2/5/2016. Military Tourniquet PFN:SOMTRL0B. Terminal Learning Objective. Reason. Hours: 0.5

Transcription

1 Military Tourniquet PFN:SOMTRL0B Hours: 0.5 Slide 1 Terminal Learning Objective Action: Communicate knowledge about the military tourniquet Condition: Given a lecture in a classroom environment Standard: Received a minimum score of 75% on the written exam IAW course standard Slide 2 Reason Slide 3 1

2 Agenda Identify imitation CAT tourniquets Identify the tourniquet effects on muscle, nerves and skin Identify the tourniquet application steps Identify the operational tourniquet techniques Slide 4 Agenda Identify the tourniquet conversion steps Identify the tourniquet reperfusion issues Slide 5 Identify Imitation CAT Tourniquets Slide 6 2

3 CAT Tourniquet Slide 7 Imitation CAT Tourniquet Imitation CAT Tourniquet (E CAT) Real CAT Tourniquet Slide 8 Identify Packing Differences Real CAT Imitation Slide 9 3

4 Windless Lock (Endview) Imitation (E CAT) CAT (GEN VI) CAT (GEN III) Slide 10 Strap Markings Imitation (E CAT) has no markings CAT (GEN III) has date stamped on strap Slide 11 Heat Welding Marks Imitation E CAT no welding marks CAT (GEN III) heat welding marks Slide 12 4

5 Key Differences Packaging Thickness of windless lock Date marking on strap Heat weld markings on strap Slide 13 Tourniquet Effects on Muscle, Nerves and Skin Slide 14 Tourniquet Effects on Muscle Biochemical changes are relatively slow After 1 hour of ischemia muscle exhibits marked changes to mitochondrial morphology Muscle fibers become swollen (less electron dense) and lose their organized network of cristae As ischemia time increases so does muscle damage All muscle fibers had returned to normal after 7 days for a tourniquet applied for 5 hours (using rhesus monkey models) Slide 15 5

6 Compartment Syndrome Concerns Compartment syndrome is always a concern Clinical signs of Compartment Syndrome: Pain out proportion of injury Pain with passive motion of muscles in the involved compartment Pallor Paresthesias Pulselessness (peripheral pulses are absent in 90% of patients with compartment syndrome) Slide 16 Extremity Compartment Syndrome The treatment for compartment syndrome is evacuation and the follow on fasciotomy performed in a controlled environment by a surgeon. Slide 17 Tourniquet Effects on Nerves A cool, cold climate appears to allow longer tourniquet times with little or no long term nerve consequences Over tightening of tourniquets has been associated with palsies by damaging the peripheral nerves (intermittent cases with pre hospital use) IDF study revealed 5.5% neurologic complications with minute evacuation times Slide 18 6

7 Tourniquet Effects on Skin Pressure necrosis Friction burns With the use of non commercially made tourniquets the twisting and shearing of the skin is more likely to occur Blisters Bruising Slide 19 Tourniquet Application Steps Slide 20 CAT Tourniquet One Handed Slide 21 7

8 CAT Tourniquet Two Handed Slide 22 Keys for Tourniquet Application The tourniquet must be tight against the extremity before the windlass is turned With one handed use, the windlass should be medially placed on the extremity, for ease of turning the windlass For proper application the pulse must be absent on the afflicted extremity The tourniquet must be available for use given any tactical scenario Slide 23 Operational Tourniquet Techniques Slide 24 8

9 TCCC Care Under Fire Tactical Field Care Tactical Evacuation Care Slide 25 Care Under Fire Care in the Line of Fire Care Behind Cover Slide 26 Situational Decision Point Move casualty to cover Speed is security Can the casualty help movement? Do I need help? Is there help? Does the team need my gun (firepower)? Where is the closest solid cover to casualty? Tourniquet / Control Hemorrhage Can I risk the time for a tourniquet? Can I risk the time for a tourniquet based on the situation? Can I risk the time for a tourniquet based on the situation and the casualty? It s your call Slide 27 9

10 Tourniquet (Care in the Line of Fire) Tourniquet Option 1 **Place over the uniform and check for absent extremity pulse Slide 28 Time is critical Only a Stop Gap or temporary solution to bleeding Exposure of wound and tourniquet skin contact still needs to be performed when tactically feasible Tourniquet Option 1 Slide 29 Advantages of Option 1 Quick application of tourniquet Some blood will be saved even with inadequate placement May be performed by the casualty themselves without medic involvement Slide 30 10

11 Disadvantages of Option 1 Tourniquet does not have skin contact risking ineffectiveness No visualization of wound Wound may be more extensive The tourniquet may be on the wound The exterior blood may be residual and the wound may be on another extremity (or worse on another casualty) Self applied tourniquet was not needed Medic simply applies pressure dressing Slide 31 Tourniquet / Care Behind Cover Movement to cover takes priority tactically Once behind cover the tourniquet is applied Slide 32 1 st Cut Clothing Tourniquet Option 2 2 nd Expose Wound 3 rd Check Downside for wounds 4 th Apply Tourniquet to Skin 5 th Check for absent pulse of the extremity 6 th Record time of tourniquet Slide 33 11

