Introduction

Despite the varying opinions on tourniquets, they have developed a tight grip on society. The first tourniquet dates back to the 6th century B.C. when Hindu physicians utilized them to prevent the spread of snake venom in Greek soldiers (6). While civilians may have heard of this technique used in literature or other forms of media, tourniquet usage for slowing the spread of venom is not recommended. It has been disproven by research (7). The Romans introduced tourniquet usage for bleeding management; however, one of their top surgeons, Galen, criticized the tourniquet, believing it pushed more blood out of the wound (6).  

If your specialty is trauma, emergency, operating room (OR), or transport nursing, you may never encounter a tourniquet. However, unless you deal with it frequently, you can comfortably apply one when the time comes. Because tourniquets must be applied quickly and accurately, there is ample room for user error and severe complications resulting from mistakes. This course has been designed to educate learners regarding tourniquet application and management.  

What is a Tourniquet?

Before discussing the application process for tourniquets, one must know what a tourniquet is. A tourniquet is a medical device to control or stop the bleeding from a severe wound or amputation to one or more extremities. The name is derived from the French word tourner, meaning to turn (6). Tourniquets may be commercially manufactured or created using everyday objects such as belts, clothing, rope, or seat belts with sticks or poles to tighten them. The Committee for Tactical Emergency Casualty Care (C-TECC) has recommended using a commercially manufactured device over others due to a 40% ineffective rate in makeshift devices. (5).

Because traumatic situations occur daily, the medical and civilian communities must be prepared to apply a tourniquet correctly. Depending on state and county regulations, EMS personnel, such as paramedics and emergency medical technicians (EMTs), are trained to use them. While not country-wide, many law enforcement officers have seen the benefits of carrying them and have undergone training to develop this skill; since law enforcement is one of the first groups to arrive on the scene, having them be able to apply tourniquets can increase survival rates.

The American College of Surgeons created the STOP THE BLEED® program to train civilians on the importance of proper tourniquet application and how to do so (1). Providers should be aware that the first line of treatment for severe bleeding is direct pressure, which can be performed quickly while another provider sets up a tourniquet (4).

Current Practice with Tourniquets

In trauma and emergencies, nurses may be trained to apply a tourniquet. It is best to follow hospital policy and the state Board of Nursing guidelines to determine if using a tourniquet is within your scope of practice. Even if it is outside your scope, it is best to understand the application procedure and how to assist the provider and assess the patient post-application.

Tourniquets should be quickly placed when a major hemorrhagic event is noticed. The Emergency Nurses Association (ENA) and other emergency medicine organizations have adjusted the primary trauma assessment, changing the standard airway, breathing, and circulation portion to reflect the importance of immediate hemorrhage control. They now advocate for providers to perform an across-the-room assessment and determine if lifesaving bleeding management needs to be performed first. The “MARCH” mnemonic, which the U.S. Department of Defense utilizes to determine treatment priority, consists of Massive hemorrhage, Airway, Respirations, Circulation, and Head injury/Hypothermia (4).

Indications and Application of Tourniquets

As mentioned previously, the only indication for tourniquets is severe bleeding due to a traumatic amputation or injury to one of the four extremities that cannot be controlled by direct pressure and elevation (1). While all tourniquets are not made equal and should be applied according to the manufacturer’s instructions, there are a few general application guidelines and steps.

The ENA recommendations on application (4, 8):

• Tourniquets should be placed as close to the amputation or injury as possible, but refrain from placing them over joints
• The tourniquet should be painful to the patient if applied correctly; this confirms that arterial bleeding is controlled
• Ensure that the time of application is legibly written on the tourniquet and documented in the patient’s electronic medical record (EMR) to keep track of the “ischemic time.”
• The report should give this information every time the patient’s care is transferred to another provider.
• A time limit of two hours is the maximum limit a tourniquet can be left on a patient.
• Ensure you follow the time limits set by the device’s manufacturer and the provider’s orders.

If one correctly applied tourniquet does not control the bleeding, it is recommended that a second one be applied two inches or less above the first one (4). Inappropriately applied tourniquets, often too loose, may increase bleeding instead of decreasing it. This is because the pressure the tourniquet applies can push blood out through the open wound, an area of lesser resistance.

It is easier for the blood to flow out of the wound than to press through the pressure of the tourniquet. Providers must ensure that the first tourniquet is applied per the manufacturer’s instructions before adding additional ones to decrease patient complication risks. If the tourniquet needs to be released for any reason,  it should only be done once a provider is at the bedside to control any bleeding due to the removal (4).

