Lessons Learned: “Four Hours of Tourniquet Time”

Below is an excerpt from a lessons learned compilation titled “First to Cut: Trauma Lessons Learned in the Combat Zone.” Though it is geared toward FST surgeons and forward medical providers, some of the lessons are applicable to tactical medics and mountain rescue. The larger take-away point is that the physiology occurring distally to a tourniquet applied for a long duration needs to be considered when changing or loosening, especially in environments where medical care may be limited (e.g., Third World).

    “Four Hours of Tourniquet Time”

    “26 y.o. male with foot traumatic amputation and
    multiple frag wounds to the right leg with a high thigh
    field tourniquet in place. Arrived to the CSH with SBP of
    100 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 bicarb and he came back. We found
    out later that the tourniquet had been in place for over 4
    hours….”

    The use of tourniquets – while rare in civilian trauma is
    very common in combat injuries. Tourniquets are the
    number 1 instrument that a medic can employ to lower the
    KIA numbers. The use of tourniquet with application until
    the absence of a distal pulse by default causes distal
    ischemia. Release of a functioning tourniquet after several
    hours can result in the release of acidic fluid and potassium.
    The patient intubated and without a head injury can be
    briefly hyperventilated. Before taking down a long
    duration tourniquet make sure the patient is well hydrated,
    resuscitated, adding an ampule of sodium bicarbonate or
    THAM can prophylax against the release of “bad humors”,
    lactic acid, and potassium. Also release the tourniquet
    slowly – if the rare arrhythmia arises re–employ the
    tourniquet and retry after further bicarb and fluid. If the leg
    is necrotic remember “life before limb” and perform an
    amputation.

    Lessons Learned:
    –Prolonged tourniquet times can result in the release
    of acidotic fluid and hyperkalemia
    –Perform 4 compartment fasciotomy with all lower
    extremities with significant tourniquet times

Chest Decompression for Non-Medics

Chest decompression for non-medics is a sticky subject. Recent observations overseas have seen an increase in improper location medially when inserting the needle. The causes of the high rate of improper placement are difficult to determine (i.e., environment, visibility, etc.) and have led to some medical directors prohibiting the procedure for non-medics within the military and LEO teams. However, the below study illustrates that proper initial training leads to high retention rates, thereby making this a skill that ought to remain at the operator level.

Abstract
Introduction: Tension pneumothorax is the second leading cause of preventable combat death. Although relatively simple, the management of tension pneumothorax is considered an advanced life support skill set. The purpose of this study was to assess the ability of non-medical law enforcement personnel to learn this skill set and to determine long-term knowledge and skill retention.

Methods: After completing a pre-intervention questionnaire, a total of 22 tactical team operators completed a 90-minute-long training session in recognition and management of tension pneumothorax. Post-intervention testing was performed immediately post-training, and at one- and six-months post-training.

Results: Initial training resulted in a significant increase in knowledge (pre: 1.3 ±1.35, max score 7; post: 6.8 ±0.62, p < 0.0001). Knowledge retention persisted at one- and six-months post-training, without significant decrement. Conclusions: Non-medical law enforcement personnel are capable of learning needle decompression, and retain this knowledge without significant deterioration
for at least six months.

Needle DC for Non-Medics

How to Build a Personal First-Aid Kit

Below is an article from the latest Journal of Special Operations Medicine. It is an even-handed review of considerations when one is building a personal medical kit. It not only applies to SOF Operators, but to patrol officers and SWAT teams as well.

Individual Medical Equipment Part 1

Needle Decompression Hazards

Historically, tension pneumothax has been the 2nd leading cause of preventable death on the battlefield. Therefore, this is an important skill and is being taught to medics at the lowest level of care. However, as with all procedures, risks are involved. Feedback from the field has indicated that medics are performing this procedure too often and TOO medial, causing multiple complications.

The above video covers the hazards of a needle decompression. Below you will find a brief review of indications, contra-indications, etc. As always, please follow local protocols.

INDICATIONS:
Needle decompression is indicated for the treatment of:
A. Tension pneumothorax and / or
B. Tension hemopneumothorax

CONTRA-INDICATIONS:
A. Chest decompression is indicated in the field only in the face of a life-threatening
tension pneumothorax. In that situation, there are essentially no contraindications since
the only alternative is almost certain death.

