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TQ Protocols
Old 04-24-2006, 12:21   #1
Cincinnatus
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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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Old 04-24-2006, 12:41   #2
Eagle5US
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Question

Dude...

Your post is all over the place. Are you making statements or asking questions?
Stopping bleeding is currently number one priority on the battlefield to allow soldiers to continue the fight until evacuation is appropriate. As such...it is the battlefield.
EMS is a whole different ballgame. Can't compare the two...goverend by two sets of rules and standards.

Focus your post and try again...

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Old 04-24-2006, 12:44   #3
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Makes a lot of sense. He has simply noticed the different needs of the two environments wants to know if his observations are accurate (I think?). You are correct that the issue of prolongued tourniquet application is definitely secondary to that of getting the casualty to the OR alive. It used to be taught over here to release the tourniquet periodically to avoid necrosis of the tissues. This, of course, flies in the face of even the most basic principle of 'life before limb', to risk the casualty's life by allowing him to bleed out is not the best of ideas. The hostile / remote environment clearly requires a more aggresive approach to pre-hospital care than domestic agencies, which is already reflected in our treatment protocols. I think that medical 'subject matter experts' in the civilian environment, who determine trauma rules and protocols for their civilian agencies, tend to have a poor understanding of what we, as combat medics are trying to achieve in the field. That is, to make sure that our guys get home to their families instead of going home in a box, irrespective of the tactical / logistic challenges.

Hope this helps.
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Old 04-24-2006, 19:13   #4
Cincinnatus
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Quote:
Originally Posted by Eagle5US
Dude...

Your post is all over the place. Are you making statements or asking questions?
Stopping bleeding is currently number one priority on the battlefield to allow soldiers to continue the fight until evacuation is appropriate. As such...it is the battlefield.
EMS is a whole different ballgame. Can't compare the two...goverend by two sets of rules and standards.

Focus your post and try again...

Eagle

Eagle,

Sorry, if I was less than clear. "Stopping bleeding is currently number one priority on the battlefield..." Should applying a TQ, again assuming serious injury to an extremity, be the default for stopping bleeding? From what I've read this is being debated, with some favoring TQs as first response, others advocating direct pressure.

Off the top of my head, I can think of five categories of traumatic injury where applying a TQ might be advised.

1) On the battlefield - "care under fire"

2) In the civilian equivalent

3) EMS responding to scene

4) Individual at scene

5) Backcountry or Katrina type situation, where EMS is unlikely to help any time soon

In which of the above should applying a TQ be the default first response?

1) and 2) it would seem that it should be, driven by "tactical" considerations.

3) arguably not as both protocols probably dictate otherwise and other options are immediately available, but perhaps in the case of mass trauma (e.g., bus or train wreck or terrorist attack) driven by number of Px and limited resources

4) as I was taught, direct pressure should be first course of action, but I'm wondering if TQ isn't every bit as valid (assuming decent TQ, using a shoe string would be likely to cause problems)

5) I'm uncertain. In all the above, it would not be unreasonable to assume that the Px will be in a hospital setting before concerns over lack of blood flow to the extremity are likely to cause problems, bleeding can be controlled by other methods, etc. However, in the back country or any situation where the Px is hours away from hospital care the issue becomes more complex, but I wonder if using the TQ to control bleeding first isn't still a good option.

That any better/ clearer?

I guess there are a couple of other questions in there as well. What are the risks in TQ use? Any besides those already noted? How should they be mitigated against or dealt with? In instances where it's reasonable to expect that the Px will be under hospital care w/in an hour, so that the risk of tissue damaged because of inadequate perfusion is minimal, is there any reason not to apply the TQ a bicep or thigh, where it is easier to restrict blood flow, than closer to a wound to the forearm/ hand or calf/ foot?
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Old 04-25-2006, 03:13   #5
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Just like as an MP we have levels of force that must be followed, as a civilian EMS employee you have SOP's that apply as well. You respond to a situation a certain way because thats what local protocol/medical director says to do. A lot of that comes down to liability in the civilian world. It's a CYA type thing. Knowing when and where those protocols apply though, and when you can "bypass" something is the important thing.

If a jack hole runs at me with a gun, I don't have to try and use IPC or USD skills on him first, I am allowed to go straight to deadly force and cap the guy. If you respond to an MVA and a guy got his arm partially amputated and has a severe arterial bleed, jump straight to the tourniquet first.

