Medicine:Tourniquet

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Short description: Medical device
A combat tourniquet commonly used by combat medics (military environment) and EMS (civilian environment).

A tourniquet is a device that is used to apply pressure to a limb or extremity in order to stop the flow of blood. It may be used in emergencies, in surgery, or in post-operative rehabilitation.

A simple tourniquet can be made from a stick and a rope, but the use of makeshift tourniquets has been reduced over time due to their ineffectiveness compared to a commercial and professional tourniquet. This may stem the flow of blood, but side effects such as soft tissue damage and nerve damage may occur.

Types

There are three types of tourniquets: surgical tourniquets, emergency tourniquets, and rehabilitation tourniquets.

Surgical tourniquets

Tourniquet
Tourniquet cuff with a releasable application handle stabilizer

In silicone ring tourniquets, or elastic ring tourniquets, the tourniquet comes in a variety of sizes. To determine the correct tourniquet size, the patient's limb circumference at the desired occlusion location should be measured, as well as their blood pressure to determine the best model.[1] Once the correct model is selected, typically two sterile medical personnel will be needed to apply the device. Unlike with a pneumatic tourniquet, the silicone ring tourniquet should be applied after the drapes have been placed on the patient. This is due to the device being completely sterile.[2] The majority of the devices require a two-man operation (with the exception of the extra large model):

  1. One person is responsible for holding the patient's limb. The other will place the device on the limb (extra large models may require two people).
  2. Application:
    1. The elastic ring tourniquet is placed on the patient's limb. If placed on a hand or foot, all fingers or toes should be enclosed within the tourniquet.
    2. The handles of the tourniquet should be positioned medial-lateral on the upper extremity or posterior-anterior on the lower extremity.
    3. The person applying the device should start rolling the device while the individual responsible for the limb should hold the limb straight and maintain axial traction.
    4. Once the desired occlusion location is reached, the straps can be cut off or tied just below the ring.
    5. A window can be cut or the section of stockinet can be completely removed.
    6. Once the surgery is completed the device is cut off with a supplied cutting card.

The elastic ring tourniquet follows similar recommendations noted for pneumatic tourniquet use:

  1. It should not be used on a patient's limb for more than 120 minutes, as the interruption of blood flow may cause cell damage and necrosis.
  2. The tourniquet should not be placed on the ulnar nerve or the peroneal nerve.
  3. The silicone ring device cannot be used on patients with blood problems such as DVT, edema, etc.
  4. A patient suffering from skin lesions or a malignancy should use this type of tourniquet.[3]

In knee replacement

The current body of evidence suggests if a tourniquet is used in knee replacement surgery, it probably increases the risk of severe side effects and postoperative pain.[4] The evidence did not show any clear benefit on patient function, treatment success, or quality of life.

Emergency tourniquets

Main page: Medicine:Emergency tourniquet

Silicone ring auto-transfusion tourniquet

The silicone ring auto-transfusion tourniquet (SRT/ATT/EED), or surgical auto-transfusion tourniquet (HemaClear), is a simple to use, self-contained, mechanical tourniquet that consists of a silicone ring, stockinet, and pull straps that results in the limb being exsanguinated and occluded within seconds of application.[5] The tourniquet can be used for limb procedures in the operating room, or in emergency medicine as a means to stabilize a patient until further treatment can be applied.[6]

Combat application tourniquet

The combat application tourniquet (CAT) was developed by Ted Westmoreland. It is used by the U.S. and coalition militaries to provide soldiers a small and effective tourniquet in field combat situations. It is also used in the UK by NHS ambulance services, along with some UK fire and rescue services. The unit utilizes a windlass with a locking mechanism and can be self-applied. The CAT has been adopted by military and emergency personnel around the world.[7]

An open hardware-based 3D printing project called the Glia Tourniquet[8] (windlass type) enables emergency tourniquets to use distributed manufacturing to make them for $7 in materials. [9] Concerns over quality control of distributed manufactured tourniquets was partially addressed with an open source testing apparatus.[10] The tourniquet tester costs less than $100 and once calibrated with a blood pressure monitor, the built-in LCD displays the measuring range of the tester (0 to 200 N), which can be used to test the validation of all tourniquets..[10]

History

Petit tourniquet engraving from 1798

During Alexander the Great’s military campaigns in the fourth century BC, tourniquets were used to stanch the bleeding of wounded soldiers.[11] Romans used them to control bleeding, especially during amputations.[12] These tourniquets were narrow straps made of bronze, using only leather for comfort.[12]

Sir Gilbert Blane advocates the issue of a tourniquet to each man in battle.