12 Tourniquet to Skin Preferred method Time of application dependent on tactical situational awareness by the medic Always think tourniquet to skin Slide 34 Multiple Tourniquet Use Bilateral tourniquet placement Tourniquet used is SOF T tourniquet Slide 35 Keys to Multiple Tourniquet Use Apply subsequent tourniquet(s) proximal to the first Apply tourniquets as close to one another as possible to expand pressure width on the tissue (side by side) Apply as many as required Slide 36 12

13 Using Multiple Tourniquets After the first tourniquet, all other tourniquets are placed proximally If second tourniquet is still inadequate consider application of a third, proximally Distal First tourniquet placed Proximal Second tourniquet placed Slide 37 Another View Expose the Wound Check Downside 1 st Tourniquet Application 2 nd Tourniquet Proximal Pulse Absent Record Time Slide 38 Tourniquet Conversion Steps Slide 39 13

14 Tourniquet Conversion Criteria Tourniquet conversion criteria: 1. Casualty shows no s/s of shock (casualty is alert and has strong radial pulse) 2. It's possible to monitor closely for bleeding 3. The wound is not an amputation Slide 40 Tourniquet Conversion Criteria If conversion criteria are met, every effort should be made to convert a tourniquet to a pressure dressing in less than 2 hours Slide 41 Tourniquet Conversion Criteria Tourniquets that have been in place for more than 6 hours, should not be converted to a pressure dressing unless close monitoring and lab capabilities are available Slide 42 14

15 Do Not Convert Criteria Injury is an amputation Tourniquet has been in place > 6 hours and monitoring and lab capability are NOT available Hemorrhagic or hypovolemic shock (absent radial pulse, altered mental status) Slide 43 Conversion Steps Ensure criteria are met Patient is not in shock (alert with radial pulses) Situation allows for close monitoring for bleeding Wound is not an amputation Tourniquet has not been in place > 6 hours (unless close monitoring and labs are available) Collect all necessary equipment Bandage element Pressure dressing material Slide 44 Prepare Bandage Element Abdominal bandage Top covering exposed Slide 45 15

16 Create Pressure Ball The abdominal bandage is tented to try and produce a ball over the possible bleeding part of the wound. The bandage is then placed on the wound and an Ace Wrap is used for the dressing. Slide 46 Wrap with Dressing One side of the ace wrap is secured, covering the bandage The ball is still visible, which will eventually be used for pressure The tourniquet is not covered in any way Slide 47 Secure Bandage Slide 48 16

17 Loosen Tourniquet Slowly Slowly release tourniquet over 1 minute Observe bandage for bleeding Monitor casualty vital signs closely If re bleeding occurs (be aware of residual blood on bandage), re tighten initial tourniquet and ensure absent pulse With continued bleeding apply additional tourniquet close and proximal to the first Mark second tourniquet time Slide 49 Tourniquet Reperfusion Issues Slide 50 Limb Reperfusion Beneficial Consequences Energy supply is restored Toxic metabolites are removed Tissue repair begins Metabolic Consequences Interaction of endothelial factors, neutrophils, and oxygen free radicals Oxygen free radicals are the main culprit for injury Hyperkalemia Acidotic fluid accumulation Slide 51 17

18 First to Cut Case Study 26 y.o. male with foot traumatic amputation and multiple fragment wounds to the right leg with a high thigh field tourniquet in place. Arrived to the CSH with SBP of 100 and a HR of 120. We had no report on duration of the tourniquet. We took down the tourniquet and he promptly coded. We put the tourniquet back up, intubated him and gave him fluid and bicarbonate and he came back. We found out later that the tourniquet had been in place for over 4hours. * COL Lorne H. Blackbourne, First to Cut, Trauma Lessons Learned in a Combat Zone Slide 52 Lessons Learned with Reperfusion Make sure the patient is well hydrated Consider Sodium Bicarbonate Release the tourniquet slowly Retighten tourniquet if a reaction develops Administer fluids and sodium bicarbonate Reattempt conversion Slide 53 Questions? Slide 54 18

19 Terminal Learning Objective Action: Communicate knowledge about the military tourniquet Condition: Given a lecture in a classroom environment Standard: Received a minimum score of 75% on the written exam IAW course standard Slide 55 Agenda Identify imitation CAT tourniquets Identify the tourniquet effects on muscle, nerves and skin Identify the tourniquet application steps Identify the operational tourniquet techniques Slide 56 Agenda Identify the tourniquet conversion steps Identify the tourniquet reperfusion issues Slide 57 19

20 Reason Slide 58 20