How to Apply a Tourniquet
Caleb CauseyDescription
The first line of defense against bleeding out of the arms or legs is a tourniquet. The myth that a tourniquet poses a threat to the limb has been debunked by numerous studies. Caleb Causey of Lone Star Medics demonstrates how to apply a tourniquet to an arm or leg and offers tips for efficient tourniquet employment based on his extensive field experience.
Once that threat has been neutralized then you can start rendering aid to yourself. Going back to our scenario, the grocery store their family, I've taken around to the arm. Well, our first line of defense against bleeding out of the arms or legs is a tourniquet. For years there's been this misconception that tourniquets are evil and this bad beast and they're not, okay. We actually have several years of documented studies saying that tourniquets are saving lives. Now that information has come to us at a great expense. So keep that in the back of your mind. However, in our textbooks of EMT in paramedic school and even in medical school they told us, the first thing you do is, if we're bleeding is a direct pressure, then you apply pressure dressing and if that doesn't work then you're gonna elevate the wound. And if that doesn't work then you're gonna do pressure points. And then finally, your last resort if you've tried everything else, use a tourniquet. Well, why are we wasting our time on doing a bunch of things that may or may not work but using a tourniquet? "Oh" well, they tell us because those work. Okay well, let's skip that. We don't have a lot of time for trial and error on the scene or at that site in the grocery store. So tourniquets are your first-line defense against any bleeding of the arms and legs. Now let's talk about how do we actually put on this tourniquet. We've had a softy wide here from Tactical Med Solutions and if I've got been shot in the arm or I have an injury in this arm, I simply, grab hold of this black piece here at the base, the buckle slide it up the arm and try to get up as high as I can. The proper placement of a tourniquet is up as a high as you possibly can but never on a joint. I'm going to cinch up and take up as much as that slack as I possibly can. And the weight of my arm on the tourniquet in my armpit is actually helping me hold that in there and allow me to do that. Once I've taken up all that slack I simply grab the windlass and start turning until all bleeding is controlled. Now that may be one spin, two spins, maybe 30. It depends on everybody's arm. Once you've controlled that bleeding, you simply put it in the anchor there, an anchoring device and don't forget the date and time it, that's just as important. We can leave tourniquets on for up to 68 hours right now. So the medics and the doctors and nurses need to know how long that tourniquet gets been on. That's applying it to arm. Let's say, we've got to apply it now to our leg. I'm gonna reset the tourniquet. Now, preparing a tourniquet for deployment is very very important. The way I like to do it and I recommend is actually we have a few pieces of that tourniquet. We have this tail end and the loop. Well, I wanna make that loop almost as long as that tail end. So that way, if I do ever have to apply it to my hand, excuse me, apply it to my arm or my leg the loop is wide enough but not overly too wide, taking up a lot of time on my arm, also have the buckle. So, once I've made that loop as long as the tail I make sure that my windlass is in line and that locking mechanism is up out of the way. I'm simply gonna fold it back onto itself as such and I can fit that in whatever type of carrying device I've got. Now, to apply the tourniquet to the leg, we can do one of two things. I can either open this loop up and shimmy it up my leg or I can take the buckle and actually undo the buckle and then, apply it up as high as I possibly can, never on a joint and cinch it down and take up as much as that slack as possible. If I can, as a little Pearls of wisdom is to keep this windlass towards the inside or the midline of the body. That's gonna help protect it later during transportation. But right now I'm gonna cinch that up as tight as I can. And then again, start turning it until all the bleeding is controllable. It doesn't matter if it's bright red or if it's a dark red, we need to control that bleeding. So turn it, put it in the locking mechanism and of course date and time it. The other way is to shimmy it up the leg, so again, I'm gonna prep the tourniquet. Be sure to make that loop and the tail match up, fix the windlass, make sure the anchoring device is out of the way. And now I'm ready to deploy it, say, I just wanna go up my leg with it. Well, I can do that. I may have to loosen this up and it may take a little bit more time. Notice I have to lift my leg up get the windlass in the inside, again, cinch it up as tight as I can and then start turning, so all bleeding is controllable locking in the locking mechanism and then date and time it. That's just as important. Remember, they need to know how long that tourniquets been on. Let's talk about placement. Why are we putting the tourniquet in certain positions or certain parts