Its all about knowing WHEN and WHY to jump to the next level. As long as there is a justifiable reason for doing so, and you don't exceed the scope of your practice, then you're golden. Theres a common sense factor that comes into play. Not everyone can figure it out on their own though if its not in black and white.

If you have a real concern about something, check your local protocols and ask your medical director as he's the one thats paid to make all those decisions.
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Old 04-25-2006, 09:09   #6
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Quote:
Originally Posted by SRT31B
Just like as an MP we have levels of force that must be followed, as a civilian EMS employee you have SOP's that apply as well. You respond to a situation a certain way because thats what local protocol/medical director says to do. A lot of that comes down to liability in the civilian world. It's a CYA type thing. Knowing when and where those protocols apply though, and when you can "bypass" something is the important thing.

If a jack hole runs at me with a gun, I don't have to try and use IPC or USD skills on him first, I am allowed to go straight to deadly force and cap the guy. If you respond to an MVA and a guy got his arm partially amputated and has a severe arterial bleed, jump straight to the tourniquet first.

Its all about knowing WHEN and WHY to jump to the next level. As long as there is a justifiable reason for doing so, and you don't exceed the scope of your practice, then you're golden. Theres a common sense factor that comes into play. Not everyone can figure it out on their own though if its not in black and white.

If you have a real concern about something, check your local protocols and ask your medical director as he's the one thats paid to make all those decisions.
I'm not an MP, and I don't play one on TV...but by gum this is an OUTSTANDING answer.

If this nutshell could be any smaller-I could only attempt to sum it up by saying the situation you are in will dictate your decision. You, as the para-professional, will have to use your training to make a decision. The what-if's are endless.

SRT31B's answer is still better though


For your other concerns...a TQ is a bold step in any situation. Place it where it works, and distal as appropriate, so as to minimize the potential tissue loss if the microvasculature does become permanently damaged. Seeping is still OK with a TQ in place-remember you are turning off the faucet completely-
While it is true that TQ's can stay in place for upto 8 hours in a surgical environment---there are other physiologic aspects within the body that are not coming into play in the OR that are certianly kicking in on the battlefield or in a trauma situation.

Once again-I refer back to SRT31B's most excellent post...follow your local protocols where applicable, and when they are not...rely on your training. You will never be faulted for doing "as trained" if done in good faith...but the second you deviate from that training "Because I asked these guys on the internet and they said do this"...then you are screwed.

Eagle
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Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
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Old 05-09-2006, 16:04   #7
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I recently went to a medical class designed specifically for operators. It was designed for the non-medically trained ones. The topic of TQ was an interesting one when addressed by 2 of the instructors, both quiet professionals one with a contractor and another still in the game. They both discussed the need for immediate bleeding control as is discussed on earlier boards. This is were I found it very interesting, unlike the thought of TQ last (I was trained this way in the military and in civilian EMS), they strongly suggested it to be placed first and very high and as far as you can get away from the injury. After the TQ is placed, you would use what ever hemorrhagic agent you choose and then apply direct pressure. Once bleeding is controlled you would loosen the TQ and drop it down the EXT until it is the appropriate 2 inches away then re-apply it if necessary. The reason behind the placement well above the injury is so that you would have plenty of space to work on the actual wound and not have to contend with the TQ also.
I really enjoyed the new way of thinking especially when we got to see it in action during a lab.
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Old 05-09-2006, 18:43   #8
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Quote:
Originally Posted by paramedicfred
I recently went to a medical class designed specifically for operators.
You mean SWAT officers, or has telephone directory assistance suddenly become that dangerous a job?
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Old 05-11-2006, 00:59   #9
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Quote:
Originally Posted by Razor
You mean SWAT officers, or has telephone directory assistance suddenly become that dangerous a job?
well, you never can be to sure with those ma' bell operators or man, even those old MCI operators running around. They all were bad news.

