How Tight to make a Tourniquet
 

I enjoy this subject because when the adrenaline is flowing in the thick of things, it is sometimes forgotten how tight is toooooooo tight.
Remember, just tight enough to slow/stop the bleeding!!! Generally, the artery spasms and shuts itself off but the vein stays wide open and flowing...the vein is a LOW pressure system therefore not much pressure is needed.

Picture #1 is an arm that another hospital wrapped up (pseudo-tourniquet) and sent to us..pt. had a badly lacerated brachial artery, significant hemorrhage and forgot their 'basic' skills
Picture #2 is the same arm, close up of the mottled hand...tooooo tight

*****pics too big, I'll shrink them and post later

here are the pics......

Ouch!

That would leave a mark.

How long before permanent damage, given it's way too tight?

Terry

6 hours of warm ischemia leads to likely permanent damage to the nerve, muscle and other tissues

I had a stud ask me on Monday if they should release and re-apply. He said he was taught 5 minutes for every 15 on. :munchin

I'd heard that too, in the past, but I think the release time was less than 5 min. I've also heard that at one time a tournaquet was no longer to be used.

Just repeating heresay

the new dictum is no release because every drop of blood is precious and to release risks bleeding....hence why it is applied 'just tight enough' to slow then stop the blood flow. If you whip it tight there is a chance (a really good chance) it is toooooo tight.
We don't teach the apply and release trick anymore...I'll check TCCC from Frank Butler to see what they are teaching the active duty guys.

Interesting swatsurgeon. For what is worth, when I was in and we were being crossed trained by our team medics, we were taught basically what I've read in this thread. That being apply the tourniquet (although, didn't look like the one in the pic. A rolled up piece of clothing or whatever and a stick or something similar). Anyway, just enough to stem the bleeding and we were taught, once applied, leave it alone til a medic or Dr took over. That was some 30 odd years ago, and I'm certainly not medic qualified. Merely relating some old training.

Ive always thought there were risks of reperfusion ie metabolic/gas exchange (increased lactate, potassium, and Co2) even the rare pulmonary embolism.

I did some checking and apparently this isnt as risky as I thought?

ccrn

the metabolic 'washout', i.e., reperfusion injury gets worse the longer the tourniquet is on. This is why we release it in "controlled" circumstances, i.e., where there is plenty of equipment, meds, personnel, etc to resuscitate the patient from the effects of the reperfusion injury. ...best in a hospital, worst in the field
One thing Doc T and I learned about in our fellowship was how to attenuate/reduce the potential for the reperfusion injury. I have done it in the field when dealing with a trapped limb that sooner or later we'll get free but know the 'washout' of lactic acid, potassium, etc will be significant once we free them
I promised Bill Harsey I would show a leg I freed with his T-2 folder...I had to cut through the hamstrings to get a guy off of an auger/post hole digger....I forgot a scalpel and I forgot the Gigli saw blade (it's a pull type flexible blade held by two handles) for the field amputation. Our 'kit' was disassembled and I rushed to get out to the field. They flew me out there and thankfully the femor (thigh bone) was very broken but the muscle belly was still attached.
Thank goodness I always carry that knife!!!!!!!!!!!!
Pic 1 leg in bag, just cut him off
pic 2 tourniquet on thigh, where I cut was the bottom muscle under the thigh
pic 3 the amputated leg torn to shreads, foot torn up boot still on.
BTW he's going great, I'm going to skin graft the stump next week.

Swatsurgeon, Thanks for directing my attention here and sharing the story, I'm glad the knife did the job.

I wish your patient the best possible recovery.

Outstanding work Doc. When I was a sprat, I saw a young man get his leg caught in an auger - not that bad, but impressive none the less. Great case of getting the job done with the tools at hand.


Mr Harsey, is that a first for one of your blades that you know of?

Yes.

I also think that Swatsurgeon's skills would have allowed him to do the job with broken glass if needed.

Is this the knife sir?


http://img.photobucket.com/albums/v6...n/T2Harsey.jpg

that's the one....Harsey T-2 folder