Issues related to the use of Tourniquets on the Battlefield.

Clink on this link below to view an interesting article on tourniquet use. We all know that for the last 10 -15 years tourniquets have come back into protocol as the treatment of choice for severe hemorrhage that has failed to controlled by direct pressure and hemostatic gauze. In a hostile situation there might not be time or room to try homeostatic agents so a tourniquet might be the device of choice. This article, among other issues, examines the use of traditional 1 " wide tourniquets as compared to the newer pneumatic tourniquets. One issue identified was the difficulty in generating enough pressure on the average size male thigh to stop severe lower extremity hemorrhage. The other finding was that tourniquets wider than 1" accomplished hemorrhage control with less pressure and therefore had less tissue injury underlying the tourniquet. It seems that newer pneumatic tourniquets accomplished hemorrhage control quicker and with less complications compared to narrower 1 " tourniquets. Pneumatic tourniquets have been used extensively in orthopedic surgery so they have been well tested in regards to hemorrhagic control.  The issue, of course, is how hospital based devices will fare in more rugged conditions. The article mentions one particular device.  The Delpi Military Tourniquet.  See link below. 

The other issues examined was the loosening or removal of a tourniquet prior to surgery and the length of time before tourniquet application results in limb ischemia / damage. It seems that tourniquets applied for under 120 minutes do not result in any additional limb damage.  Removal or loosening is more conversational.  Protocols differ from region to region, so you must follow your regional protocol.  To this author it would seem reasonable to loosen a tourniquet that has achieved hemorrhage control if you are approaching the 120 minute mark and assess for resumption of bleeding.  If bleeding does not resume the tourniquet may remained loosened to prevent limb ischemia. Remember this is just a thought and does not constitute a treatment guideline.  You must always follow your protocols and Medical Directors guidelines. It would be rare in civilian prehospital emergency medicine to be with a patient who has had a tourniquet on for 120 minutes so the issue is probably not that pressing. Of course you might be performing a back county rescue, dealing with a lockdown / active shooter, or confined space situation so the issue should be addressed and protocols developed. 

Link to article

Delfi Emergency Military Tourniquet website

Delphi Military Tourniquet Brochure

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Pelvic Fractures

Pelvis Fractures

Anatomy

The pelvis is a ring-like structure of bones at the lower end of the trunk. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis) that grow together as people age. Strong connective tissues (ligaments) join the pelvis to the large triangular bone (sacrum) at the base of the spine. This creates a bowl-like cavity below the rib cage. On each side, there is a hollow cup (acetabulum) that serves as the socket for the hip joint.

Many digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels that go to the legs pass through it. The pelvis serves as an attachment point for muscles that reach down into the legs and up into the trunk of the body. With all of these vital structures running through the pelvis, a pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage.

Management of Exsangunating Pelvis Injuries

Introduction

Trauma patients who present with unstable pelvic fractures have sustained a high energy injury that is commonly associated with disruption of arteries and veins resulting in major hemorrhage. Patients with pelvic fractures who present in shock have a mortality of 30-50%. When combined with injuries in other body regions such as the abdomen, the mortality rises even higher, approaching 100% in some series. However a systematic multidisciplinary approach to these injuries, directed initially only at hemorrhage control, can lead to significant improvements in survival.

Key Points

Pelvic Injury

• An unstable pelvic injury with signs of shock should be treated as a vascular injury.
• Hemorrhage may be from fractured bone and disrupted veins and arteries.
• High energy trauma is associated with multi-cavity injury, and there may be hemorrhage in the chest or abdomen as well as the pelvis and long bones.

Management

• A multidisciplinary approach is essential. All team members must know their roles and key decisions.
• Appropriate resuscitation maneuvers are as important as hemorrhage control interventions.
• Management of massive transfusion, coagulopathy and hypothermia are vital for success.
• A damage control approach should be adopted for all these patients: do the minimum necessary to save life.