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Great segment. Could someone comment on the location of tourniquet placement. I see that TCCC recommends 2-3" above the site of bleeding if can be visualized; whereas, some of our trauma surgeons still prefer placement "high and tight" regardless. Is there good evidence one way or another?
Great question! I prefer a couple of inches above the wound for a variety of reasons. That limits the amount of tissue affected. In the rare event of true ischemic injury, this would limit the territory damaged. I don't have trial data, but it would make sense that this would cause less pain and fewer issues when the tourniquet is taken down. With proper exposure of the rest of the limb, I can't think of any real benefit to the old-school "high and tight" method. Extreme scenarios like a mass casualty with inadequate exposure might initially be treated this way, but I see little reason not to be more targeted in the vast majority of scenarios.
I agree with Dan's response. Evidence is scant due to the nature of what would need to be studied. I am a huge fan of reducing TQs altogether or getting them as distal as possible if they can't be reduced. It reduces the tissue ischemia, pain, and reperfusion injury down the line. If life threatening hemorrhage is not controlled with a distal TQ, the wound track isn't clear, or you can't find a wound then "high and tight" is the way to go. Once you know where the bleeding is coming from 2-3" above that site is all you need.
What you do matters.