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View Full Version : How Tight to make a Tourniquet


swatsurgeon
01-28-2005, 16:01
I enjoy this subject because when the adrenaline is flowing in the thick of things, it is sometimes forgotten how tight is toooooooo tight.
Remember, just tight enough to slow/stop the bleeding!!! Generally, the artery spasms and shuts itself off but the vein stays wide open and flowing...the vein is a LOW pressure system therefore not much pressure is needed.

Picture #1 is an arm that another hospital wrapped up (pseudo-tourniquet) and sent to us..pt. had a badly lacerated brachial artery, significant hemorrhage and forgot their 'basic' skills
Picture #2 is the same arm, close up of the mottled hand...tooooo tight

*****pics too big, I'll shrink them and post later

swatsurgeon
01-28-2005, 16:07
here are the pics......

CPTAUSRET
01-28-2005, 16:12
Ouch!

That would leave a mark.

How long before permanent damage, given it's way too tight?

Terry

swatsurgeon
01-28-2005, 16:59
6 hours of warm ischemia leads to likely permanent damage to the nerve, muscle and other tissues

NousDefionsDoc
01-28-2005, 17:33
I had a stud ask me on Monday if they should release and re-apply. He said he was taught 5 minutes for every 15 on. :munchin

Kyobanim
01-28-2005, 18:12
I had a stud ask me on Monday if they should release and re-apply. He said he was taught 5 minutes for every 15 on. :munchin

I'd heard that too, in the past, but I think the release time was less than 5 min. I've also heard that at one time a tournaquet was no longer to be used.

Just repeating heresay

swatsurgeon
01-28-2005, 21:46
the new dictum is no release because every drop of blood is precious and to release risks bleeding....hence why it is applied 'just tight enough' to slow then stop the blood flow. If you whip it tight there is a chance (a really good chance) it is toooooo tight.
We don't teach the apply and release trick anymore...I'll check TCCC from Frank Butler to see what they are teaching the active duty guys.

12B4S
01-28-2005, 23:07
Interesting swatsurgeon. For what is worth, when I was in and we were being crossed trained by our team medics, we were taught basically what I've read in this thread. That being apply the tourniquet (although, didn't look like the one in the pic. A rolled up piece of clothing or whatever and a stick or something similar). Anyway, just enough to stem the bleeding and we were taught, once applied, leave it alone til a medic or Dr took over. That was some 30 odd years ago, and I'm certainly not medic qualified. Merely relating some old training.

ccrn
02-01-2005, 22:37
Ive always thought there were risks of reperfusion ie metabolic/gas exchange (increased lactate, potassium, and Co2) even the rare pulmonary embolism.

I did some checking and apparently this isnt as risky as I thought?

ccrn

swatsurgeon
02-02-2005, 09:50
the metabolic 'washout', i.e., reperfusion injury gets worse the longer the tourniquet is on. This is why we release it in "controlled" circumstances, i.e., where there is plenty of equipment, meds, personnel, etc to resuscitate the patient from the effects of the reperfusion injury. ...best in a hospital, worst in the field
One thing Doc T and I learned about in our fellowship was how to attenuate/reduce the potential for the reperfusion injury. I have done it in the field when dealing with a trapped limb that sooner or later we'll get free but know the 'washout' of lactic acid, potassium, etc will be significant once we free them
I promised Bill Harsey I would show a leg I freed with his T-2 folder...I had to cut through the hamstrings to get a guy off of an auger/post hole digger....I forgot a scalpel and I forgot the Gigli saw blade (it's a pull type flexible blade held by two handles) for the field amputation. Our 'kit' was disassembled and I rushed to get out to the field. They flew me out there and thankfully the femor (thigh bone) was very broken but the muscle belly was still attached.
Thank goodness I always carry that knife!!!!!!!!!!!!
Pic 1 leg in bag, just cut him off
pic 2 tourniquet on thigh, where I cut was the bottom muscle under the thigh
pic 3 the amputated leg torn to shreads, foot torn up boot still on.
BTW he's going great, I'm going to skin graft the stump next week.

Bill Harsey
02-02-2005, 11:51
Swatsurgeon, Thanks for directing my attention here and sharing the story, I'm glad the knife did the job.

