My major major problem is not with the 99% of mutual benefits that are derived from lessons learned from combat medicine, but specifically the 1% of cases in which TCCC instead poses a major health hazard when certain applications are considered in civilian trauma management. The most major exception by far is the widespread use of TQ applications to save lives in combat while under fire, where there is a much larger degree of risk that is acceptable given the circumstances then when these same techniques are applied in a controlled hospital or ED environment.
If you have access to pubmed or medline feel free to read through all of these, i'm not gonna turn this discussion into a thesis.
The tourniquet. Instrument or weapon?
Sanders R.
PMID: 4715692 [PubMed - indexed for MEDLINE]
Pneumatic tourniquet paralysis. Case report.
Aho K, Sainio K, Kianta M, Varpanen E.
Abstract
We describe a 31-year-old man in whom a paresis and sensory defect of the left arm developed after amputation of the index finger. The operation was performed in a bloodless field, using a pneumatic tourniquet. The sensory defect resolved in two months and the paresis in five and a half months. We consider that direct pressure produced by the tourniquet caused the nerve lesion.
The incidence of large venous emboli during total knee arthroplasty without pneumatic tourniquet use.
Parmet JL, Horrow JC, Berman AT, Miller F, Pharo G, Collins L.
Department of Anesthesiology, Allegheny University of the Health Sciences, Hahnemann Division, Philadelphia, Pennsylvania, USA
"Compared with previous investigations of large venous emboli during total knee arthroplasty with a pneumatic tourniquet, multiple logistic regression analysis discloses a 5.33-fold greater risk of large venous embolism accompanied the use of a tourniquet during total knee arthroplasty. Implications: One third of knee replacements performed without a tourniquet demonstrated large emboli. Reducing marrow cavity invasion did not decrease the release of large emboli. Compared with knee replacement without tourniquet, tourniquet use places patients at a 5.33-fold greater risk of having a large emboli."
Complications are sometimes associated with use of a tourniquet. Among these the most feared, (although very infrequent) is death caused by pulmonary embolism from leg vein thrombi before tourniquet inflation (1) or after tourniquet deflation (2,3). Frequently, hemodynamic alterations are observed after tourniquet release, including hypotension, bradycardia, or even asystole (4). Neurologic deficits (tourniquet paralysis), caused usually by high tourniquet pressure and/or prolonged ischemic times, are sometimes observed (5,6).
Lower limb exsanguination and embolism.
Boogaerts JG.
Department of Anaesthesiology, Charleroi University Hospital Centre, Belgium.
Abstract
We report a case of fatal pulmonary embolism during lower limb exsanguination in orthopaedic surgery. A 76-year-old woman underwent an open fixation of an external femoral condyle fracture one day after injury. Subarachnoidal anaesthesia was performed and Esmarch compression bandages were applied in preparation for tourniquet ischaemia. At this time, the patient lost consciousness, became apneic and collapsed. Resuscitation procedures were instituted and transoesophageal echocardiography revealed pulmonary embolism. In spite of haemodynamic support and thrombolytic therapy, the patient died. Postmortem examination revealed multiple thromboemboli of recent origin in the right heart cavities, in the pulmonary arteries and in the popliteal and tibial veins of the injured leg. Preventive, diagnostic and therapeutic options of this catastrophic event and indications of pulmonary embolectomy are discussed.
Rhabdomyolysis-myoglobinurea: consequences of prolonged tourniquet.
Williams JE Jr, Tucker DB, Read JM 3rd.
Abstract
The authors review the literature on rhabdomyolysis and myoglobinuria and relate these phenomena to prolonged intraoperative tourniquet time in a case report. They alert the practitioner to the clinical manifestations, diagnosis, and treatment of such problems and emphasize the importance of early recognition.
