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So when we consider tourniquets, there's two variations. There's the homemade and the commercially bought. Now of course, the preference would be using something that's actually designed to work as a tourniquet, but there's going to be times, whether it's wilderness, whether it's out and about in a shop that doesn't have a first aid kit or doesn't have a tourniquet in it, that we may actually need to improvise. If you don't have one in your first aid kit and if you do not have one in your first response kit and you think you could fall into this category of a delayed response of emergency medical services or an arterial bleed, that's hard to control, you should invest in one of these. Because they work. They work really well. So here's the idea on how to use this. You can see that it's leaking through, no matter how much pressure he's putting here, it's not stopping the arterial bleed. Now, one point of interest. Make sure that you're actually putting direct pressure over the actual laceration. I have had calls where they couldn't get it to stop and what happened is the bandaging moved off the point of the injury and they were putting extremely direct pressure on a non-affected part of the arm. And so therefore, the artery was allowed to not have any pressure and of course, it would remain bleeding. And once we recovered it with direct pressure, the bleeding stopped and we were fine. However, in this case, we're gonna say he is putting direct pressure right over the wound and it's still not stopping. Maybe he's got a bleeding issue, maybe he's on blood thinners, it doesn't matter why. The fact is, direct pressure is not controlling it. So it's leaking through. (Let go for a moment while I slip this over.) If that was a problem, I could unlace this all the way and fish it through, around, and then re-lace it. But again, one second of stopping the hold, it's not gonna ruin the whole situation. So the point here now, is that we want to put this tourniquet as close to the bleeding wound as possible. We want to damage as little good tissue as we can, so we're actually gonna put this as close to that site of the injury as possible. Tighten it down and then bring it up and fasten the Velcro. Now, look at this crank that's built into the actual tourniquet, is now tightened. Go ahead and let go. And we're going to tighten it until the bleeding stops. So if we can see a pulsation of blood and we're turning this tightness of the tourniquet handle, you will see it eventually stop bleeding. That's when you know you have enough pressure. I'm now going to fasten it into this resting spot. With the makeshift, you would have to tie those in place and tie another knot, so it doesn't unwind. But with this tourniquet device, it actually has a cradle to hold the stick in. Now look, if I'm actually using this tourniquet appropriately, there will be a delay in the refill of the capillary areas. This is another test. It should be delayed, it should not refill in the length of time it takes to say capillary refill, it should be longer than that. That tells me that the tourniquet is actually working and we're not allowing the blood to go past that point. I'm going to now finish the bandage, tie it off. I'm gonna mark on their hands the time that I actually tied the tourniquet so that the surgeons can know how long this extremity went without oxygenation. This allows them to understand how long it takes for the tissues to die, what the rate of tissue death might be, and whether or not they can start a recirculation process and start regenerating oxygenated blood back into this oxygen-starved area. They can also help with blood clot prevention with certain medications. The point is can we stop the bleeding before the person goes into hypovolemic shock? That's really the idea here. We've just got a lot of good skills now to try to prevent the loss of limb, even with tourniquet use. So if this is a life-threatening bleed, can't be controlled with direct pressure, consider use of tourniquets, and we could actually save this person's limb. But for sure, save their life. While commercial tourniquets have clear advantages - like, ease of use, speed, and reliability - there may be moments when they're not at hand, and therefore necessitate improvisation. To make your tourniquet, gather a sturdy fabric like gauze for instance, or think of a thick necktie, strip or maybe even a piece of t-shirt, roughly two inches wide. This width minimizes tissue damage. Additionally, you'll need a windlass - which is a rigid tool like a pen or stick. Place the tourniquet 2-3 inches above the injury. If the source of bleeding is unclear, go high up on the limb, close to the torso. Wrap your fabric strip around the limb, tie a basic square knot, position the windlass atop, and tie another knot. Then, twist the windlass until the pulse is gone. Essentially, you're tightening the tourniquet until we stop blood flow. If you're unfamiliar with pulse checking, just ensure the bleeding is stopped. Remember, this might be uncomfortable for the patient, but it's a life-saving measure and follows National guidelines. Lastly, secure your windlass, preventing unintentional unwinding. Use the leftover fabric or any suitable material to do this. Tourniquets, simple as they might seem, can be the difference between life and death in a serious hemorrhage. In fact, they are so important, many institutions are now placing bleeding kits right alongside AEDs! But remember, no matter which you opt for, consistent practice is key.
Tourniquets are tight, wide bands placed around an arm or a leg to constrict blood vessels in order to stop blood flow to a wound.
Generally, tourniquets should only be considered if the venous or arterial bleeding incident is life-threatening and if EMS response will be delayed. Other reasons to consider using a tourniquet include:
- If bleeding cannot be controlled by direct pressure
- If the injury is in a location where direct pressure isn't possible
- If multiple people need help with life-threatening injuries and help is limited
- If the scene is unsafe or becoming unsafe
Warning: Tourniquets can be extremely painful. Therefore, it's best to warn the victim beforehand. And tell them why they'll be wearing a tourniquet.
How to Provide Care
If you have a commercial tourniquet, great. If not, anything that you can wrap around an injured limb will work – a piece of rope, an insulated wire. Tie that into a knot and then insert a screwdriver, stick, or pen and begin twisting to tighten.
Your goal in using a tourniquet is to control bleeding before hypovolemic shock sets in due to blood loss.
Pro Tip 1: What may seem like a wound that won't stop bleeding, may just be due to pressure that's not being applied directly over the wound. Bandages can slip. Victims could be in shock and not applying as much pressure as it appears. Make certain that direct pressure truly fails before considering a tourniquet.
We will assume that you've already made sure the scene is safe, and you're wearing latex-free gloves or have thoroughly washed your hands and have determined that the victim is currently not in shock.
- Apply the tourniquet over the extremity where the injury as occurred and a couple inches above the wound to limit tissue damage. Avoid wrapping around joints and follow the manufacturer's instructions.
- Secure the tourniquet as tightly in place as possible.
- Slowly tighten the tourniquet handle until bleeding stops.
- Fasten the handle to the tourniquet.
- Test the victim's toenail or fingernail to make sure you get a delayed capillary response, so you know the tourniquet is working as it should.
- Write down on the victim's dressing what time the tourniquet was applied and give that information to EMS.
The ABCs of Bleeding
Regardless of the bleeding incident, it's important to understand these simplified steps to trauma care response:
A – Alert! Call 911.
B – Bleeding. Find the bleeding injury.
C – Compress. Apply pressure and stop the bleeding by:
- Applying direct pressure with a clean cloth or dressing pads.
- Using a tourniquet.
- Packing or stuffing the wound and then applying pressure.
A Word About Perfusion
Perfusion is how your body's circulatory system delivers oxygen and nutrients to your organs, all of which require varying amounts of perfusion. Your heart, for instance, requires constant perfusion to continue working.
Your brain can last four-to-six minutes without perfusion, before damage begins to set in. Your kidneys can last 45 minutes and your skeletal system about two hours.
What does this have to do with tourniquets?
Pro Tip 2: It's important to keep in mind that limiting perfusion is a bad thing. But when we apply a tourniquet to a victim, that's exactly what we're doing. We're voluntarily cutting off the supply of oxygen and nutrients to a part of someone's body. So, it bears repeating:
Tourniquets should only be considered if the venous or arterial bleeding incident is life-threatening and if EMS response will be delayed.