The remote terrain and serrated peaks surround you in their rugged embrace as you settle into base camp for the evening. Coupled with the companionable warmth of your travel group, the surrounding vistas only reinforce why you enjoy traveling to the remote bounds of the backcountry. Then it comes. The high pitched, goosebump inducing, banshee wail from one of your group members. The next second, the beatific moment is flushed down the toilet, landing you face first into the surreal, panic inducing, whirlpool of managing a life threatening bleed you never prepared for.
You make your way mechanically towards the incessant wails on wooden legs. Immediately you notice a small group formed around someone lying on the ground, your mind quickly registers it as John. Panic wafts off the group as they struggling to stem the flow of blood pulsating from his lower leg. Your mind pinballs erratically as you take in the scene. In a moment of frozen panic, you note the forgotten ax as it lies next to a small stack of wood, the rapidly expanding pool of blood and the slick hands pressing futility against a mangled calf as blood oozes through their clenched white fingers.
What do you do?
We are rarely prepared to manage the worst case scenario as these events may only occur once in a lifetime. However, the number one cause of death outside the hospital from traumatic injuries, that aren't immediately fatal, have been linked directly to loss of blood, especially from extremity injuries. With that being said, it is important that one understands the basic types of bleeding that can occur and the current standards on approaching bleeding control.
Types Of Bleeds:
This image identifies three different types of bleeding that can occur from traumatic injuries. Most injuries will include a mixture of one or more of the these types depending on the severity of the injury and the structures involved.
Arterial Bleeding: Blood will typically be bright red in color and will initially have a strong pressure. One may visualize pulsating that corresponds with each heartbeat. Blood loss can be rapid from arterial injuries. Larger artery injuries like the brachial artery (found in bicep) or femoral arteries (found in the thigh) can result in death in less than 5 minutes. This will often require the placement of a tourniquet or advanced steps like wound packing to stem the flow and prevent loss of life.
Venous Bleeding: Blood will typically be a deeper red. One will often notice a continuous oozing coming from the wound. As the venous system operates on a much lower pressure, one will not visualize pulsating. These types of bleeds can still be life threatening if a large enough vein has been injured. Direct pressure or pressure dressings such as an Emergency Trauma Bandage or Israeli Bandage will normally work well to control this type of bleed. Large venous injuries may require tourniquet placement.
Capillary Bleeding: Think pinpricks, superficial cuts or simple abrasions. These are not life threatening by themselves. They will clot off without any need for emergent intervention. Bandaids will be your friend.
Over the years tourniquets have gained in popularity with much of the decades-old dogma being pushed aside by new evidence based studies fueled by the military, and to a lesser degree, civilian-based medical organizations. With much of the data obtained from the wars in Iraq and Afghanistan, the military has witnessed first hand the significant impact widespread training and usage of these devices can have when used properly on severely injured patients.
The information we provide below references windlass style tourniquets such as the SAMXT, C.A.T of SOFT-W as shown above. During our training and real world experiences, these products still offer the best advantage during in field usage due to their ease of application, durability and reliable function. Alternative options, specifically variable pressure pneumatic device such as the EMT tourniquet, are superior options for the hospital and surgical arenas as they provide bleeding control at much lower occlusion pressures and help prevent additional tissue, vessel and nerve injuries due to reduced pressures and shearing forces.
Tourniquets should be used as the first line device for life threatening bleeds from any extremity unless the wound location or injury pattern does not allow for proper tourniquet placement
How To Apply
Identify the source of bleeding
Place tourniquet 2-3 inches above the site of bleeding. If unable to find bleeding site rapidly, place tourniquet at the highest point on extremity possible. Do not place the tourniquet over joints or hard objects like keys, wallet, or other items which will inhibit proper tourniquet function.
Next, pull the tail through the device's buckle system till all slack has been removed and secure. You can check to ensure you have proper belt tension by trying to slide three fingers under the webbing. If you are able to easily slide your figures under the webbing you need to pull additional tension on the belt and resecure. The SAMXT uses a Trueforce® buckle and velcro; the C.A.T a single eyed buckle and velcro, and the SOFT-W a metal buckle tensioning system. As each device varies in design and function it is important to familiarize yourself with how this step is to be accomplished with your specific device.
Once the proper tension has been achieved, twist the windlass till bleeding is controlled. This should typically take 2-3 full twists. If you have to twist the tourniquet 5+ times you did not remove enough slack during the previous step. Return to step 4 and remove additional slack before again progressing to this step. Only do so if you notice poor bleeding control in conjunction with excessive windlass rotations. An additional tourniquet may be needed if adequate compression has been achieved and bleeding persists.
Once bleeding control has been achieved, place the windlass into the catch device. Pull any additional tail through the catch device, as applicable, and secure the time tab over both the windlass and tail.
Extra Tourniquet Info:
(Keep in mind that lower, and from time-to-time upper extremities, may require 2 tourniquets to be placed due to a larger mass. If this is required, place the second tourniquet just above the one previously placed or just below if room does not permit.)
If a second tourniquet cannot be placed correctly due to limited space, one can use wound packing or pressure dressings to help achieved additional hemorrhage control. (Check out our upcoming blog on wound packing for more info.)
Commercial tourniquets have been proven safe and effective for use in the prehospital setting. Current teaching shows that they can be left in place for 2 hours without any notable signs of long-term injury in most patients when correctly applied.
Ensure any tourniquet being used has a width of at least an 1.5 to 2+ inches. Thinner material such as rope, shoe strings or thin vulcanized rubber should not be used! These materials can cause severe tissue damage and poor bleeding control due to their narrower widths. These products inflict significantly greater shearing forces to the underlying tissue and structures which in turn cause increased injury.