM and MM and who ever else, that believe the old St Johns heave ho that tourniquets bad and do not use, and when you put on a tourniquet you have lost that limb and the soaking up the blood is "controling the bleeding", and if the dressing bleeds through just place another on top, an another and another. What I am saying is keep teaching, because we are in a paradym shift. And all truth will go through the phases. We want everyone to accept the information as self evident, and we are not there yet.
Great post JANES. I had completely forgot about this:
"Tk aren't that great at stopping lower leg and forearm bleeds as the vessels travel between two bones. That doesnt mean you don't attempt to apply them there. A way to add advantage when placing them distal to an extremity joint is to pad underneith the tk between the bones (with a traingular, vacuum gauze or something similiar) to help force more point pressure in between the two bones. Instead of causing circumferencial pressure around the limb, now you are forcing pressure in between the bones where the vessels are."
Thanks for the refresher.
"Tk aren't that great at stopping lower leg and forearm bleeds as the vessels travel between two bones. That doesnt mean you don't attempt to apply them there. A way to add advantage when placing them distal to an extremity joint is to pad underneith the tk between the bones (with a traingular, vacuum gauze or something similiar) to help force more point pressure in between the two bones. Instead of causing circumferencial pressure around the limb, now you are forcing pressure in between the bones where the vessels are."
Thanks for the refresher.
Armymedic said:
I'm a little on the fence about applying a tourniquet to all penetrating trauma during CUF. Not every GSW is life threatening, and yes you cant tell so you treat the worst case scenario. So lets look at a worst case scenario. GSW to the thigh. You can bleed as fast as i liter per minute. There should be a significant amount of blood coming out, then you apply a tk. If there isn't, lets look at the worst case scenario again - complete femoral artery disection and by some chance the permanent cavity the projectile created has seal. The bleed should tamponade after about 1.5 liters. What I'm trying to get at is that if the bleed is life threatening, in most circumstances you will know. You will see a lot of blood. If you get a wound with little or no bleeding (on the EXTREMITIES), it wil most likely have no great vasculat damage and great circulatory compromise, a tk is going to be more of a tactical hindrance. I would say that it is very important to stress life threatening bleeding vs non-life threatening bleeding. Butler states one of the five bigest mistakes WRT tk's coming back from the deserts are that they are being applied when they should not be. The other issue is that when someone is in combat they are very vasoconstricted due to catecholamines from stress. They aren't going to bleed as much in the CUF phase as they will when things settle down and the situation transitions to the TFC phase. Then they will start to bleed more. If you teach to put it on everything, I won't say thats wrong, but it can be better. Not every GSW deserves a tk, the key is getting good enough to diferentiate which one do and which ones don't.
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For the blood flow in the lower limbs, (if I recollect correct) 60% in the lower arm and 40% between in the lower leg flow between betwen the bones.
I am not sure about padding the TK on the distal portions limbs (not sure enough to dispute what JANES wrote), but you must accept at least 50% reduction in effectivenss if applied below the joints. But, direct and indirect pressure is also more effective below the joints, so it is almost an even trade off. And there is always Quickclot if you have it.
I am not sure about padding the TK on the distal portions limbs (not sure enough to dispute what JANES wrote), but you must accept at least 50% reduction in effectivenss if applied below the joints. But, direct and indirect pressure is also more effective below the joints, so it is almost an even trade off. And there is always Quickclot if you have it.
This concept is a little hard to grasp. I'll try to explain it a bit further. Its not padding proximally or distally. You actually place padding under the tourniquet where there is the soft spaces between the two bones. For example, you dont place the padding on the tidia, you place it in the grove between the tib and fib. Then when the tk is tighened it forces the pad in between the bones. The theory is that this will apply more pressure to the vessels in there as opposed to circumferential pressure where the vessels are protected by the bones. Does that make sense?
And I think its actually 70% in the lower legs
And yes thats the first little yellow head I have ever used...I think
And I think its actually 70% in the lower legs
And yes thats the first little yellow head I have ever used...I think
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JANES said:
"They" have found what you said to be true. At the time of injury, you may not be able to tell how bad you are hit. So this protocol removes all doubt. People have died with the TK in thier hands, realizing too late they should have applied it to themself.
