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Old 04-24-2006, 11:21   #1
Cincinnatus
Guerrilla
 
Join Date: Mar 2005
Location: Vermont
Posts: 342
TQ Protocols

This is a spinoff from the Hemorragic Control Agents thread. The issue of when and under what circumstances to apply a TQ is one that I'd like to discuss a little further.

My training (WEMT/ NREMT-B through SOLO, and a few other classes w/ RESQDOC, Insights, and EPI), and experience (I don't ride with a squad) are pretty limited and I have some questions about what should govern TQ application.

It seems to me that "street" medics, ED staff, and many Docs, are opposed to, or at least somewhat down on TQ use. I think the concerns are that for much bleeding a TQ is unnecessary - direct pressure will suffice, and that if improperly applied, or left on too long, a TQ can cause problems, in extreme cases to include loss of limb.

It seems to me that these concerns are a bit overblown, and reflect a preconception as to the nature/ circumstances of the emergency and the resources available to treat it.

In any kind of "care under fire" scenario, I'd think that applying a TQ, when the Px is bleeding heavily from an extremity, should be the first resort as it will control, or at least reduce, the bleeding, will free the Px or medic's hands for other chores, and, if properly applied, is likely to remain in place (even if the Px moves/ is moved), and requires no further immediate attention. If circumstances allow, additional measures to include pressure, packing the wound, clamping the artery/ vein, administering QC or other agent, depending on the time, resources, and skill level of those on scene can be pursued.

It seems to me, that getting the bleeding stopped, or at least very much slowed, immediately is the overarching goal. To this end, I also wonder if the advice about applying the TQ immediately above the wound is truly best. I can apply, using the Tourni-Kwik one hand TQ, quickly and consistently, through clothing, the TQ at the bicep tightly enough that I can't feel a radial pulse. Applying the TQ below the elbow, I am not always as successful. (This holds true for my legs to a degree, applying the TQ at the thigh will greatly reduce the strength of the pulse at the ankle, I need a windlass TQ to actually stop it consistently, and applying below the knee is less effective.)

In most places in the US, someone injured can be in an ambulance in under twenty minutes and in the ED in well under an hour. The risk of loss of limb or nerve or other tissue damage seems, if not remote, certainly not great. My understanding is that in Iraq (haven't heard for Afghanistan) troops are generally med evaced so quickly that they would be receiving ED type care in the same time frame.

The other concerns re: TQ use that one hears often expressed are the need to leave the TQ on until the Px is in a hospital setting. The underlying issues here, if I understand them correctly, are that releasing the TQ can cause what clots have formed to be dislodged by the increased pressure, and that toxic substances built up in the tissue below the TQ (due to lack of pefusion) can cause shock and poison the Px.

It would seem, though, that if the Px were to be at the ED or aid station within the hour, this would be a secondary concern and that in the field, once bleeding has been stopped/ reduced the wound can be examined, pressure/ packing/ QC applied, and a decision to relax the TQ considered if, for whatever reason, it seemed unlikely that the Px would be in the care of an ED or aid station in a timely manner.

Further, while some of the compelling arguments for the above apply only in a "care under fire" or similar scenario, applying the TQ and treating the wound in a somewhat more leisurely manner would seem to have benefits in a lot of trauma cases.

Finally, I wonder what the proper protocols should be in a remote or austere environment, or in a Katina type situation where help is a while in coming.

Does this make sense? I appreciate any input from those more qualified and experienced than myself.

TIA
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