Tourniquets for Surgery: Safety Aspects
Authors: K. B. Cartera; A. Shawa; A. B. M. Telferb
Affiliations: a Department of Clinical Physics and Bioengineering, Glasgow, UK
b Division of Anaesthesia, Glasgow Royal Infirmary, UK
DOI: 10.3109/03091908309032577
The list goes on and on, these are all TQ related major complications that occurred in a controlled hospital setting.
99% of combat med leads to tremendous advances in trauma med. TQ use is an exception and it is a major one, and I wish non combat medics/.civ lay persons would stop thinking that the application of a TQ is a safe and commmonly appropriate treatment, because its simply not. Convential methods are not only safer, but also can be much more effective as well.
Since I doubt your even gonna take the time to read any of those, the majority of those cases (all peer reviewed) and recent resulted in patient fatality as a result of TQ application while in an OR.
Wow your so far out of your lane it isn't funny. So we can agree that that takes care of your nonsense about how "The old thinking of a TQ means loss of limb is bogus. When you take a TQ patient into the local ED they aren't going to sit and wait to have them triaged and be placed into a wheel chair in the waiting room, they are being moved to vascular surgery to have the bleed controlled."
I guess in a way your right, even in a controlled monitored scheduled OR procedure TQ use doesn't always lead to loss of limb, it also often leads to ****ing death.
Moving on to the second part of your nonsense regarding the upcoming rollouts for NR as well as AHA and The "progressive states" actively encouraging tq application immediately. Don't look now, but im again gonna counter your nonsense accusition with more of those pesky facts and evidence. First of all two of my current Dept heads currently sit on the board of the AHA and are are entirely responsible for the upcoming rollouts, obvioulsy as an instructor and a coworker, I think im fairly well versed on whats coming down the pike and whats not, as for NR, one of my former colleagues from school also happen to sit on the NR board of directors as luck would have it, pm your number im sure hed love to speak to you. ok onto more facts.
First a direct quote from the NYS DOH Beureu of Emergency Services guidelines for both my local EMS council, State Emergenncy MED advisory committee who dictates all policy for all Professional rescuers throughout NY as well as REMSCO, REMAC and NR, this if from when I first went through as a -B 9 years ago.
Bleedeing control shock management:
BSI, Direct pressure, manual artial blockage, tourniquet application. note time of application.
Wow how advanced we all were back then. See us Yankees are reel smart n stuff n if someones got a 12 gauge hole in their leg we wrap a tourniquet around it. we also do other crazy stuff like pull people out of fires even though they might hurt their necks instead of letting them sit there and cook to death.
Fast forward to your so called 'modern progessive rollouts'... some examples
The EMJ: Tourniquet use in the civilian prehospital setting
The military have been at the forefront of reintroducing tourniquet use into modern practice. Effective modern combat body armour means that extremity trauma now accounts for the highest anatomical distribution of injury. In the combat setting high velocity penetrating trauma and blast injury are common, resulting in extensive wounding and mangled extremities.14 Soldiers require a rapid system of haemorrhage control which can be self applied while under fire. The requirement for continued use of a tourniquet is then reassessed when the fire‐fight is won.
In contrast in civilian practice the medical practitioner is generally working in a safe environment (not under fire) with early access to definitive care; furthermore, the common mechanisms of non‐battle injury do not normally produce catastrophic external haemorrhage.
Indications for tourniquet use will be rare in the civilian pre‐hospital environment. In the majority of cases external haemorrhage will be controlled by applying a stepwise approach
However, immediate application of a tourniquet may be justifiable in the following examples:
* Extreme life‐threatening limb haemorrhage, or limb amputation/mangled limb with multiple bleeding points, to allow immediate management of airway and breathing problems. (Following treatment of any airway or breathing problems the need for a tourniquet can be reassessed in the circulatory assessment and may be converted to a simple method of haemorrhage control.)
or
* Life threatening limb haemorrhage not controlled by simple methods.
or
* Point of significant haemorrhage from limb is not peripherally accessible due to entrapment (and therefore it is not possible to initiate simple methods of haemorrhage control such as direct pressure).
or
* Major incident or multiple casualties with extremity haemorrhage and lack of resources to maintain simple methods of haemorrhage control.
and
* Benefits of preventing death from hypovolaemic shock by cessation of ongoing external haemorrhage are greater than the risk of limb damage or loss from ischaemia caused by tourniquet use.