In 1718, French surgeon Jean Louis Petit developed a screw device for occluding blood flow in surgical sites. Before this invention, the tourniquet was a simple garrot, tightened by twisting a rod (thus its name tourniquet, from tourner = to turn).


In 1785 Sir Gilbert Blane advocated that, in battle, each Royal Navy sailor should carry a tourniquet:

It frequently happens that men bleed to death before assistance can be procured, or lose so much blood as not to be able to go through an operation. In order to prevent this, it has been proposed, and on some occasions practised, to make each man carry about him a garter, or piece of rope yarn, in order to bind up a limb in case of profuse bleeding. If it be objected, that this, from its solemnity may be apt to intimidate common men, officers at least should make use of some precaution, especially as many of them, and those of the highest rank, are stationed on the quarter deck, which is one of the most exposed situations, and far removed from the cockpit, where the surgeon and his assistants are placed. This was the cause of the death of my friend Captain Bayne, of the Alfred, who having had his knee so shattered with round shot that it was necessary to amputate the limb, expired under the operation, in consequence of the weakness induced by loss of blood in carrying him so far. As the Admiral on these occasions allowed me the honour of being at his side, I carried in my pocket several tourniquets of a simple construction, in case that accidents to any person on the quarter deck should have required their use.[13][14][15][16][17][18][19][20][21]

In 1864, Joseph Lister created a bloodless surgical field using a tourniquet device. [22][23] In 1873, Friedrich von Esmarch introduced a rubber bandage that would both control bleeding and exsanguinate. [24][25] This device is known as Esmarch's bandage. [25] In 1881, Richard von Volkmann noted paralysis can occur from the use of the Esmarch tourniquet, if wrapped too tightly. [22] Many cases of serious and permanent limb paralysis were reported from the use of non-pneumatic Esmarch tourniquets. [24][25][22][14][15][16][17][18][19][20][21]

After observing considerable number of pressure paralysis with non-pneumatic, elastic, tourniquets, Harvey Cushing created a pneumatic tourniquet, in 1904. [22][26] Pneumatic tourniquets were superior over Esmarch’s tourniquet in two ways: (1) faster application and removal; and (2) decrease the risk of nerve palsy. [22]

In 1908, August Bier used two pneumatic tourniquets with intravenous local anesthesia to anesthetize the limb without general anesthetics. [27]

In the early 1980s, microprocessor-based pneumatic tourniquet systems were invented by James McEwen. [28][29][23] These modern electronic pneumatic tourniquet systems generally regulate the pressure in the tourniquet cuff within 1% of the target pressure and allows real-time monitoring of the inflation time. [29] Modern pneumatic tourniquet systems include audiovisual alarms to alarm the user if hazardously high or low cuff pressures are present, automatic self-test and calibration, and backup power source. [23]

In the 2000s, the silicon ring tourniquet, or elastic ring tourniquet, was developed by Noam Gavriely, a professor of medicine and former emergency physician.[30][31] The tourniquet consists of an elastic ring made of silicone, stockinet, and pull straps made from ribbon that are used to roll the device onto the limb. The silicone ring tourniquet exsanguinates the blood from the limb while the device is being rolled on, and then occludes the limb once the desired occlusion location is reached.[1] Unlike the historical mechanical tourniquets, the device reduces the risk of nerve paralysis.[32][33] The surgical tourniquet version of the device is completely sterile, and provides improved surgical accessibility due to its narrow profile that results in a larger surgical field. It has been found to be a safe alternative method for most orthopedic limb procedures, but it does not completely replace the use of contemporary tourniquet devices.[34][35] More recently the silicone ring tourniquet has been used in the fields of emergency medicine and vascular procedures.[31][36]