We also teach that if you put it one in CUF, then once in the CCP or area of realitive safety where you can take care of your wounds:
Apply direct pressure to your wounds, loosen the TK to assess how bad you are bleeding. If bleeding is severe (spurting, blood soaks thru first dressing, etc), retighten the TK, etc etc.
Yes, makes perfect sense in theory, as padding under any TK does make them more effective. I not sure of the practical application, and also for instruction of non med pers. Placement for added pressure between the bones would need to be almost perfect to increase effectiveness. (I'll admit, I never read or heard of distal padding for the commercial TKs)JANES said:
JANES said:And I think its actually 70% in the lower legs
Ok then, I do have the percentages backwards.
Keep it simple for the troops. Don't worry about giving them more crap like padding the tk on distal extremities. They are trying to digest enough as it is. It should be taught to medics as another tool in the box (or out of the box!).
Medics sould have an Emergency and Military Tourniquet. This is the best tk for the casualty if they are going to be monitored because its pneumatic and if it rips or malfunctions or altitude change (helo) may deflate. Its not a good idea for the troops to carry these for those reasons. This one shouldn't need padding as the bladder will conform a little better the the bones. The strap tk's you CAN pad undernieth. Ideally the CAT gets applied CUF, then EMT applied during the reassess in TFC.
Everything regarding application in CUF and reassessing in TFC you mentioned last is great. Good to keep it simple and tell everyone to put it on. If I get shot in the arm, and its not bleeding too bad though...I think I'll defer a tk and keep fighting! But thats my perogative.
Medics sould have an Emergency and Military Tourniquet. This is the best tk for the casualty if they are going to be monitored because its pneumatic and if it rips or malfunctions or altitude change (helo) may deflate. Its not a good idea for the troops to carry these for those reasons. This one shouldn't need padding as the bladder will conform a little better the the bones. The strap tk's you CAN pad undernieth. Ideally the CAT gets applied CUF, then EMT applied during the reassess in TFC.
Everything regarding application in CUF and reassessing in TFC you mentioned last is great. Good to keep it simple and tell everyone to put it on. If I get shot in the arm, and its not bleeding too bad though...I think I'll defer a tk and keep fighting! But thats my perogative.
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Janes,
Armymedic beat me to the first four points, so I won't repeat the first three.
I want to re-enforce his fourth:
Marking it has to be done. This is both an MSI for CF Medics, and a NATO STANAG (2350-Ed2) for everybody who
would apply a tourniquet.
Armymedic beat me to the first four points, so I won't repeat the first three.
I want to re-enforce his fourth:
Marking it has to be done. This is both an MSI for CF Medics, and a NATO STANAG (2350-Ed2) for everybody who
would apply a tourniquet.
Theres books and regs and then theres reality. If rounds are flying past my head, I'm not going to dig for a pen. The time on their forehead can wait until the TFC phase. The blood with the finger is reasonable, but finger painting with a sauage finger on a guys forehead when he's got a helmet on isnt going to be very legible.
If you've got a problem with my post, please let me know and I will gladly remove it, or by all means remove it yourself, but if you do I fully expect that you don't save a copy for yourself. If you're going to focuss on the negative then there is no reason it should stay up. After all you are in charge not me. I'm just trying to help some people out. If it's not up to your standard, I'll take my info and go home and provide the info through a different medium where people can appreciate it. And if you're going to warn or ban me again for standing up for myself, then let me know ahead of time so I can erase my info myself.
If you've got a problem with my post, please let me know and I will gladly remove it, or by all means remove it yourself, but if you do I fully expect that you don't save a copy for yourself. If you're going to focuss on the negative then there is no reason it should stay up. After all you are in charge not me. I'm just trying to help some people out. If it's not up to your standard, I'll take my info and go home and provide the info through a different medium where people can appreciate it. And if you're going to warn or ban me again for standing up for myself, then let me know ahead of time so I can erase my info myself.
medicineman
Army.ca Legend
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Padding TK`s - oddly enough, when I first learned to put one on a hundred odd years ago, it was just whatever you were using and a stick or whatever you were using to wind your windlass with. Every American combat medical reference I`ve read says to pad them regardless - the bulk gives extra pressure and it causes somewhat less gross damage to nerves travelling close to the arteries concerned. They also help out with the problem inherent with the low leg and forearm. When I teach TK`s they get the C.A.T. and improvised, and I always teach to use the padding on the improvised ones. I also always teach the guys to have at least 2 TK`s - whatever commercial one they are issued (C.A.T. at the moment) and something for an improvised one - and a triangular bandage does well for that, as long as they have something to wind the windlass up with, it works quite well. And in the Stan, most everyone has a scarf of some sort as well.