CONNECTICUTS groundbreaking new TQ rollout
4.
Treatment of Amputations
a. Stump
(1) Control any active bleeding WITH DIRECT PRESSURE AND
PRESSURE POINTS.
(2) If there is no active bleeding, apply a sterile dressing.
(3) A tourniquet SHOULD NOT BE applied unless the above
methods have failed to control bleeding.
San Joaquin:
Tourniquet - Only authorized models are: SOF Tactical Tourniquet or
the Combat Application Tourniquet (CAT) required by 09/01/08
(the only allowable pressure bar or TQ devices are Izzy or trauma bandages like I have been suggesting.)
and of course the one your couldnt be less informed about THE NR
ARTERIAL TOURNIQUETS
NATIONAL REGISTRY OF EMTS
(NREMT) has made revisions in order to reflect the
PREHOSPITAL TRAUMA LIFE
SUPPORT COURSE (PHTLS)
And what are those shocking new recommendations
PHTLS RECOMMENDATION
If external bleeding from an
extremity cannot be controlled
by pressure, application of a
tourniquet is the reasonable
next step in hemorrhage
control.
Direct hand pressure
Pressure Bandage
Hemostatic Agent
Tourniquet
Indicated:
Lifesaving in modern battlefield
casualty care
Law enforcement, disaster, mass
casualty environments
Extension to civilian prehospital care
Delawares grounbreaking new TQ rollouts from last year...
External Bleeding Protocol:
Apply direct pressure to the hemorrhaging wound
If direct pressure is not adequate to control hemorrhage, a provider may use a
tourniquet for hemorrhage that is anatomically amenable to tourniquet application
and note time of application.
For hemorrhage that cannot be controlled with above, apply approved hemostatic
agent with direct pressure.
When bleeding controlled, may substitute an adequate pressure dressing for
direct pressure.
Contact medical control, in addition to a standard report, provide information on
hemostatic agent and tourniquet as appropriate.
On arrival to a health care facility, a report to the medical staff must include the
type of bleeding, the methods used to control the bleeding, the name of the
hemostatic agent used to control the bleeding, the number of hemostatic agent
dressings used, whether any dressings were lost en route. If a tourniquet was
applied to control hemorrhage, when it was applied and if medical control
requested an attempt to release the tourniquet, what occurred at the bleeding
site.
I think you might start to see my point, or maybe not, TQ has its place, it had its place on my bus 10 years ago and it has its place now and forever,
So just to sum it all up, everything from your first paragraph utter bull****.
This is modern thinking and has proven to save far more lives than the old school method of, direct pressure, direct pressure again, elevate, pressure point and last resort TQ.
So please provide modern research that justifies your response. I guarantee you will not make that statement after reading the research.
This statement is where i'd apreciate your comment....
and finally paragraph 3.
The old thinking of a TQ means loss of limb is bogus. When you take a TQ patient into the local ED they aren't going to sit and wait to have them triaged and be placed into a wheel chair in the waiting room, they are being moved to vascular surgery to have the bleed controlled:shocked2::shocked2::shocked2:
color me shocked please refer to the 2 dozen journal articles referring to emboli/clots etc resulting in death while in Surgery.
TQ's have their place, when your buddy eats a 7.62x39 and missed his saapi and the next one probably has your name on it, ya im going tq, mass cas, everyone gets a TQ before any real triage starts happening, lose a leg from a partial amputation to save a life, sure, but to call decade old standard of care a new lifesaving revolution and all the reports the contrary are bull**** means you sir are just dumb.
But don't worry, if you ever stab yourself in the neck during your sword swalling show, ill slap a tq on you no problem.