of the body? Well, for one thing, we've got, if you'll think about it, our upper arm here has got one bone. This part of the arm has two bones and every body is developed and made up a little bit different than the other, than the next. So we've got one bone here, two bones here. Well, to make it simple for everybody to remember, well, we just place it up as high as we can. but an anatomically, the reason why is the objective is that tourniquet is to actually occlude and restrict blood flow from going past those and through those arteries and veins. And the best way you can do that is compress it up against the bone, the muscle tissue and also constrict the vein or artery itself. If we move it down farther lower, we've got two bones to compete with and technically could a vein or artery, if we've got those two bones here that vein artery could get pushed and protected between those two bones and when the tourniquet clamps down, it's not including it at all. So we need to put it up as high as we possibly can but never on a joint. Your legs are very similar to your arms. Here we've got one bone, one solid bone. Here, your lower leg, we've got two bones and the same thing can happen there. So that's why we plant up as high as we possibly can. Those veins and arteries running through your legs and your arms, there are a lot larger up here. So again, we're getting more meat if you will and more arteries and surface area to cover up there. That's why we're putting the placement up as high as we possibly can. There are a lot of myths surrounding the tourniquet. And for years we've been told at the laypersons level all the way through health healthcare professionals that the tourniquets were a dangerous thing and there are absolute last resort. And in our textbook it says, okay, direct pressure first. If that fails, then use a pressure dressing. If that fails, then you're going apply pressure points. If that fails then you're gonna go to elevate the limb above the heart. And if you've tried everything else go ahead and apply a tourniquet. Well, in ours, in these scenarios you may not always have time for trial and error to figure out what's working and not. And I always asked, well, why are we doing tourniquet last? "Oh" because it works. Well, why don't we bump that up a little bit? Over the years, there have been a lot of studies on tourniquets and they are working and they are saving lives. Tourniquets can fail, nine times out of 10, the most common reason that they're failing is because there are people are applying them too low in the arms and legs. They think they've got it up high enough and they really don't. So be sure you get it as up as high as possible on the arm or leg. A second reason is binding of the buckle. I've seen my students be in classes, they get in a big hurry and they start binding up that buckle. It doesn't take much for these buckles to bind up if you're not paying attention. So be sure you're training on utilizing that buckle. And then also not taking up the slack, you've got to take up that slack when you're pulling that tail. If you don't take up the slack, you're windlass as you crank it up is gonna eat up all the slack instead of actually compressing and actually trying to occlude that vein or artery. So don't forget, that tourniquet is your first-line defense against any bleeding out of the arms and legs. Also the placement, be sure you place it high up on the arms and legs as well and tourniquets do save lives.
Where can a tourniquet like the one he is using be bought?
Do we still write a "T" on the forehead of the injured?
This video assumes that any responder carrying a tourniquet also has some common sense. Given the rise in the popularity of tourniquets as EDC items, I am not so sure that this is a valid assumption. The statement that a tourniquet is the "first line of defense against bleeding out of the arms or legs" is TOTAL NONSENSE if taken literally. A tourniquet is not appropriate for minor bleeding -- which brings us to two issues. 1. The individual treating the wound needs to have some common sense and make a quick judgement whether to do directly to a TQ, or use some other method to control bleeding. You don't use a TQ when a bandaid would be sufficient -- that much ought to be obvious but the current emphasis towards "always immediately use a TQ" is just as wrong as the advice two decades ago that the TQ is only a last resort. 2. There is an addage: "If your only tool is a hammer every problem looks like a nail." What that means here is that if you only carry a TQ, then you have nearly no choice about treating wounds of the arms and legs and (perhaps more importantly) you have no means of treating wounds anywhere else. The arms and legs represent only about half of the human body. There is a lot of body where a TQ is totally useless.
How to, in case I come across it?
Why not have a small pen that fits inside the tightening "handle" available for using to date/time when the tourniquet was applied? Make it so it snaps or clicks into position so it won't easily come out during handling. What are the chances of having a pen or marker handing when treating a victim with severe arm/leg bleeding?
