Several adjuncts are available in prehospital medicine for the management of hemorrhage.
Tourniquets: The recent and ongoing conflicts in Iraq and Afghanistan have contributed to resurgence in prehospital tourniquet use. What was once considered a last-resort intervention is now a first-line intervention for extremity hemorrhage. Several commercial tourniquets are on the market for purchase by EMS providers and departments, and each has their own design feature that differentiates it from another.
Tourniquet placement is of great importance when controlling compressible hemorrhage. PHTLS doctrinally recommends the placement of the device approximately 2–3 inches from the wound site. However, the application of that doctrine can be difficult if an extremity is mangled or has several different sites of bleeding. For those situations, EMS providers should consider tourniquet placement that is "high and tight." A mangled extremity can make it difficult to ensure that the tourniquet is compressing the tissues and vessels against bone for adequate hemostasis. Likewise, several sources of bleeding on the same extremity can make it difficult to place the tourniquet 2–3 inches from the most severely bleeding wound site. High and tight placement will ensure that all sources of hemorrhage are controlled in the extremity.
The following are a couple of pearls to remember when placing a tourniquet on a patient:
- Cinch the strap of the tourniquet down as tight as possible before twisting the windlass that tightens the tourniquet. If an EMS provider fails to do this, there is an increased risk of tourniquet failure from too much slack in the strap itself that will prevent the tourniquet from tightening down and generating enough compression to stop the bleeding, and
- If a single tourniquet does not stop the bleeding, leave the first tourniquet in place and place another tourniquet proximal to the first one. Make sure there's no space in between the two devices.
Tourniquets are bleeding control adjuncts but are not 100% effective at all times. They are prone to slippage, which can lead to restart of the bleed. EMS providers must be intently focused on reassessment of not only the patient's physiological status but also on the effectiveness of the interventions that have been placed as well.
