TCCC - The 10 most common tourniquet errors

The 10 most common mistakes are:

#1: The tourniquet is only applied after all other measures for bleeding control (compression, pressure bandage) have been unsuccessful.

This may be correct in a civilian setting according to S3 guidelines or SOPs, but in a preclinical tactical situation it is simply not helpful. Here time equals circulating volume. Especially in the phases "Care under Fire" and "Tactical Field Care", the tourniquet is the first choice for critical extremity bleeding.

#2: The tourniquet is applied too close to the wound

According to Trema guidelines, the tourniquet is applied one hand's breadth distal to the armpit or groin. There is the mnemonic "high and tight."
In the TCCC guidelines, during the "Tactical Field Care" phase, application 2-3 inches (or 5-7 cm) above the source of bleeding is recommended. In a civilian setting, it is also referred to as one hand's breadth above the source of bleeding.

Especially under stressful operational conditions, some misapplications have occurred. Example: the tourniquet was applied on the knee, which is not compressible.

Due to stress stability, TREMA recommends in its guidelines that the tourniquet be applied one hand's breadth distal to the armpit or groin.

Also to be considered is that if an artery is torn by the injury, it can retract deep proximally into the extremity. By applying the tourniquet only one hand's breadth above the source of bleeding, I may not even block the artery, so the wounded person may continue to bleed into a partially tied thigh, for example.

#3: Use of improvised tourniquets (belts, clothing)

As experience reports show, improvised tourniquets do not generate effective compression. Tests have shown that 99% of improvised tourniquets without a windlass could not achieve effective compression. Also, 30% of improvised tourniquets with a windlass could not achieve effective compression of the artery. Of the materials chosen as improvised windlasses (e.g., pens), 75-80% broke before they could achieve sufficient compression.

Also, improvised tourniquets require a much longer time to apply. So again, it's a time vs. circulating blood volume factor.

#4: The wound is not dressed after applying a tourniquet

Time management or the phases of care are of particular importance here. Of course, in the "Care under Fire" phase, we do not dress the wound immediately after applying the tourniquet. In the "Tactical Field Care" phase, when working through the algorithm at C - Circulation, the injury should be dressed with as germ-free a material as possible using bandaging material (e.g., Israeli or Olaes bandage).

In the case of an amputation injury to the major long bones (femur, tibia), it is also possible to continue bleeding from the bone. Bleeding from the bone cannot be controlled with a tourniquet. Dressing the amputation injury with a compression bandage reduces or stops further blood loss from the bone. Additionally, the TREMA guidelines recommend immobilizing the affected extremity to promote blood clotting and minimize further blood loss.

#5: No proper "pre-tightening" when applying the tourniquet

The so-called "pre-tightening" is of great importance. It describes the tightest possible application of the tourniquet around the extremity before working with the windlass.
Explanation: There is another band in the tourniquet's Velcro strap that builds up compression when working with the windlass. However, this band is finite and creates a function-limiting bulge around the windlass without having achieved effective compression on the extremity. If I can fit three fingers between the tourniquet and the extremity after tightening and securing the Velcro strap, my "pre-tightening" is not sufficient.

Important: The "pre-tightening" should not create prior compression on the extremity.

#6: The tourniquet is not secured

To secure the tourniquet, one of the two tri-rings is used on the SOF-T Wide, and on the CAT, it is hooked into the clip and secured with Velcro. If not secured, the windlass can move freely, and the compression can easily come undone.

It is also important to note that the wounded person suffers increasing pain due to the hypoxia of the tied tissue. If the patient is conscious, there is a possibility that they could release the tourniquet themselves to alleviate their pain. For this reason, securing the tourniquet and constant reassessment are very important. Attention should also be paid to the field of analgesia in this regard.

#7: Application of the tourniquet over joints or pockets

We briefly addressed the application of tourniquets over joints at #2. Obviously, effective compression of the artery cannot be achieved when a tourniquet is applied over a joint.

In the police and military fields, leg or upper arm pockets are often used. From writing instruments to bandage packets, all sorts of equipment are stored there. Existing pockets, leg holsters, or protective gear should be removed before applying a tourniquet, as effective compression of the artery is also not possible with objects between the extremity and the tourniquet. The items between the extremity and the tourniquet act as a buffer and have a negative impact on compression.

#8: Tourniquet is not applied horizontally

Anatomically, it is only natural that at a certain point near the groin or armpit, the tourniquet cannot be applied horizontally. If a tourniquet is applied diagonally to the extremity, effective compression may initially be achieved. However, if the wounded person is transported/repositioned, the tourniquet may slide, thereby loosening, as the band is longer due to the greater angle, compared to a horizontal application. Consequence: The patient (perhaps unnoticed) starts bleeding again.

To also eliminate this source of error, TREMA recommends applying the tourniquet one hand's breadth distal to the armpit or groin. Here, incorrect application due to anatomical characteristics is almost excluded.

#9 The tourniquet is not prepared and easily accessible at all times

As North American Rescue has already pointed out, it makes little sense to carry the CAT tourniquet in plastic wrap. The wrap should be removed and the tourniquet should be carried in the same way it was removed from the packaging. The windlass is in the secure clip, the securing Velcro is open, and the tourniquet is ready for self-application.

The tourniquet should be attached to the jacket, vest, or plate carrier in a location that is easily visible from the outside and easily accessible with both hands. Two tourniquets should be included in personal equipment. One is to be worn on the vest, and the second can be carried in the Individual First Aid Kit (IFAK). The IFAK and the tourniquet carried on the 2nd line are intended for self-application or for application by the wearer on someone else. The wounded person is initially treated with their own carried materials (TQ, IFAK).

Carrying equipment and the tourniquet only in the car or in a backpack can lead to a significant loss of time when needed. Early application of a tourniquet is extremely important. Statistics show that the survival rate with the application of a tourniquet only when symptoms of hemorrhagic shock were present was only 4%.

#10 Opening the tourniquet temporarily to allow tissue perfusion

A tourniquet can be left in place for up to two hours without risks. Apart from the increasing hypoxic pain of the wounded person, there are hardly any dangers involved. If tourniquets are left in place for more than two hours, temporary damage to muscles and nerves can occur. From about 3.5 hours onwards, more extensive temporary damage can occur. If a tourniquet has been left in place for longer than 5 hours, opening it can have serious consequences on the body. Toxins have accumulated at the tourniquet site over time, which can flood into the body when it is opened. This myth can actually be dangerous! A tourniquet left in place for this long should only be opened under medical supervision and in a clinic with an Intensive Care Unit (ICU).

Statistics from Americans during Operation Iraqi Freedom in Iraq show that out of 499 wounded individuals and 862 applied tourniquets, only 1.5 percent had peripheral neuropathies. There was also no loss of limbs due to ischemia.

In summary: The tourniquet was applied for a reason - a life-threatening arterial bleeding in the extremities. Opening the tourniquet would allow much-needed volume to leave the hemodynamic system at the injury site. It therefore contradicts the original purpose of the tourniquet application.

The video presentation by TACMed Australia featuring Dr. Dan Pronk and Jeremy Holder.

The article first appeared on TREMA Nord. We are allowed to share this valuable information with kind permission.

TREMA online: www.trema-europe.de