What type of tq do you recommend and why?
Lone Star Medics, thank you for the informative video, demonstrating TK use with a proven device. As a retired USSF 18D, I agree that TK is the best choice for pre-hospital control of extremity hemorrhage caused by high velocity trauma, which is what your scenario addressed. Here are some scholarly articles supporting TK use. Providing scholarly support to the argument for TK application usually stops the anti-TK arguments, which are usually based on outdated, mythological thought. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660095/ http://www.sciencedirect.com/science/article/pii/S0736467909006386 http://journals.lww.com/annalsofsurgery/Abstract/2009/01000/Survival_With_Emergency_Tourniquet_Use_to_Stop.1.aspx http://journals.lww.com/jtrauma/Abstract/2008/02001/Prehospital_Tourniquet_Use_in_Operation_Iraqi.7.aspx
Lone Star Medic: I don't doubt that tourniquets can be safe, if applied by trained medics using proper procedures. But many viewers of this video do not have medical training, or access to those particular products that you mention. When most people think tourniquet, they envision something like a rope or article of clothing, tied with a knot, and a stick or tool inserted to provide torque when twisting. And you seem to miss my last sentence, which gave an exception for life threatening bleedouts. When creating an instructive video like this one, you have to consider the audience and how they will interpret the information. In this case, there are likely many people who will not understand the finer points and procedures that you have in your mind as basic assumptions.
Anatomically and physiologically speaking; the brain must continue to function in order for the rest of the body to. The body may continue to function without the use of all the other organs, such as the spleen or even other body parts of the body like an arm or a leg. But if the brain stops, everything else stops; immediately. So we need to keep the brain working by feeding it. We feed it by giving it several things such as sugar and oxygen for example. Well if there is no blood left to send that sugar or oxygen to the brain, the body dies; immediately. This is bad. Another reason we no longer use the acronym “ABC” when assessing a patient. Instead we use “CAB” so as to identify and treat moderate to severe external bleeding first (the Circulation part); then assess a patient’s Airway then Breathing… in that particular order. If this still doesn’t make sense, I encourage you to attend a training course that teaches such modern-day techniques and why we do utilize tourniquets as such.
I guess the Committee on Tactical Combat Casualty Care (CoTCCC), over 12 years of combat on two fronts with thousands of injuries and deaths, and a simple understanding of human anatomy and physiology accounts for nothing, Denver? Regarding your reasons you think this is bad advice: 1. Yes if the tourniquet (tq) is applied too tight it can tear tissue instead of occluding blood flow. This happens more often with certain tq's than other brands. I have not been able to find any documented cases of either the CAT or SOFT T Wide causing such an injury. To do so would require a great amount of force and more than likely either one of these two tourniquets would break apart before that could happen. If you are worried about "losing the limb"; please show me any documented case in the history of tq use in a pre-hospital setting where the patient lost a limb due to an extended time frame. Also, let us not forget that if we don't stop the bleeding, then we lose the entire patient. So do we want to lose or do we want to lose big? “Well doctor, we saved the limb… but the patient bled out and died. But hey! We saved the limb.” 2. There are several recent (past 15 years or so) well documented case studies that prove that a tq can remain tight and left on a limb for up to six to eight hours before the concern of necrotic tissue. Granted it is a topic of discussion right now with CoTCC and other healthcare professionals on what pre-hospital protocols should be considered after that initial six to eight hours. Yes, there is a risk of circulating necrotic cells and the toxins related to necrotic tissue/cells throughout the human body resulting from either a penetrating traumatic injury or from tq use past the 6-8hr mark. Not to mention the fact we also risk circulating clots throughout the body. Which can cause pulmonary embolisms and that is bad for the patient. In regards to the old school of thought by "elevating the limb" first; this has proven to be absolutely useless and a complete waste of time on the battlefield. Now we may not be on a battlefield here back home, but bleeding is bleeding. When dealing with moderate to severe bleeding, time and blood are two things we don't have a lot of. The average human adult only has about five to six litters of blood in their body. Once blood has been spilt on the ground, we can’t put it back in the body. Therefore we need to save and maximize as much as we possibly can... as effectively and efficiently as we can.