Complications of Tourniquets

Over the centuries, tourniquets have received their fair share of criticism. You may recall that the Roman surgeon Galen did not like using tourniquets. During the US Civil War, tourniquets received a bad reputation due to the lack of antibiotics, inexperienced application, and transport delays to the field hospitals. These factors led to increased amputation cases, causing many to believe that tourniquets were the cause. World War I brought similar opinions; however, World War II introduced a new view, citing that tourniquets helped save lives by decreasing blood loss and reducing overall complications (6).

With the proper training and education, tourniquet application can be a lifesaving benefit to society. However, as with everything in life, there are risks of complications developing as a result of usage. Modern medicine and technology have certainly changed how tourniquets are manufactured, applied, and managed. Despite those advancements, patients who have tourniquets applied can be at risk of severe complications.

Nerve injury, pressure sores, necrosis, and thrombosis are some potential problems that can arise. Decreasing the time a tourniquet remains applied can help lower the chances of these complications. Compartment syndrome is a rare occurrence that accompanies severe injury and swelling. Without the ability to remove the extra fluid caused by swelling secondary to the injury, the pressure grows and presses on the veins, nerves, and arteries. This eventually causes complete occlusion and total loss of limb if not treated (8).

Rhabdomyolysis can be a primary complication due to the tourniquet or a secondary complication of compartment syndrome. Since there is a decreased or complete stop of blood flow to cells past the tourniquet, these cells become oxygen-deprived, and eventually, the cells will die. After death, muscle cells release creatine kinase (CK), myoglobin, electrolytes, lactate dehydrogenase, and aldolase into the circulatory system, which reaches the kidneys and causes acute renal failure (2). (

Despite these risks, the mortality rate of those who had a tourniquet applied was significantly lower than that of those who did not. It is important to note that estimating the survival benefit and elements to compare each group was challenging. Some comparators were the use of blood transfusions; fewer were pointed out in the tourniquet group, and there were few adverse effects of tourniquet usage (3).

Parts and Troubleshooting

Various manufacturers produce tourniquets. Therefore, reviewing each type and listing each manufactured device’s components would be challenging. A few essential parts apply to every tourniquet on the market. They all have a strap, usually two inches wide, designed to fit around the affected limb. Some of these are adjustable to fit either arm or leg, while others come premade to fit one or the other. The next part is what makes the tourniquet tighten. Whether it be a windlass/stick, pneumatic/air, buckle, or dial, each tourniquet has a mechanism for tightening it (5).

It is imperative to be able to troubleshoot any complications that may arise while using a tourniquet quickly. A patient could bleed out in minutes if an issue is not resolved promptly. Knowing how to apply and remove a tourniquet is essential before you are in a situation where a patient needs one. Ensure you obtain proper hands-on training from your facility or the device manufacturer. It is also necessary to know what to do if the device fails or the bleeding continues after application.

As mentioned above, tourniquets should only be removed if there is a proper team at the bedside to mechanically or surgically manage the blood loss. If the bleeding continues despite the initial tourniquet application, the device may need to be tightened or reassessed to ensure proper application per the manufacturer’s instructions. The next step would be to apply a second tourniquet two inches above the first (4). If all methods fail—including direct pressure and elevation—immediate surgical intervention or cauterization is indicated.

Conclusion

Tourniquets have unfortunately become a required device in today’s society. With the growing war on terror, the home front has become a battlefield in unexpected ways. Concerts, movie theaters, malls, and schools are now the targets of unsolicited attacks, leaving everyday civilians and medical providers to act as army medics.

Because of the severity of injury and loss of life that can occur, everyone should be educated on proper tourniquet application before using one in an emergency. Nurses in the emergency or trauma setting, including out-of-hospital areas, should advocate for tourniquets in their workplace if they are not there and receive proper education.

While most tourniquets are used in the prehospital setting, it is always possible that they may need to be applied during the initial resuscitation phase in the emergency/trauma room. If the patient undergoes elective surgery, the surgeon and their team may use a tourniquet in a controlled environment.

Any patient who is actively hemorrhaging in one or more of their extremities is a candidate for a tourniquet. Patients should be educated on the device’s potential risks; however, this may be a decision made by providers due to the other injuries a patient may have that prevent them from giving informed consent.

Nurses need to ensure that, in addition to the correct application, they know the proper documentation process for tourniquet application in their charting system. This should include the time of application, time of removal if applicable, and reapplication time. Nurses should know troubleshooting strategies when tourniquets are part of the patient’s treatment. They should ensure adequate support from the entire care team and provide additional methods of treating blood loss if the tourniquet fails, such as surgery or bedside cauterization.