June 2021

The Generalist: Anywhere Emergency Medicine

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Constantine P., PA-C -

Listening to the tourniquet discussion and want to take exception to Dr. Shepherd's recommendation for placing a tourniquet just above the wound. He is correct that you never want to place a tourniquet over a joint but a tourniquet should be placed over a SINGLE bone which means the humerus or femur, especially for laypeople placing tourniquets. Granted that does expose more of the limb to ischemic damage but if the patient is actually bleeding enough to warrant a tourniquet the bleeding is the life threat not the ischemic damage to the limb. I run a mass-casualty preparedness program for the Federal Government and have been a teaching TCCC/MARCH since the 1990's the old paradigm of placing a tourniquet (which I learned as a Navy Corpsman 35 years ago) just proximal to the injury was set aside many years ago in TCCC because there were too many wounds that did not achieve adequate hemorrhage control especially during resuscitation of the patient. Once hemorrhage control has been achieved then, depending on the injury, a pressure dressing could be attempted and release the tourniquet, we teach to leave the tourniquet on the limb just above the elbow or knee in case the pressure dressing fails. I apologize for the "rant..."

Heidi J., MD -

Oh, this is a good point! I'll pass this along to Drs. Shepherd and Newson for their thoughts. Thanks for taking to time to connect.

Heidi J., MD -

Here is Dr. Shepherd's reply:

Thanks very much for your valuable insight.
There is certainly controversy as to the initial location of tourniquet placement and I was certainly taught to place "high and tight" so as to maximise haemorrhage control and improve arterial occlusion against a single bone. There is also an argument for placing a tourniquet as distal as effective and in my practice (where feasible) I do take this approach.

Within the civilian world we are probably seeing different degrees of extremity injury as compared to the military or disaster setting (we also may have the ability for a more nuanced approach due to being more likely to have a single (or small number) of patients).

There is no doubt in my mind that an aggressive approach to haemorrhage control is important. I personally feel that if you have a single patient it may be reasonable to try a tourniquet more distally for tissue preservation, but clearly with multiple patients or severe uncontrolled haemorrhage it makes most sense that first tourniquet is as effective as possible.

Clearly a grey area in the middle remains, this is where we get to make our own decision on scene. I'm sure either initial strategy could be easily justified.

Thanks for the opportunity for our listeners to get even more quality information. The discussion adds deeper detail to this important area (something that can be hard to plan in a podcast).

Take care.

Constantine P., PA-C -

Thank you so much for the discussion. Tourniquet use is still one of the those things that a lot of civilian practitioners have reservations about, I've worked community ERs for the first 12 years of my career. In general, with the exception of an amputation, we have been really encouraging our practitioners overseas to start with a high and tight tourniquet to achieve hemostasis as quickly as possible and then as soon a possible convert it over with wound packing and a pressure dressing. The Joint Trauma System recommendation is to convert tourniquets over within 3 hours.

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ROP 2021 June Full episode audio for MD edition 124:30 min - 136 MB - M4AROP 2021 06 June Individual MP3s 151 MB - ZIPROP 2021 06 June Written Summary 331 KB - PDF

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