Backcountry Safety: Tourniquets
This article was published in the Backcountry Safety Column of the "Hunt Alaska" Magazine, Spring 2016.
Story by Jon Hunt.
Life or Limb? The use of tourniquets is riddled with historical controversy, scientific research, and superstition. For centuries they have been applied in numerous applications including surgery, battlefield wound care, emergency medical services, disaster relief, and most recently, terrorism response scenarios. Over the 20+ years that I have conducted safety training programs, the standard of care on the use of tourniquets has fluctuated drastically. The intent of this short article is to inform the reader of the most current data and rationale behind tourniquet use.
Recent military conflicts as well as terrorism response (i.e. Boston Marathon) have had a profound impact on our understanding of trauma and the corresponding use of arterial tourniquets. Although significant research has been done, the topic remains controversial. The most compelling data appears to be from studies completed at the U.S. combat support hospital in Baghdad (2006). Starting in 2006, the facility had 499 patients, for whom 862 tourniquets were applied to 651 limbs. Of those soldiers for whom tourniquets were applied, no limbs were lost due to tourniquet use. The study concluded that damage to the limbs was minor in light of the major survival benefits. Keep in mind these soldiers are typically very healthy people in their 20’s. They typically received definitive medical treatment within two hours.
This research, joined with data from recent terrorism events, appears to be a major contributor to recent tactical medicine standards that are starting to overflow into urban medicine.
Why all the controversy? Historically, many negative outcomes are associated with tourniquet use, including: muscle/nerve injury, ischemia, gangrene, amputation, compartmental syndrome, and even death. This appears especially true when tourniquets are left in place too long (2+ hours), released outside of definitive medical care, improvised (usually slow to apply or too narrow), used unnecessarily, and used incorrectly (loosened, slipped, malfunctioned, or placed distal of the wound). The clinical studies of the U.S. combat support hospital in Baghdad have helped to shed new insight on tourniquet use. Research evidenced, “when tourniquets were used after a patient bled excessively, lost vital signs, went into shock, or the tourniquet was applied too late, a soldier’s survival rate was at 10%, whereas early use of a tourniquet led to 90% survival. “Severe hemorrhage from injured extremities continues to be one of the leading sources of preventable death in the battlefield.”
The American College of Emergency Physicians (ACEP) “believes that aggressive hemorrhage control is a critical component of out-of-hospital care.” Significant advancement in trauma patient management, primarily due to advances in tactical medicine from the military medicine has shown that tourniquets have incredible value when used properly and quickly. In addition, Hemostatic Agents (ie. QuikClot gauze) have also become a significant game changer, but we don’t have time to discuss that in this article.
There is a huge difference between trauma patient management in tactical medicine and community-based programs:
The target audience for the American Red Cross, American Heart Association, and the Health & Safety Institute typically experience less frequent cases of severe hemorrhaging than military or tactical medicine. Therefore, their approaches are unique. Patient management in these community programs focus on assessment using the “A.B.C.” acronym --
Starting with the 2010 Guidelines, treatment is directed at C.A.B. -- Compressions, Airway, Breathing. Research has evidenced that chest compressions are the most significant treatment for saving lives in cardiac emergencies. Heart disease is the number one killer of men and women in the U.S., so naturally the focus is on good CPR, especially compressions and prompt AED use. 2015 Guidelines continue this trend of 30 compressions followed by 2 breaths. These programs place little emphasis on looking for bleeding until you get into first aid. An increased emphasis on severe bleeding in some of these programs is starting to place more emphasis on tourniquet use and practice.
Tactical Medical Training
Prior to 2001, direct pressure of a wound on the battlefield was standard procedure. The U.S. Military’s Tactical Combat Casualty Care (TCCC) guidelines now use a tourniquet as the primary treatment for severe bleeding, done prior to direct pressure, pressure points, etc.
This paradigm first stops severe bleeding, followed by other priorities. This model is proven to save lives in combat because severe bleeding is identified as the most preventable cause of death on the battlefield. The Army prehospital trauma life support pneumonic is now “M.A.R.C.H.” --
How is this relevant for hunters? It is not unusual for avid hunters to encounter a trauma patient with perfuse bleeding. This is easily complicated by little or no first aid training or supplies, remote situations, and inclement weather. This is a deadly combination. The loss of blood due to a severe hemorrhage is among the quickest things that will kill you. All of the community-based programs still teach direct pressure as the first treatment in attempt to stop external bleeding. However, you must be able to quickly apply a tourniquet if bleeding is not stopped. Traditional wisdom says only use a tourniquet as a last resort, to save “life or limb”. Now we see that tourniquets are stopping the bleeding effectively, with drastic reductions in amputations and limb damage.
Which Commercial Tourniquet is best?
There are numerous military grade tourniquets that are proven, compact and affordable. Most importantly, consider if the tourniquet can be easily applied to yourself as well as to a buddy. This single factor makes my favorites the:
What If The Bleeding Is Not On The Extremity:
The most current Tactical Medical perspective is simply to use a tourniquet on extremity (arms or legs) as a first choice for severe hemorrhages. If it is bleeding in the creases of the neck, groin, or armpits wounds are now being packed with gauze, preferably a sterile hemostatic z-fold gauze such as QuikClot. In the chest, back or abdomen, no wound packing or tourniquets are ever applied; these people need medical care fast; this often requires prompt surgical intervention.
“No better alternative on the battlefield is proven for stopping bleeding in major limb trauma than tourniquets.” This philosophy is very applicable to hunters. As Dr. Nicholas Senn, founder of the Association of Military Surgeons of the United States, wrote: “The fate of the wounded lies in the hands of the ones who apply the first dressing.”
The benefits of tourniquet application far outweigh the risk. The sooner a tourniquet is applied, the better your chance of survival.
At Frontier Safety and Supply, we often offer CPR/AED, First Aid, and Wilderness First Aid Certifications. An intensive 2-hour training and/or certification in bleeding control are available, focusing on trauma management including tourniquet use, wound packing, airway and hypothermia treatment. We would be honored to help you have a meaningful training experience at your workplace, or for a small group of hunting partners.
 COL John F. Kragh Jr., Military Medicine: Volume 176. “Minor Morbidity with Emergency Tourniquet Use to Stop Bleeding in Severe Limb Trauma: Research, History, and Reconciling Advocates and Abolitionists.” (July 2011): 817.
 Gerard S. Doyle, MD, MPH. Collective Reviews. “Tourniquets: A Review Of Current Use With Proposals For Expanded Prehospital Use.” (2008): 1.
Kragh Jr., 821.
 Thomas J. Walters, PhD. Annals of Surgery, Volume 249, Number 1. “Survival With Emergency Tourniquet Use To Stop Bleeding In Major Limb Trauma.” (January 2009): 1.
 American College of Emergency Physicians, Policy Statement, “Out-of-Hospital Severe Hemorrhage Control." (2014).
 Doyle, 3.
 Cathy Gotschall, Sc.D., Office of Emergency Medical Services, National Highway Transportation Safety Administration. (2014) 1.
 Doyle, 3.
 Walters, 6.
 Dr. Nichlas Penn. National Association Of Emergency Medical Technicians. “Bleeding Control for the Injured, Part 1.” Power Point Training Presentation. (2015).