Removal - there will be a protocol for removal. Essentially, it`s don`t actually remove it, but loosen it under control with a pressure dressing =/- QC in place in place first and after about an hour. It stays on though, as something might happen that blows the clot and it starts again, and therefore it can be tightened quickly.
Marking - I see where you`re coming from Janes - crack crack by your ear is a bit of a deterrent to getting the head marked, but I think something should be done and sooner than later - if the poor slob goes unconscious, someone needs to know it`s there, especially if it`s gotten itself hidden.
Packing wounds - the new kit list for the TCCC bags is going to include a PriMed dressing. It`s vaccum compressed Kerlix for packing wounds and will be taught as part of the bleeding control package.
Lastly, I don`t take too much offence to the paint brush over the CFHS (you should hear me some days), however, as our first aid courses at the moment are essentially off the shelf what is taught to civvies, that happens. There are alot more people out there than you think though, that are closing the TK circle and alot of them are in fact physicians. Problem is getting the first aid instructors out there to think outside the box and not by their rote learning - alot of them know only what they are taught on their courses and they aren`t given alot of leeway as to what they are allowed to teach. Also, there are some medics that are either set in their ways or have had so much civvy paramedicine shoved down their necks they forget they are in the military and the environments are quite different.
Phew.
MM
Removal - there will be a protocol for removal. Essentially, it`s don`t actually remove it, but loosen it under control with a pressure dressing =/- QC in place in place first and after about an hour. It stays on though, as something might happen that blows the clot and it starts again, and therefore it can be tightened quickly.
Marking - I see where you`re coming from Janes - crack crack by your ear is a bit of a deterrent to getting the head marked, but I think something should be done and sooner than later - if the poor slob goes unconscious, someone needs to know it`s there, especially if it`s gotten itself hidden.
Packing wounds - the new kit list for the TCCC bags is going to include a PriMed dressing. It`s vaccum compressed Kerlix for packing wounds and will be taught as part of the bleeding control package.
Lastly, I don`t take too much offence to the paint brush over the CFHS (you should hear me some days), however, as our first aid courses at the moment are essentially off the shelf what is taught to civvies, that happens. There are alot more people out there than you think though, that are closing the TK circle and alot of them are in fact physicians. Problem is getting the first aid instructors out there to think outside the box and not by their rote learning - alot of them know only what they are taught on their courses and they aren`t given alot of leeway as to what they are allowed to teach. Also, there are some medics that are either set in their ways or have had so much civvy paramedicine shoved down their necks they forget they are in the military and the environments are quite different.
Phew.
MM
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JANES said:
You didn't mention anything about rounds flying, just tourniquet application. There are role 1, 2, and 3 personnel reading
this, so we should be clear on proper doctrine before shortcuts. Not every tourniquet will be at the FEBA.
Had there been a problem, this thread wouldn't be here. I can assure you that all the staff here are capable of
putting together their own thoughts without copying your post. If you like, we can discuss the rest of this via
private mail. Alternately, you are free to discuss your concern with any of the staff here.
OM
speaking of old school, isn't writing on the forehead a little old school? If you feel that strongly about it, why not create a sticker or tag, or fluorencent pink tape that can be quickly, effectively and positively applied where it will be seen, make space for the time maybe even punch/cut outs, ever seen a Deer tag?Issue one in the same packaging as the TK? My pen never works when I need it most. grease pencil melts, not everyone has a sugical marker. Pencil works if you press hard enough, but the scar will be there for a LONG time
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JANES said:
I'm not sure what your arguing here. We're discussing tourniquets, not
Afghanistan, not just tourniquets on a current operation or TCCC.
I only mentioned FEBA because you seem to be blinded by TCCC and
care under fire. If your going to claim
,
then your discussing full spectrum. As I mentioned, all roles. If your
going to train, train correctly.
