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The Annoyed Man wrote: Fri Feb 22, 2019 12:45 pm

crazy2medic wrote: Wed Feb 20, 2019 10:14 pm Interesting, but typically arteries are fairly deep! Only a few places are they near the surface! What I was taught that a tourniquet is last ditch effort to keep the patient from bleeding to death! When placing a tourniquet you are sacrificing the limb below the tourniquet!

Apparently, you can maintain a tourniquet in position for several hours before risking the limb. I was just now reviewing the notes I wrote down back then (April of 2016) during Caleb Causey’s 2-day Medic 1 class, and he told us that you can leave a windlass type tourniquet (i.e. CAT or SOFTT-Wide) on for up to 6-8 hours before tissue starts dying. The principle thing is that, once applied, it should be left in place until medical personnel with better equipment remove it. The beauty of the windlass-type tourniquet is that you can tighten it only as tight as needed, without overtightening it. You crank on the windlass until the arterial bleeding stops, and no further than that. My guess as to why tissue doesn’t die sooner is that this method allows for some collateral circulation to still provide some blood to the distal tissues, without routing it through the damaged major artery....but that’s just my guess.

Anyway, 6-8 hours is how long you can leave a tourniquet on before tissue death occurs. And beyond that, I’d rather lose a limb to amputation than to bleed out into the dirt. So, I could be wrong, but if that’s the yardstick, my guess is that most people would take amputation over death too.

I’ve also been told that having a tourniquet applied to a limb for REAL hurts like the very devil. But pain ain’t nothin’ but a thang, and it’s transient. I’ll take the pain for as long as I have to, if I know that there’s a morphine light at the end of the pain tunnel. In class, we did put tourniquets on one another and tighten them down, but not to the point of loss of pulse in that extremity. It was more about the mechanics of application than actually achieving hemostasis, but even so, it was pretty uncomfortable.

Crazy2medic, does that information more or less match your own training?

Abuse to the dog aside, when I was watching that particular video, I thought that this new clamp would probably not work to stop a femoral bleed. It would be extremely valuable for penetrating trauma to tissues - chest, abdomen, arms, legs, etc. - but if someone has a clipped femoral or brachial artery, they’re gonna bleed out without a tourniquet.

Pretty much! I've been a paramedic for better than 12yrs, what they drilled into us is that a tourniquet was not to be applied lightly, you needed to believe that it was the only way to save the patient! I took a patient from a little hospital to a ft worth hospital, which was an hour trip! Patient an elderly man had fallen thru a glass coffee table and one of the glass shards penetrated to and Nicked the femoral artery mid thigh, the ER doctor was incompetent to say the least, after her two attempts to stop the bleed she threw her hands up and walked out of the room saying I can do this here! I place a pressure dressing on his thigh, told my partner help me get this as tight as possible, we did and made the trip to Ft Worth without so much as a drop coming through the bandages!

The Annoyed Man wrote: Fri Feb 22, 2019 12:45 pm

crazy2medic wrote: Wed Feb 20, 2019 10:14 pm Interesting, but typically arteries are fairly deep! Only a few places are they near the surface! What I was taught that a tourniquet is last ditch effort to keep the patient from bleeding to death! When placing a tourniquet you are sacrificing the limb below the tourniquet!

Apparently, you can maintain a tourniquet in position for several hours before risking the limb. I was just now reviewing the notes I wrote down back then (April of 2016) during Caleb Causey’s 2-day Medic 1 class, and he told us that you can leave a windlass type tourniquet (i.e. CAT or SOFTT-Wide) on for up to 6-8 hours before tissue starts dying. The principle thing is that, once applied, it should be left in place until medical personnel with better equipment remove it. The beauty of the windlass-type tourniquet is that you can tighten it only as tight as needed, without overtightening it. You crank on the windlass until the arterial bleeding stops, and no further than that. My guess as to why tissue doesn’t die sooner is that this method allows for some collateral circulation to still provide some blood to the distal tissues, without routing it through the damaged major artery....but that’s just my guess.

Anyway, 6-8 hours is how long you can leave a tourniquet on before tissue death occurs. And beyond that, I’d rather lose a limb to amputation than to bleed out into the dirt. So, I could be wrong, but if that’s the yardstick, my guess is that most people would take amputation over death too.

I’ve also been told that having a tourniquet applied to a limb for REAL hurts like the very devil. But pain ain’t nothin’ but a thang, and it’s transient. I’ll take the pain for as long as I have to, if I know that there’s a morphine light at the end of the pain tunnel. In class, we did put tourniquets on one another and tighten them down, but not to the point of loss of pulse in that extremity. It was more about the mechanics of application than actually achieving hemostasis, but even so, it was pretty uncomfortable.