I wish your patient the best possible recovery.

NousDefionsDoc
02-02-2005, 19:30
Outstanding work Doc. When I was a sprat, I saw a young man get his leg caught in an auger - not that bad, but impressive none the less. Great case of getting the job done with the tools at hand.


Mr Harsey, is that a first for one of your blades that you know of?

Bill Harsey
02-03-2005, 08:23
Outstanding work Doc. When I was a sprat, I saw a young man get his leg caught in an auger - not that bad, but impressive none the less. Great case of getting the job done with the tools at hand.


Mr Harsey, is that a first for one of your blades that you know of?
Yes.

I also think that Swatsurgeon's skills would have allowed him to do the job with broken glass if needed.

ccrn
02-04-2005, 22:10
Is this the knife sir?


http://img.photobucket.com/albums/v652/ccrn/T2Harsey.jpg

swatsurgeon
02-05-2005, 06:40
that's the one....Harsey T-2 folder

52bravo
02-05-2005, 07:12
like to know some more of field amputation Swatsurgeon

can you make a guide, on pain/anesthesia medicine ect, and when to do it. like to have one form one ho has don it.

Frank

swatsurgeon
02-05-2005, 08:50
field anesthesia dpends on, what you would expect, what is available to you.
I carried both local anesthetics as well as IV analgesics and sedatives.
For local anethesia, I like 0.5% lidocaine with epinephrine, 1:200,000.
Remember with lidocaine, there is a toxic level/dosing that you don't want to exceed.
1% has 10 mg of lido per mL
0.5% has 5 mg/mL
we try to stay below 5-6mg/kg, with 7 mg/kg being truly toxic, therefore just do the math....the average 70 kg person can "safely" receive ~350-420mg...translation 35-42 mL of 1% lidocaine.
In the field I try to balance local with IV. The body is already hyped up and pain is a funny thing when you're that hyped, it doesn't always hurt as much as we expect it to under normal circumstances and I take advantage of that.....meaning use what I have to in the field not what I preconceive as needing in the operating room.
Technique: IV morphine or fentanyl, titrate to get them in space, give IV versed 2-5 mg, or Ketamine ~100mg, be ready to support respirations, inject lido 0.5% with epi around skin edges, wait 2 minutes for lido effect, re-inject only when pain found/caused by what I am doing, titrate the IV drugs, give until in farther in space, keep cutting...faster is better. When down to bone, inject the periosteum (covering of bone) then saw through. Make sure you know anatomy so you can clamp major vessels before cutting them (if possible),....all done under tourniquet!!
this is a brief review but brings out some important points.
Sometimes you have nothing but a knife and tourniquet...it sucks but life over limb and a limb under tight tourniquet will dull sensation.
I hope you never have to do this to someone but if you do, do it right.

Bill Harsey
02-05-2005, 08:55
Is this the knife sir?


http://img.photobucket.com/albums/v652/ccrn/T2Harsey.jpg
Thanks for posting the link ccrn. This is a Harsey (me) design made by Lone Wolf Knives in Portland Oregon.

An important feature of this knife is the steel, CPM S-30V. It's made by Crucible Steel in Syracuse New York using the particle metal process they invented. The result is unusual strength and sharpness because of the alloys and how it is made. This is an extraordinary tool steel for blade use. This isn't a sales pitch, just stating proven fact. Many others in the knife industry are now using this steel on the premium knives they manufacture.

The first ever production use of this steel was by Chris Reeve and myself in the knife called the Yarborough for United States Army Special Forces. We had been working with the test runs of this alloy for a year before it was commercially available. This is because Chris told Crucible what alloy mix he wanted in that type of steel and they did it. We both work closely with the metallurgical side of Crucible Specialty Tool Steels.

swatsurgeon
02-05-2005, 09:07
take it from someone who has now "field tested" (operationally or operatively??) this knife...the steel with its edge is as good as a scalpel and for that Mr. Harsey should be proud. The patient and I are most grateful for the craftmanship and sharpness of this edged tool.
It is my constant companion, is presently hooked onto my jeans waistband and will remain there .....until such time that a (?) new Harsey knife takes it's position.

