In regards to the World War II, the Mayo brothers are famously quoted as saying, "The only victor in war is medicine." This no more true than in the prevention of exsanguination with tourniquets. In fact, today, fatalities from extremity hemorrhage are far more common from military trauma (9%) than civilian trauma (0.02%). One report by Dorlac et al (J Trauma 2005) found that 50% of 14 civilian cases were due to gunshot wounds, with the remaining due to stab wounds and lacerations, and that 8 might have benefited from tourniquet use. On the other hand, a report by Rasmussen et al out of Operation Iraqi Freedom showed the frequency of vascular trauma to be 6.6% (N=209) with 79% of these injuries involving the vascular of the extremities.
The existence of similar devices dates back to the Greeks. Galen, the famous Roman surgeon, heavily criticized their use as causing more bleeding from wounds. Though this may due to improper use, as recent observations in the orthopedic literature have shown improperly pressurized tourniquets can restrict venous return without impeding arterial input causing increased bleeding from operative fields. One of the earlier known written descriptions of tourniquets can be found in von Gersoff's Feldtbuch der Wundtartzney ("Field Manual of Wound Medicine") published in 1517. By the end of the 16th century, vascular surgery (and thus amputations) were the major indication for tourniquet use. The medieval physician de Chauliac describes "constricting bands for the reduction of pain and control of hemorrhage during amputation."
Use of tourniquets during combat medical care was first described by Etienne Morel in 1674 during the Siege of Besancon, France. The term "tourniquet", derived from the French verb to turn ("tourner") can be attributed to Petit. Petit is also responsible for an improved screw type tourniquet [seen below] introduced in the early 1700s that facilitated use higher up on the leg. Anecdotal history of their use from this point on was far from storied.
While the majority of soldiers in Operation Iraqi Freedom received definitive care for their vascular injuries within the hour, historically, soldiers commonly had much less expeditious care. This was most evident in recent history during the American Civil War. Due to the inexperience of the physicians to traumatic injuries, general lack of field medics, and poor education of soldiers, combat wounded were left on the battlefield for hours, if not days, with minimal if no first aid. Tourniquets placed out of fear for hemorrhage were seldom released at great cost to life and limb. The excessive use (or misuse) of tourniquets during the Civil War led many physicians to vilify their use altogether. During the Battle of Bull Run, Manassas even proclaimed it is "far safer to to leave the wound to nature, without any attempt to arrest the flow of blood than depend upon the common army tourniquet."
Condemnation of tourniquets persisted through the First World War. An excerpt from a British manual from 1918 entitled Injuries and Diseases of War warned that, "the employment of [a tourniquet], except as a temporary measure during an operation, usually indicates that the person using it is quite ignorant both of how to stop bleeding properly and also of the danger to life and limb caused by the tourniquet... If an orderly has applied a tourniquet, it is the duty of the medical officer who first sees the patient to remove it at once, and to examine the limb so as to ascertain whether there is any bleeding at all, and if there is, to use proper measures for its arrest." It was not until the Second World War and the increased use of field medics, that tourniquet use was given its place in the management of exsanguinating wounds. Bailey wrote in his seminal text that tourniquets should be, "regarded with respect because of the damage it may cause, and with reverence because of the lives it undoubtedly saves. It is not to be used lightly in every case of a bleeding wound, but applied courageously when life is in danger."
Their use became increasingly favored during the Korean War. Dr. Hughes, a military surgeon, wrote of their use, "I do not recall ever seeing limb loss as a result of a tourniquet. They were important, even life saving, in Korea. Successful use of the tourniquet depends on what it is made of, and how it is applied." The combination of medics and soldiers trained on their judicious use and "dustoff crews" (US Army medical evacuation helicopter crews) able to quickly evacuate the wounded, led to a dramatic decrease in complications from tourniquet use and the ability to repair otherwise fatal vascular injuries. By the Vietnam War, average time from injury to definitive care dropped to as little as 90 minutes. With the deployment of forward surgical facilities, such as the US Marine Corps' Forward Resuscitative Surgical System, time to definitive care now averages less than 60 minutes.
Translating the military's experience with tourniquets to the civilian world is difficult. Civilian injuries are uncommonly exsanguinating and military injuries are more commonly from blasts. For the vast majority of civilians, penetrating vascular injuries can be managed with direct pressure, elevation, and wound packing. It is rare that injuries require a tourniquet for control of bleeding. There are, however, mass casualty incidents where our streets more closely resemble battlefields, such as bombings and building collapses. In these situations, triaging or moving patients with vascular injuries may present opportunities to use tourniquets to prevent exsanguination and death. The principle of "life before limb" is as true here at home as it is on the battlefield. We must remember this life saving devices when patients are in need and time is of the essence. Here are some simple rule for tourniquet use:
Simple Rules for Tourniquet Use:
1. No patient should exsanguinate because of fear of tourniquet use.
2. Presence of bleeding or amputation does not necessitate tourniquet use; attempt direct pressure, elevation, and pressure dressings first
3. Attempt to place more than 3cm from a wound edge, and never over a joint or clothing
4. Never cover over or bandage a tourniquet; in fact, tell conscious patients to alert every medical provider to its presence
5. Mark and communicate the time a tourniquet is placed
6. Never loosen a tourniquet in the face of present shock, recurrent hemorrhage upon reevaluation, or inability to definitively control the vascular injury
References:
Chambers LW, Rhee P, Baker BC, et al.: Initial experience of the US Marine Corp Forward Resuscitative Surgical System during Operation Iraqi Freedom. Arch Surg 2005, 140:26-32.
Cuadrado D, Arthurs Z, Sebesta J, et al.: Cause of death analysis at the 31st Combat Support Hospital during Operation Iraqi Freedom. In 28th Annual Gary P Wratten Army Surgical Symposium; May 2006; Silver Spring, Maryland Walter Reed Army Institute of Research; 2006.
Dorlac WC, DeBakey ME, Holcomb JB, Fagan SP, Kwong KL, Dorlac GR, Schreiber MA, Persse DE, Moore FA, Mattox KL: Mortality from isolated civilian penetrating extremity injury. J Trauma 2005, 59:217-222.
Longmore T: Treatment of gunshot wounds. In Gunshot Injuries: Their History, Characteristic Features, Complications and General Treatment, with Statistics Concerning Them as They Have Been Met With in Warfare London: Longman's, Green and Company; 1895:770-772.
Mabry RL: Tourniquet use on the battlefield. Mil Med 2006, 171:352-356.
Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL: Echelons of care and the management of wartime vascular injury: a report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. Perspect Vasc Surg Endovasc Ther 2006, 18:91-99.
Richey SL: Tourniquets for the control of traumatic hemorrhage: a review of the literature. World J Emer Surg 2007, 2:28.
Rocko JM, Tischler C, Swan K: Exsanguination in public – a preventable death. Journal of Trauma 1982, 22:635.
Schwartz AM: The historical development of methods of hemostasis. Surgery 1958:604-610.
Tuttle AD: Handbook for the Medical Soldier New York: William Wood and Company; 1926.
from Dr. George Singer
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