Tourniquet Placement
 

I have run into a problem with one of the civilian instructors that I work with, who says that during his 18D training... that he didn't complete, that he was taught, that deliberate tourniquets are supposed to be placed 2-3 inches above the wound. Even if the wound is below the elbow and the knee, where as I was taught that trying to place a tourniquet over Tib/Fib or Radius/Ulna will ultimately fail due to the bones being in the way and will not allow the tourniquet to properly work. If any of you guys could please give me your imput on this I would appreciate it. Thanks

Make sure the tourniquet is placed somewhere between the heart and the wound.

Sorry, I couldn't resist that. My bad. Gave myself a demerit.

In my experience I have had success placing tourniquets on the distal portions, on occasion however, I have had to back it up with a second just proximal to the first or sometimes proximal to the joint. Depends on the wound tract as to where occlusion is going to work

A tourniquet placed around any part of the body is dependent on the force vectors of "radial' compression....fancy term for it works in a circle and if some structure is blocking a force vector like the tibia, the forces become spread around the rest of the circle so the gastrocnemius (posterior muscle) will literally push anteriorly to compress another area.....bottom line, place the tourniquet as close to but above the injured area unless it is right at a joint then the 2-3 inches makes sense since compressing a joint really won't work. Field, E.D. or O.R., it'a all the same.

ss

Related to tourniquet placement. I just completed BCT3 in preparation for an upcoming deployment and the instructors taught us the latest change to TCCC in terms of tourniquet placement. Guidance was as follows:

Care Under Fire Phase:

If needed, apply a hasty tourniquet as high on the limb as possible and as quickly as possible. This is regardless of injury site.


Tactical Field Care:

Once time allows, apply two deliberate tourniquets side by side closer to the injury site. Slowly release the hasty tourniquet, ensuring the deliberates are effective.


The instructors supported this approach with research and information from the field. I'd like to hear some thoughts on this as my medical section debated this for quite some time following the course.

Milon

That's perfectly reasonable and in common practice. You don't have time to reevaluate the wound during CUF, so by placing it as proximal as possible, you avoid that little bullet fragment that traveled over 10" up the leg and shredded the popliteal artery. In this instance, if you placed a tourniquet just 2-3" above the GSW site, you would have stopped the visible bleeding, but you would be causing a massive compartment syndrome proximal to your tourniquet

I agree...it does make perfect sense for CUF conditions.......once can evaluate the injury, place another and remove proximal one...common sense wins this one.
This is actually where the blackhawk ITS system (internal TQ system) was coming from...all 4 TQ's (2 UE, 2LE) were all very proximal to get control ASAP, then apply your second one closer to hemorrhage.
ss

I really appreciate all the imput, but I'm just trying to get clarification on the deliberate placement. I even tried placing one on my forearm and my lower leg and sure enough I still had a radial pulse and a dorsalis pedis pulse, of course I could only make the soft-t so tight before I was afraid I was going to break my own bones. But I just need to know if there any documentation to support this so I can get this wanna be 18D to shut up.

placed appropriately but more importantly, a quality TQ (SWAT-T, CAT, SOFF-T, etc commercially available) used correctly, they will stop all arterial flow. I have used many of the commercially available ones and have had few not stop flow. Each one has its quirks and MUST be deployed as per instructions and not just used to the users discretion which can lead to non occlusion of artrial flow. Trust me, a medical provider or anyone without medical skills but proficient with a TQ who has adequate training on a quality TQ will stop your blood flow.....

ss

tell the wanna be....use it where ever they 'think' they should, then follow their medical direction and SOP to do it 'right'

Ok so I can't find a BCT3 Manual or a SOCM manual to save my life but ironically the old FM 4-25.11 on First Aid even says that to have maximum effectiveness that a tourniquet should be placed above the knee and above the elbow. Is there any where I can get the Manuals for either BCT3, ALC or SOCM so I get this in writing and get this guy to shut up.

Hey SGT,

How about you take a step back and take a deep breath. It is the principle of medicine that need not be violated. You seem HELL BENT on spotlighting yourself as Mr. Medical Sharpshooter.
CLS Guidelines teach 2-3 inches above. You have ample advice from current providers and recent graduates of BCT3 and TCCC above.
Once you have been in medicine awhile, you will find that it s a PRACTICE...meaning that things can, and are, done and taught differently in different arenas by different people but the principles remain the same.

Take the information you have been given and move out smartly.

Unless you have been through SFAS and even attempted the 18D Course, you really have exactly ZERO room to be chastising your "18D Wannabe"...

At least he stepped up to be assessed, and was selected. Though he failed - AT LEAST HE TRIED.

EDITED TO ADD
Looking in the most current CLS INSTRUCTORS MANUAL, ISO 0873, Chapter 4 "Combat Application Tourniquet" (Arm or Forearm) page 4-14, Step #2, it reads:
Position the CAT Tourniquet band two inches above the wound

You have your Reference, now man up and apologize to your "18D Wannabe"

Thank you Eagle,
I saw so many really good medics not make it thru the course. I would have been happy to have most if not all of them work on me. Just the way it is. People who have not been thru it should not ever call someone who tried and didn't make it a wannabe.

The reason I call him a wanna be is because all he talks about is how he was in group and that he is pretty much an 18D but guess what he's not. And the reason I am so critical about this is because I teach CLS for an IRT company so I'm teaching privates that are deploying ASAP to a unit that is already down range and if they put a tourniquet on wrong and get somebody killed because they had to get taught by the book, when the book is wrong, how do you think that soldiers confidence in not only himself but in medics and CLS training going to be. Also as far as going to selection I'd be more than willing to go if t weren't for having to learn my job all over again for a year, because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

You have GOT to be kidding me
 

Guess what? NEITHER ARE YOU - but at least he manned up and gave it a shot.
Guess what again YOU ARE TEACHING IT WRONG

Unless they put the TQ around their patient's neck, they aren't going to kill someone by "incorrect" placement. The book isn't wrong YOU ARE :rolleyes:

BLAH BLAH BLAH - never heard that EXCUSE before :boohoo: Thank you for saving us the training slot.

The only thing that outweighs your arrogance here is your ignorance. As a "seasoned medic" you have the medical knowledge equivalent of a 1st grader when you look at the big picture. You can patch holes in the field and wipe snot and take vitals in the Aid Station.:munchin

I have the distinct impression that they most certainly were NOT impressed with you either.

Your attitude, and your SA, both suck balls.

With your grammar, spelling, major penis fixation, and abject lack of any situational awareness whatsoever...I can't say I am too impressed with you.

Edited to read: (Dammit...Eagle got to the post button first).