Most modern pneumatic tourniquet systems include the ability to measure the patient’s limb occlusion pressure (LOP) and recommend a tourniquet pressure based on the measured LOP to set safer and lower tourniquet pressures. [23] Limb occlusion pressure is defined as "the minimum pressure required, at a specific time by a specific tourniquet cuff applied to a specific patient’s limb at a specific location, to stop the flow of arterial blood into the limb distal to the cuff.” [23]

After World War II, the US military reduced use of the tourniquet because the time between application and reaching medical attention was so long that the damage from stopped circulation was worse than that from blood loss. Since the beginning of the 21st century, US authorities have resuscitated its use in both military and non-military situations because treatment delays have been dramatically reduced. The Virginia State Police and police departments in Dallas, Philadelphia and other major cities provide tourniquets and other advanced bandages. In Afghanistan and Iraq, only 2 percent of soldiers with severe bleeding died compared with 7 percent in the Vietnam War, in part because of the combination of tourniquets and rapid access to doctors.[citation needed] Between 2005 and 2011, tourniquets saved 2,000 American lives from the wars in Iraq and Afghanistan.[37] In civilian use, emerging practices include transporting tourniquetted patients even before emergency responders arrive and including tourniquets with defibrillators for emergency use.

There are currently no standards for testing tourniquets although there have been several proposed devices to ensure that the appropriate pressures could be generated including many commercial systems and an open source system that can be largely 3D printed.[38] This would allow distributed manufacturing of tourniquets.[39][40]