52bravo
02-05-2005, 09:42
field anesthesia dpends on, what you would expect, what is available to you.
I carried both local anesthetics as well as IV analgesics and sedatives.
For local anethesia, I like 0.5% lidocaine with epinephrine, 1:200,000.
Remember with lidocaine, there is a toxic level/dosing that you don't want to exceed.
1% has 10 mg of lido per mL
0.5% has 5 mg/mL
we try to stay below 5-6mg/kg, with 7 mg/kg being truly toxic, therefore just do the math....the average 70 kg person can "safely" receive ~350-420mg...translation 35-42 mL of 1% lidocaine.
In the field I try to balance local with IV. The body is already hyped up and pain is a funny thing when you're that hyped, it doesn't always hurt as much as we expect it to under normal circumstances and I take advantage of that.....meaning use what I have to in the field not what I preconceive as needing in the operating room.
Technique: IV morphine or fentanyl, titrate to get them in space, give IV versed 2-5 mg, or Ketamine ~100mg, be ready to support respirations, inject lido 0.5% with epi around skin edges, wait 2 minutes for lido effect, re-inject only when pain found/caused by what I am doing, titrate the IV drugs, give until in farther in space, keep cutting...faster is better. When down to bone, inject the periosteum (covering of bone) then saw through. Make sure you know anatomy so you can clamp major vessels before cutting them (if possible),....all done under tourniquet!!
this is a brief review but brings out some important points.
Sometimes you have nothing but a knife and tourniquet...it sucks but life over limb and a limb under tight tourniquet will dull sensation.
I hope you never have to do this to someone but if you do, do it right.


do u use the lidocain as a nerveblock ?

the danish army had one man in a tank (up side down), in a river some year back. if think is was dec. and ice in on the river ect.
he got the food stuck under the cannon and the top of the tank, tib-fib frac, we almose cut the leg off, but he's hypotermia was not that sever, I dont know how almosed 3hr in wather, i think hes temp was 35c at the CSH at tuzla air base.

ccrn
02-05-2005, 23:07
Very nice knife, although Id be tempted to buy the tactical folder instead especially for a deployment.

I'm wondering how you dressed the stump for transport-

ccrn

swatsurgeon
02-06-2005, 09:48
if you look at the pics I posted, he basically looked like that with a sterile 'burn' sheet covering the stump...it's alread
y dirty so just trying to keep it from getting much dirtier...LOL
really doesn't make much difference...
ONE VERY IMPORTANT ISSUE: this happened on a farm and farms around the world have one thing in common, animal waste....you MUST use appropriate antibiotics to cover this, i.e., a penicillin or derivative, without fail or the infection will only get worse despite being on other antibiotics

NousDefionsDoc
02-19-2005, 11:18
Check this out (http://www.cr-tr.net/Matadora/spechost/)

Bill Harsey
04-27-2005, 23:34
Swatsurgeon,
Any word on our guy who tangled with the post hole auger?

swatsurgeon
05-02-2005, 07:58
Bill,
he's being fitted with his prosthesis this week. overall doing well except for some phantom pain. nasty injury........
just had another get himself with a circular saw and took off his right arm....sent him for replantation at Univ. of VA.....
this is why the swatsurgeon uses NO POWER TOOLS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Bill Harsey
05-02-2005, 08:27
Bill,
he's being fitted with his prosthesis this week. overall doing well except for some phantom pain. nasty injury........
just had another get himself with a circular saw and took off his right arm....sent him for replantation at Univ. of VA.....
this is why the swatsurgeon uses NO POWER TOOLS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Swatsurgeon,
Thanks for the update. We all know there is no easy ending there and hope the best for your patient.

How did a guy cut his arm off with a circle saw? Obvious answer, with it running.

swatsurgeon
05-02-2005, 10:32
was using it WITHOUT the guard and hit a knot in the wood, it jumped and got him....pics to follow.

Bill Harsey
05-02-2005, 10:43
was using it WITHOUT the guard and hit a knot in the wood, it jumped and got him....pics to follow.
Which guard are you referring to?
The one that covers the whole saw or the small one that swings over the bottom of the blade?

That would be amazing if he ran it without the one that covers the top of blade.