Crazy2medic, does that information more or less match your own training?

Abuse to the dog aside, when I was watching that particular video, I thought that this new clamp would probably not work to stop a femoral bleed. It would be extremely valuable for penetrating trauma to tissues - chest, abdomen, arms, legs, etc. - but if someone has a clipped femoral or brachial artery, they’re gonna bleed out without a tourniquet.

TAM,
I believe the current TCCC standard is still 6-8 hours before serious risk to the extremity occurs, and if I recall correctly it's the lactic acid (& other bad stuff) concentration that builds up in the limb after extended application (2+ hours, or >6 hours in some literature) that necessitates in-hospital removal (I'd need to research updated literature before speaking definitely on it; something about renal failure), plus the rapid drop in blood pressure when the limb re-perfuses if not controlled. Of course, you also wouldn't want to blow the clot that may have formed by releasing it too soon before getting to the ER.

In TCCC, the first phase of care is called 'Care Under Fire'. As the name implies, you're still in contact so the only treatment administered (other than returning fire...) is to apply a TQ for major hemorrage. (In TECC, the civilianized version of TCCC, this phase is called 'Direct Threat Care', or the 'Hot Zone').

One circumstance where it's acceptable to remove the TQ (it's actually now recommended, especially if evac time is expected to be over 2 hrs) is when re-evaluating the casualty in the 'Tactical Field Care' phase (this is the second phase of TCCC) if you realize that a TQ is not actually necessary (ie, that major hemorrage isn't present, or the bleeding is controlled; the casualty isn't in shock; & a pressure dressing is more appropriate). This is called 'converting' the TQ; applying a pressure dressing (or packing with gauze, then pressure dressing) then slowly loosening the TQ to ensure the bandage doesn't soak through. If it does soak through, then obviously the TQ was needed. If in doubt, just leave it alone. Also, for traumatic amputations the TQ must not be removed. (ETA: also, don't convert a TQ that's been applied for more than 2 hrs).

Regarding tightness, the windlass should be tightened until the distal pulse is absent. If there's still a distal pulse, compartment syndrome is a risk (this might not be as big of a deal with civilian transport times, but I'm not sure. I knew a guy that nearly bled out back when TQ's were still 'taboo', & before CAT TQs were invented. His teammates applied an improvised TQ, which saved his life, but the scar from cutting his leg open to drain the fluid was about as horrendous as the injury. He was air evac'd from the demo range on Ft Bliss to the ER, so it wasn't an extended care scenario).

Throughout care, & every time the casualty is moved, the TQ must be re-assessed to ensure it's still tight. Part of the body's response to trauma is swelling/muscle tension; after awhile (as early as 1 minute) this swelling might go down, which will cause the TQ to fail if it isn't re-tightened (or, during movement it gets bumped/dragged & loosens up).

Sorry for the thread drift... To get back on topic, I'm wondering if the IT Clamp would also be effective in lieu of a chest seal, especially if there's only an entrance wound??

Mike S wrote: Fri Feb 22, 2019 11:15 pm
Sorry for the thread drift... To get back on topic, I'm wondering if the IT Clamp would also be effective in lieu of a chest seal, especially if there's only an entrance wound??

I would say no, without direct evidence or experience. Chest seals allow for one way release of air pressure. IT Clamp approximates the wound. It is not designed for release of pressures. Chest seals allow for air pressure to be released to, hopefully, inhibit tension pneumothorax.

When I was about 14 years old, (late 1960s early 1970) a person slipped near a swimming pool; at a motel in Houston and 1 of his legs went through a plate glass door and the other leg went through a plate glass window next to the door. Arteries in both legs were severed. He lost a LOT of blood, passed out etc etc.
It's a delicate balance between bleeding out and losing a life and losing a limb. I think in scouts way back then we were taught to loosen the TK every 5 minutes for a few seconds to prevent loosing a limb, which I did. Now they say leave it on and don't loosen it, they've saved limbs during wars that had TKs on for hours..

Anyway we only had 1 tourniquet in the first aid kit for 1 leg, and I "borrowed" a drunk guy's wide belt from a drunk's pants laying on a table by the pool. The Ambulance arrived nearly 40 minutes later.
Over 60 years later, that man has both legs, large scars, but walks fine, and owns one of the largest carpet cleaning companies in Las Angeles California. We talked on the phone last year.