See also

References

  1. ↑ 1.0 1.1 "Silicone ring tourniquet versus pneumatic cuff tourniquet in carpal tunnel release: a randomized comparative study". Journal of Orthopaedics and Traumatology 14 (2): 131–5. June 2013. doi:10.1007/s10195-012-0223-x. PMID 23361654. 
  2. ↑ "The effect of sterile versus non-sterile tourniquets on microbiological colonisation in lower limb surgery". Annals of the Royal College of Surgeons of England 93 (8): 589–90. November 2011. doi:10.1308/147870811X13137608455334. PMID 22041233. 
  3. ↑ "Use of a new exsanguination tourniquet in internal fixation of distal radius fractures". Techniques in Hand & Upper Extremity Surgery 13 (4): 173–5. December 2009. doi:10.1097/BTH.0b013e3181b56187. PMID 19956041. 
  4. ↑ "Tourniquet use for knee replacement surgery". The Cochrane Database of Systematic Reviews 2020 (12): CD012874. December 2020. doi:10.1002/14651858.cd012874.pub2. PMID 33316105. 
  5. ↑ HemaClear Instructional Video for the Orange Model (Large) on YouTube
  6. ↑ EmergencyEED
  7. ↑ "Testing of Battlefield Tourniquets". Advanced Technology Applications for Combat Casualty Care 2004 (ATACCC) Conference. St. Petersburg, FL.: US Army Institute of Surgical Research. 16–18 August 2004. http://www.usaccc.org/ataccc/index.jsp. 
  8. ↑ EXERCISE CAUTION WITH CLINICAL USE Tourniquet, Glia Free Medical hardware, 2023-07-22, https://github.com/GliaX/tourniquet, retrieved 2023-07-29 
  9. ↑ "The Glia Tourniquet Project" (in en). https://glia.org/pages/the-glia-tourniquet-project. 
  10. ↑ 10.0 10.1 "Distributed manufacturing of an open-source tourniquet testing system". HardwareX 15: e00442. September 2023. doi:10.1016/j.ohx.2023.e00442. PMID 37457304. 
  11. ↑ "Reviving a Life Saver, the Tourniquet". New York Times. January 19, 2014. 
  12. ↑ 12.0 12.1 "Thigh tourniquet, Roman, 199 BCE-500 CE". sciencemuseum.org.uk. July 2009. https://collection.sciencemuseumgroup.org.uk/objects/co86342/thigh-tourniquet-roman-199-bce-500-ce-tourniquet. 
  13. ↑ Observations on the diseases incident to seamen. London: Joseph Cooper; Edinburgh: William Creech. 1785. pp. 498–499. 
  14. ↑ 14.0 14.1 "Pulmonary Embolism After Application of a Sterile Elastic Exsanguination Tourniquet". Orthopedics 38 (12): e1160-3. December 2015. doi:10.3928/01477447-20151123-08. PMID 26652340. 
  15. ↑ 15.0 15.1 "Tourniquet paralysis". The Australian and New Zealand Journal of Surgery 44 (2): 124–8. May 1974. doi:10.1111/j.1445-2197.1974.tb06402.x. PMID 4533458. 
  16. ↑ 16.0 16.1 "The pressure distribution under tourniquets". The Journal of Bone and Joint Surgery. American Volume 67 (3): 433–8. March 1985. doi:10.2106/00004623-198567030-00014. PMID 3972869. 
  17. ↑ 17.0 17.1 "The tourniquet in surgery". The Journal of Bone and Joint Surgery. British Volume 44-B (4): 937–43. November 1962. doi:10.1302/0301-620X.44B4.937. PMID 14042193. 
  18. ↑ 18.0 18.1 "Ischaemic lesions of peripheral nerves: a review". Journal of Neurology, Neurosurgery, and Psychiatry 14 (2): 76–87. May 1951. doi:10.1136/jnnp.14.2.76. PMID 14850993. 
  19. ↑ 19.0 19.1 "The arterial tourniquet". Annals of the Royal College of Surgeons of England 65 (6): 409–17. November 1983. PMID 6357039. 
  20. ↑ 20.0 20.1 "Tourniquet paralysis syndrome". A.M.A. Archives of Surgery 68 (2): 136–44. February 1954. doi:10.1001/archsurg.1954.01260050138002. PMID 13123650. 
  21. ↑ 21.0 21.1 (in en) The Tourniquet Manual — Principles and Practice | Leslie Klenerman | Springer. Springer. 2003. doi:10.1007/b97532. ISBN 9781852337063. https://www.springer.com/gp/book/9781852337063. 
  22. ↑ 22.0 22.1 22.2 22.3 22.4 Kragh, John F.; Swan, Kenneth G.; Smith, Dale C.; Mabry, Robert L.; Blackbourne, Lorne H. (2011-07-22). "Historical review of emergency tourniquet use to stop bleeding". The American Journal of Surgery 203 (2): 242–252. doi:10.1016/j.amjsurg.2011.01.028. ISSN 0002-9610. http://dx.doi.org/10.1016/j.amjsurg.2011.01.028. 
