2/12/2018 TOURNIQUETS, FROM THE BATTLEFIELD TO YOUR BACKYARD Trauma Symposium RICHARD KING, MD, FACEP 01/26/2018 WARNING

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1 TOURNIQUETS, FROM THE BATTLEFIELD TO YOUR BACKYARD 2018 Trauma Symposium RICHARD KING, MD, FACEP 01/26/2018 WARNING T H I S P R E S E N TAT I O N C O N TA I N S S O M E V E R Y G R A P H I C I M A G E S V I E W E R D I S C R E T I O N I S A D V I S E D 1

2 WHAT DO YOU SEE? LETS TALK BLOOD Normal blood volume Adult ~ 5 liters Kids ~ 75 cc/kg Normal blood composition 45% Red Blood Cells 55% Plasma 2

3 LETS TALK RED BLOOD CELLS Red blood cells 45% of blood volume Responsible for oxygen delivery (DO2) LETS TALK OXYGEN DELIVERY BLOOD FLOW (SV X HR) Direct relationship between the amount of red blood cells and O2 delivery DO2= C.O. x Hb x SaO2 x PaO2 3

4 LETS TALK PLASMA Plasma 55% of blood volume Contains CLOTTING FACTORS LETS TALK PLASMA CLOTTING FACTORS IN PLASMA FIBRIN 4

5 FIBRIN - PLATELET CLOT WHAT DO YOU SEE? 5

1674, first reported use by French Army surgeon Etienne Morel HISTORY OF TOURNIQUETS (TQ) French tourner meaning to turn 1874 Lister described use of TQ to obtain a bloodless field in OR Royal Army

6 1674, first reported use by French Army surgeon Etienne Morel HISTORY OF TOURNIQUETS (TQ) French tourner meaning to turn 1874 Lister described use of TQ to obtain a bloodless field in OR Royal Army Medical Corp Journal we are inclined to think that tourniquets are an invention of the Evil One Blackwood M. Treatment of wounds from fire trench to field ambulance. TORNIQUETS ARE BAD American College of Surgeons, Advanced Trauma Life Support the judicious use of a pneumatic tourniquet may be helpful and lifesaving. 6

7 Preventing arterial blood flow will result in ischemia. Previous application of tourniquets when not indicated shift risk > benefit An incorrectly placed TQ can actually cause increased bleeding from distal injury TOURNIQUETS ARE BAD Nerve damage, muscle injury, skin necrosis All GSW to extremities 47% of 110 TQ applications J Trauma Feb;60(2): Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. J Trauma May;54(5 Suppl):S Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. < 2 hours little risk of permanent ischemic injury. > 2 hours can result in permanent nerve, muscle, and skin injury 1. PREVENTING ARTERIAL BLOOD FLOW WILL RESULT IN ISCHEMIA. > 6 hours muscle damage near complete and may require amputation 5.5% of 110 (6) TQ use resulted in nerve minutes (~2-3 hrs) Mean ischemic time for TQ use with ZERO 78 minutes J Trauma May;54(5 Suppl):S Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. 7

8 Combat Casualty Care, Military practice to apply TQ to all extremity wounds All GSW to extremities 47% of 110 TQ applications were not indicated 2. PREVIOUS APPLIC ATION OF TOURNIQUETS WHEN NOT INDIC ATED SHIFT RISK > BENEFIT Do the math. 58 applications indicated = 58 lives saved 52 applications not indicated 35 injured but not actively bleeding (20 open fx) 14 actively bleeding but direct bandaging not attempted first. J Trauma.2003 May;54(5 Suppl):S Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. Combat Casualty Care, Military practice to apply TQ to all extremity wounds < 78 minutes? ZERO ischemic injury 2. PREVIOUS APPLICATION OF TOURNIQUETS WHEN NOT INDICATED SHIFT RISK > BENEFIT minutes? 5.5% have some nerve injury. 1 pt s bilateral peroneal and radial paralysis (187 minutes) 3 pt s forearm peripheral nerve injuries noted 1 pt. paresthesia and weakness of the distal foot. J Trauma.2003 May;54(5 Suppl):S Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. 8

9 AN INCORRECTLY PLACED TQ C AN ACTUALLY C AUSE INCREASED BLEEDING FROM DISTAL INJURY. Pre-hospital practitioners must be familiar with commercial TQ s that have been proven in studies to be effective. TQ s must completely and consistently occlude arterial blood flow Pressure required to occlude blood flow in an extremity increases exponentially with the circumference of the limb. Combat Application Tourniquet showed 100% effectiveness in occluding distal arterial flow using human volunteers Evaluation of a possible tourniquet system for use in the Canadian Forces. J Trauma TOURNIQUETS ARE GOOD 9