I apologize for the confusion. Yes, I do mean SWAT officers, both federal and local. I haven't had the opportunity to take a non-SWAT operator class.
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Old 05-11-2006, 08:01   #10
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I'm not sure who is teaching that method (placed high, then move low) but that is not a standard of care I have ever seen, read about or taught. It makes no sense......tourniquet use, by design and by practice should have it immediately above the injury. There is NO WAY the tourniquet should be 'in the way'. The salvage rate for limbs would go down if the device were left 'high'....sometimes even for a short time. The chance of a compartment syndrome in the next higher level muscle compartmewnt would be a threat to limb survival that we don't worry about when it is placed JUST ABOVE the injury.
I would be happy to have those instructors have an open debate here or any place of their choosing on the technique thay are teaching. Are they Trauma surgeons, medics, nurses, techs or what. Is their training in the real world worrying about the patient from time of injury to discharge from the hospital or transfer to rehab for prosthesis fitting?
Please note that I am not referencing military medicine, only civilian law enforcement. I teach this stuff and an concerned as hell that someone is teaching a more dangerous method of tourniquet use....this is why they fell 'out of favor' years ago.

ss
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Old 05-11-2006, 10:09   #11
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Quote:
Originally Posted by paramedicfred
...I apologize for the confusion. Yes, I do mean SWAT officers, both federal and local. I haven't had the opportunity to take a non-SWAT operator class.
Just a bit of advice, take it or not, you WILL want to say officers in the future here. The term "operator," and its use when speaking of LE has been discussed here. If you would like to do some reading here is a thread that may shed some light on the subject for you. I remember its use not being popular with the QP's here. But who am I.

Again, just my .02.


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Old 05-13-2006, 17:16   #12
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Quote:
Originally Posted by swatsurgeon
I'm not sure who is teaching that method (placed high, then move low) but that is not a standard of care I have ever seen, read about or taught...

ss
Not to split hairs with you SS, but its taught here in the 18-Delta course to apply the TQ on the humerus or femur instead of distal to the elbow/knee when there are injuries requiring the use of the TQ. The theory behind it was, its easier to occlude blood flow when you arent trying to pinch the vessels between two bones as is the case with the Rad/Ulna and in some cases with the Tib/Fib. Once hemostasis has been obtained the TQ can be loosened and the wound reassessed.

We spent a couple weeks on Hem Control and each instructor had a diffenrt opinion on the use of TQ's... and HCA's as well.

Crip
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Old 05-13-2006, 21:10   #13
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Crip,
as I mentioned, I am referring to civilian medicine, not military. The rules are very different in your world. We have learned from the military experience and have modified it. The circumstances in the civilian world are usually much different than in combat.
But, the idea of an easier time occluding the radial or ulnar artery flow by placing the tourniquet higher (on the axillary or brachial artery) is incorrect. I have proven this time and time again. It absolutely depends on the type of tourniquet used, the physics of the instrument and how it is applied and the desired effect of it.
Any doc, medic, etc can prove this with a doppler on the distal radial artery while they apply different tourniquets to different levels of the arm....try it, don't take my word for it. People should believe because they challange dogma, not just by listening to "experts"....just my 2 cents.

ss
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'Revel in action, translate perceptions into instant judgements, and these into actions that are irrevocable, monumentous and dreadful - all this with lightning speed, in conditions of great stress and in an environment of high tension:what is expected of "us" is the impossible, yet we deliver just that.
(adapted from: Sherwin B. Nuland, MD, surgeon and author: The Wisdom of the Body, 1997 )

Education is the anti-ignorance we all need to better treat our patients. ss, 2008.

The blade is so sharp that the incision is perfect. They don't realize they've been cut until they're out of the fight: A Surgeon Warrior. I use a knife to defend life and to save it. ss (aka traumadoc)
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Old 05-18-2006, 13:28   #14
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I apologize with the delay to your questions. I have been a bit busy.
The instructors were both 18D. The instructors both were instructing as if in a combat zone not in a civilian EMS system. They both stated to follow your local protocals during true calls. They based their instruction on experience.
I see that the discussion continued. Interesting.
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Old 05-18-2006, 13:32   #15
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Quote:
Originally Posted by Surgicalcric
Just a bit of advice, take it or not, you WILL want to say officers in the future here. The term "operator," and its use when speaking of LE has been discussed here. If you would like to do some reading here is a thread that may shed some light on the subject for you. I remember its use not being popular with the QP's here. But who am I.

Again, just my .02.


Crip
Crip,
I appreciate the advice and will follow it. I need all the advice I can get. I did not know (which is no excuse) about the proper terminology in this forum. Sorry about the confusion.
ParamedicFred
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