CAUSES OF TENSION PNEUMOTHORAX:
A. Blunt force trauma to the chest that ruptures a portion of lung tissue
B. Fractured rib that punctures the lung tissue
C. Spontaneous pneumothorax for no apparent reason
D. Conversion of a simple pneumothorax to a tension pneumothorax by positive pressure
ventilation as with a bag-valve mask device etc.
E. Open pneumothorax that is covered and left unattended developing into a tension
pneumothorax

SIGNS/SYMPTOMS
A. Chest pain
B. Severe respiratory distress
C. Tachycardia
D. Hypotension
E. Decreased or absent breath sounds on affected side

LATE SIGNS / SYMPTOMS:
A. Cyanosis
B. Distended neck veins
C. Tracheal deviation away from affected side

Pic 3
(Source: Canadian Tactical and Operational Medical Solutions)

COMPLICATIONS:
A. Creation of pneumothorax where none existed previously
B. Laceration of lung tissue
C. Bleeding from laceration of intercostal blood vessels
D. Severe pain to conscious patient (since this is life-threatening, the procedure must be
continued )
E. Local hematoma
F. Laceration and/or puncture of the heart

Tactical K-9 Care: Part 1

In the tactical environment, a tactical medic may be the only care provider able to assist a working dog that has been injured. The goal of the following article is introduce medics to common problems associated with working dogs in a tactical environment. In addition to this article, medics ought to find a veterinarian that has experience with working dogs and work with them to become more familiar with anatomy and what is “normal” for canines, as well as become comfortable working with them.

The following article is from the Journal of Special Operations Medicine, vol. 7, edition 2, pg 33-47.

Care of the Military Working Dog

Tactical K-9 Care: Part 2 will focus on treatment of trauma.

Improvised Medicine: Part 2

In a previous entry, we discussed improvising in the field and demonstrated a method of creating a scalpel handle out of its wrapper. This entry will focus on the safety pin and several of its uses. It’s always a good idea to have 4 or 5 of these in your kit. They can be used to solve many medical and non-medical problems. They are inexpensive, don’t expire, and take up hardly any space.

Here is a list of a few things you can do with a safety pin:

-Pin the tongue to the lip to maintain the airway
-Splint a finger
-Make a sling out of a casualty’s shirt
-Close abdominal wounds or large lacerations
-Make a tracheal hook
-Secure an ET or Cric tube.

Like most improvised medicine, these techniques are not definitive treatments, but in certain situations you may not have any other option. You can never carry everything, so knowing how to employ items you have can be a life saver…literally.

S.W.A.T. Tac Med Course

A new training company is offering a course in Florida for those interested in attending. The company is formed of current and former Military and LE personnel. Here is an excerpt from the course flyer and a link:

Sign up today for an intensive program geared towards the certified Tactical Medic Provider. This 24hr course over 2 days will provide you an opportunity to evaluate your current skill level in both the medicine and tactics involved in SWAT missions.

SWAT Medic Flyer

Casualty as a Fluid Infusion Device: IV Bag Placement

Summary

This study was designed to identify the most effective underbody
position when using the patient’s own body weight as an
infusion device. Twenty volunteers had an air-less 500ml bag of
saline located at various under-body positions. Mean pressures
and flow rates through a 14G cannula were measured in vitro at
room temperature. Locating the fluid bag at the buttock cleft
delivered the highest mean flow rate at 135ml/min. This underbody position may provide flow rates sufficient to achieve the clinical aim of fluid resuscitation in the military pre-hospital
environment.

Fluid Infusion IV Bags

A dictum of tactical medicine is to carry equipment that has dual use. In the case of fluid infusion, medics are instructed to use their blood pressure cuffs or the patient if no other device is available. Medics have the option of carrying pre-made fluid infusers or an extra BP cuff, but the former violates the rule of dual use and the latter may be too bulky. The above article offers a valid, though not new, solution, because it explores the best location if a medic chooses to use the casualty.

TCCC 2009 Guidelines

You will notice WoundStat has been removed as the secondary hemostatic.

TCCC 2009 Guidelines