10 During Operation Iraqi Freedom OIF) and in Afghanistan (Operation Enduring Freedom OEF) More medical data collection than any other wars. WHY ARE TQ S GOOD? OVER A DECADE OF MILITARY EXPERIENCE Data used to characterize injury patterns, medical care provided, casualty outcomes, and mortality causes. The information was used to promote and evaluate changes in the medical care provided to trauma casualties. A Decade of Advances in Military Trauma Care Elon Glassberg, M.D., M.H.A. The Trauma and Combat Medicine Branch Medical Corps Surgeon General s Headquarters Military POB Israel Defense Forces 02149, Ramat Gan Israel. A potentially salvageable death is an injury that led to the death that would be survivable under optimal medical care. During OEF or OIF in the last decade reveals that up to 25% of all deaths were potentially salvageable. OVER A DECADE OF MILITARY EXPERIENCE (90%) of these deaths is attributed to exsanguination (8%) Airway compromise (1%) Tension pnuemothorax Current military practice has reduced morality rate to <10% The lowest mortality rate in military history. A Decade of Advances in Military Trauma Care Elon Glassberg, M.D., M.H.A. The Trauma and Combat Medicine Branch Medical Corps Surgeon General s Headquarters Military POB Israel Defense Forces 02149, Ramat Gan Israel. 10

11 Possibly the most significant advancement in prehospital trauma care in recent years is the widespread implementation of tourniquet use. OVER A DECADE OF MILITARY EXPERIENCE During the the Vietnam War, tourniquets were considered a last resort. Perceived risk of limb shortening in 0.4% and localized limb palsy in 1.5% most often incomplete and temporary A Decade of Advances in Military Trauma Care Elon Glassberg, M.D., M.H.A. The Trauma and Combat Medicine Branch Medical Corps Surgeon General s Headquarters Military POB Israel Defense Forces 02149, Ramat Gan Israel. In 2001, Afghanistan tourniquets were not issued equipment By 2004, following a large number of deaths from extremity hemorrhage, some SOF units started using tourniquets. OVER A DECADE OF MILITARY EXPERIENCE By 2007, US military was equipped and trained in tourniquet use. Tourniquets on the battlefield associated with increased survival. Death rate from extremity hemorrhage declined by 85% after full implementation of protocols for tourniquet use. A Decade of Advances in Military Trauma Care Elon Glassberg, M.D., M.H.A. The Trauma and Combat Medicine Branch Medical Corps Surgeon General s Headquarters Military POB Israel Defense Forces 02149, Ramat Gan Israel. 11

12 IS THE EXPERIENCE FROM A WAR ZONE RELAVANT HERE AT HOME? SO WHAT? That data is from a battlefield, not a civilian environment. BOSTON BOMBING WHAT DO YOU SEE? 12

13 IED SAN BERNARDINO SHOOTING ARE THE WEAPONS DIFFERENT? 13

14 SANDY HOOK ELEMENTRY MILITARY MECHANISIMS AND INJURIES ARE MORE COMMON IN CIVILIAN LIFE THAN EVER BEFORE 14

15 FBI ACTIVE SHOOTER INCIDE NTS WHERE DOES THIS HAPPEN? 15

16 CORRECT APPLICATION HURTS! COMBAT APPLICATION TOURNIQUET 16

17 COMMERCIALLY AVAILABLE TQ S BEWARE OF IMMITATION PRODUCTS AVOID ebay TRUSTED SITES #1 NorthAmericanRescue.com Rescueessentials.com Lapolicegear.com 17

18 MAKESHIFT TQ S ARE NOT IDEAL. 18

19 QUESTIONS??? HOW MUCH TIME??? Blood loss 750mL mild anxiety 1500mL anxious, increased heart rate 2000ml confused, low blood pressure 2500ml unconscious, low blood pressure. Ex. Femoral artery.06 x 5000ml/min = 300ml/min 2000/300 = 6 min *** Cardiac output normal equals 5L/min Cardiac output under stress/fear ~10L/min. 19

M.A.R.C.H. M.A.R.C.H. 10/11/2017. Hartford Consensus 2 April Comparison of Statistics for Battle Casualties,

M.A.R.C.H. M.A.R.C.H. 10/11/2017. Hartford Consensus 2 April Comparison of Statistics for Battle Casualties, Presented by: Envision/EM Care 15 th Annual Advanced Emergency and Acute Care Medicine Conference Stop the Bleed EAST COAST TACTICAL MEDICINE Dr. A. Scott Whyte Danny Devlin Emergency Physician Level II