The crucial role of tourniquets in trauma care

May 07, 2022

Matthew D. Sztajnkrycer, M.D., Ph.D., an emergency medicine specialist at Mayo Clinic's campus in Rochester, Minnesota, says two common scenarios come to mind in which he's seen tourniquets save lives:

Motor vehicle or motorcycle crashes. Dr. Sztajnkrycer — often called Dr. Matt — reports that patients arrive with tourniquets after farm and industrial incidents or car and motorcycle crashes have resulted in a partial or complete limb amputation. A tourniquet applied at a traumatic injury scene like this has saved the lives of patients he's treated in the Mayo Clinic emergency department.
'Household misadventures'. Dr. Sztajnkrycer indicates that emergency department patients who've experienced a household misadventure are prevalent as well. The most serious of these injuries — in terms of hemorrhaging — typically involve plate glass windows.

"The brachial artery can sever; they're bleeding to death in their own home," says Dr. Sztajnkrycer. "Someone usually shoves them in the car and drives them to the hospital. The car they rode in is often filled with blood."

In these circumstances, tourniquets are applied by emergency department staff, stemming the blood loss.

Tourniquets' critical role and training for use

Tourniquets have been used in varying forms since the time of Sushruta, an Indian surgeon, in 600 B.C., according to Dr. Saied and colleagues in a Feb. 2015 issue of Iranian Red Crescent Medical Journal. Another instance of early tourniquet use involved Dr. Etienne Morel in the 1674 Battle of Flanders — considered the beginning of modern tourniquets — per a 2007 Emergency Medicine Journal publication by Dr. Lee and colleagues.

Tourniquets have a long but also conflicting history. Some have called tourniquets "an instrument of the devil that sometimes saves a life," such as in a 2001 report to The Red Cross by Dr. Coupland and colleagues. More recently, tourniquets have been viewed as invaluable lifesavers provided they are applied appropriately and correctly.

A tourniquet's primary purpose is to stop life-threatening external bleeding, says Dr. Sztajnkrycer. Most such bleeding situations are trauma induced. Emergency medical services regularly use tourniquets today alongside other bleeding control methods. He says tourniquets are useful because it's difficult to maintain consistent pressure for an extended time using simple pressure; and tourniquets both avoid disrupting a forming clot and allow safer patient transport.

Tourniquets often are misunderstood and misapplied, says Dr. Sztajnkrycer, noting a recent study published in Journal of Trauma and Acute Care Surgery that suggests that they're misused up to one-quarter of the time.

"Having a tourniquet is great," he says, "but knowing how to use it is way better."

Some tourniquet mishaps Dr. Sztajnkrycer has witnessed include:

Placing the tourniquet in the wrong location
Using a tourniquet in the wrong situation
Applying the tourniquet's band too loosely
Breaking the windlass
Loosening the tourniquet after the bleeding is controlled

The big fear with tourniquets is that limiting blood supply to the limb can result in amputation. This does not appear to be the case in most civilian tourniquet applications, notes Dr. Sztajnkrycer. Having a tourniquet in place for two or fewer hours — the time in which most patients can get to a hospital — should not have any ill effects beyond those caused by the injury requiring the tourniquet. It typically takes at least 4 to 6 hours for tourniquets to cause harm.

For correct tourniquet use, he says one must decide if:

The bleeding is life-threatening
The location is suitable for tourniquet use
Another bleeding control method, such as hemostatic gauze, would better fit the situation

To help equip the public to properly use bleeding control methods such as tourniquets to stop life-threatening bleeding, The American College of Surgeons (ACS) Committee on Trauma administers the Stop the Bleed program.

Improvised tourniquets

Unfortunately, sometimes an individual may encounter massive bleeding and not have a modern commercial tourniquet on hand. Dr. Sztajnkrycer says he's often asked about improvised tourniquets, such as belts, scarves or neckties.

He indicates that a 2017 study on law enforcement tourniquet use published in Prehospital Disaster Medicine showed that improvised tourniquets failed six out of seven times. Despite this low success rate, Dr. Sztajnkrycer says improvised tourniquet use is worth learning, as it can save lives.

"An improvised tourniquet is better than nothing, but you need to understand the physics," he says. "We need to be better about teaching improvised tourniquet techniques."

How to be prepared to use a tourniquet correctly

Tourniquet use requires training because it isn't always intuitive, per Dr. Sztajnkrycer. Spending a morning learning how to put on a tourniquet is probably not enough. It's not uncommon for lay providers to be taught how to use them and then forget how to do so a couple of months later. This is especially true given that the tourniquet is almost always used under stress and brains have difficulty processing under extreme stress.

"Tourniquet application is not as easy as people think," he says. "You think it is a simple device, but to get it right and tight, and use the windlass appropriately, there are nuances."

Dr. Sztajnkrycer suggests that reviewing tourniquet application at least quarterly is crucial for preparedness. He asserts that the best way to reinforce how to do something such as using a tourniquet is to teach others and troubleshoot their mistakes.

"If you teach 15 to 20 people tourniquet application regularly, training others to be force multipliers, you reinforce it for yourself," he says.

Knowing how to downgrade from a tourniquet to hemostatic or pressure dressing also is crucial for treating hemorrhaging trauma patients, and he suggests that tourniquet training for medical providers — as opposed to the general public — should incorporate this skill.

Beyond training a facility's trauma team members, he encourages tourniquet training for others working near the trauma bay who don't have specialized trauma knowledge, such as phlebotomists, radiation technologists or emergency department desk representatives.

"Train an extra pair of hands to put on tourniquets so you can spend your time on more-advanced skills," he says.