  23. ↑ 23.0 23.1 23.2 23.3 23.4 Noordin, Shahryar; McEwen, James A; Kragh, Colonel John F; Eisen, Andrew; Masri, Bassam A (December 2009). "Surgical Tourniquets in Orthopaedics". The Journal of Bone and Joint Surgery-American Volume 91 (12): 2958–2967. doi:10.2106/jbjs.i.00634. ISSN 0021-9355. http://dx.doi.org/10.2106/jbjs.i.00634. 
  24. ↑ 24.0 24.1 Saied, Alireza; Ayatollahi Mousavi, Alia; Arabnejad, Fateme; Ahmadzadeh Heshmati, Afshin (2015-02-18). "Tourniquet in Surgery of the Limbs: A Review of History, Types and Complications". Iranian Red Crescent Medical Journal 17 (2). doi:10.5812/ircmj.9588. ISSN 2074-1804. http://dx.doi.org/10.5812/ircmj.9588. 
  25. ↑ 25.0 25.1 25.2 Austin, M. (1963-05-01). "THE ESMARCH BANDAGE AND PULMONARY EMBOLISM". The Journal of Bone and Joint Surgery. British volume 45-B (2): 384–385. doi:10.1302/0301-620x.45b2.384. ISSN 0301-620X. http://dx.doi.org/10.1302/0301-620x.45b2.384. 
  26. ↑ Prevoznik, Stephen J. (1970-02-01). "Injury from Use of Pneumatic Tourniquets". Anesthesiology 32 (2): 177–177. doi:10.1097/00000542-197002000-00025. ISSN 0003-3022. http://dx.doi.org/10.1097/00000542-197002000-00025. 
  27. ↑ Stevens, Donald S. (July 2005). "Bier Block With Steroid for CRPS". Regional Anesthesia and Pain Medicine 30 (4): 409. doi:10.1097/00115550-200507000-00015. ISSN 1098-7339. http://dx.doi.org/10.1097/00115550-200507000-00015. 
  28. ↑ McEwen, J. A. (1981). "Complications of and improvements in pneumatic tourniquets used in surgery". Medical Instrumentation 15 (4): 253–257. ISSN 0090-6689. PMID 7300701. https://pubmed.ncbi.nlm.nih.gov/7300701. 
  29. ↑ 29.0 29.1 Radulovic, Aleksandar; Cerovac, Sonja (2023-10-26). "The history of tourniquet use in limb surgery". International Orthopaedics. doi:10.1007/s00264-023-06018-y. ISSN 0341-2695. http://dx.doi.org/10.1007/s00264-023-06018-y. 
  30. ↑ "Unit of Physiology and Biophysics- Noam Gavriely". http://tx.technion.ac.il/~medicine/faculty/Gavriely.htm. 
  31. ↑ 31.0 31.1 "Auto-transfusion tourniquets: the next evolution of tourniquets". Open Access Emergency Medicine 5 (5): 29–32. 6 December 2013. doi:10.2147/OAEM.S39042. PMID 27147871. 
  32. ↑ "Pain and paraesthesia produced by silicone ring and pneumatic tourniquets". The Journal of Hand Surgery, European Volume 36 (3): 215–8. March 2011. doi:10.1177/1753193410390845. PMID 21131688. 
  33. ↑ "Surgical tourniquets in orthopaedics". The Journal of Bone and Joint Surgery. American Volume 92 (5): 1318–22; author reply 1322-3. May 2010. PMID 20439692. 
  34. ↑ "Nondrainage decreases blood transfusion need and infection rate in bilateral total knee arthroplasty". The Journal of Arthroplasty 29 (5): 993–7. May 2014. doi:10.1016/j.arth.2013.10.022. PMID 24275263. 
  35. ↑ "The silicone ring tourniquet in orthopaedic operations of the extremities". Surgical Technology International 23: 251–7. September 2013. PMID 23860930. 
  36. ↑ "A sterile elastic exsanguination tourniquet is effective in preventing blood loss during hemodialysis access surgery". The Journal of Vascular Access 14 (2): 116–9. April–June 2013. doi:10.5301/jva.5000107. PMID 23080335. 
  37. ↑ "Trauma medicine has learned lessons from the battlefield". The Economist. 12 October 2017. https://www.economist.com/news/international/21730145-civilian-doctors-are-saving-more-lives-after-terrorist-attacks-copying-their-military. 
  38. ↑ Liu, Dawei; Kulkarni, Apoorv; Jaqua, Victoria F.; Cole, Christina A.; Pearce, Joshua M. (2023). "Distributed manufacturing of an open-source tourniquet testing system" (in en). HardwareX 15: e00442. doi:10.1016/j.ohx.2023.e00442. PMID 37457304. PMC 10338363. https://linkinghub.elsevier.com/retrieve/pii/S2468067223000494. 
  39. ↑ Stout, James. "3D-printed tourniquets could save lives in conflict zones" (in en-US). https://www.newscientist.com/article/2322015-3d-printed-tourniquets-could-save-lives-in-conflict-zones/. 
  40. ↑ Loubani, Tarek (2022-03-25). "Reinventing 3D printed tourniquets for Ukraine is a mistake" (in en). https://trklou.medium.com/reinventing-3d-printed-tourniquets-for-ukraine-is-a-mistake-be2937f0ad65. 

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