Tourniquet Use in the Civilian Pre-Hospital Setting - ITS Tactical

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Tourniquet Use in the Civilian Pre-Hospital Setting

By Bryan Black

I recently came across an article I’d downloaded from the Emergency Medical Journal online a few years back, entitled “Tourniquet Use in the Civilian Pre-Hospital Setting.”

My reasoning for bringing up this article is to turn it into a discussion and hear others opinions on the topic and hear from our medics out there. To summarize this EMJ article, which I’ve attached here (PDF), it’s focus goes into exploring the potential problems and mistrust of tourniquet use, why civilian pre-hospital tourniquet use may be necessary, define the indications for tourniquet use and provide practical information on tourniquet application and removal.

While I’d highly suggest you read the entire article yourself, I’ve highlighted some bullet points of the article below. All sources of the can be found within the original article.

Problems with Tourniquet Use

  • The majority of external hemorrhage can be controlled by direct pressure.
  • Previously tourniquets have been used inappropriately when not clinically indicated (for example, for all gunshot wounds of the limbs.)
  • Preventing arterial blood flow to a limb with result in ischaemia (restriction in blood supply). Continuous application for longer than 2 hours can result in permanent nerve injury, muscle injury. Muscle damage is nearly complete by 6 hours, with likely required amputation. The general conclusion is that a tourniquet can be left in place for 2 hours with little risk of permanent ischaemic injury.
  • An incorrectly applied tourniquet will actually cause increased bleeding from distal soft tissue injuries and damaged arteries if there is occlusion of the lower pressure venous outflow, but inadequate occlusion of arterial blood flow.
  • A policy of periodic loosening of a tourniquet in an attempt to reduce limb ischaemia has often led to incremental exsanguination (bleeding out) and death.
  • A properly applied tourniquet is painful and this has experientially led to inadequate tightening or inappropriate pre-hospital removal. The patient will require strong analgesia (pain killers) after stabilization of vital signs.

Reasons to Tourniquet in Civilian Practice

  • Penetrating trauma from firearms and stabbings.
  • Police Officers working in tactical environments who may benefit from a self-applied tourniquet for “care under fire.”
  • Terrorist incidents with penetrating and/or blast injury to limbs.
  • Rural incidents or wilderness medicine where there are limited resources and delayed, often unconventional, transport to definitive care.
  • Industrial accidents. From personal communication there are a number of examples of tourniquet use to prevent hemorrhage from limbs following entrapment or shredding by industrial or farming machinery.

Indications for Use

  • Extreme life-threatening limb hemorrhage, or limp amputation/mangled limb with multiple bleeding points, to allow immediate management of airway and breathing problems.
  • Life threatening limb hemorrhage not controlled by simple methods.
  • Point of significant hemorrhage from a limb is not peripherally accessible due to entrapment (unable to provide direct pressure.)
  • Major incident or multiple casualties with extremity hemorrhage and lack of resources to maintain simple methods of hemorrhage control.

Principles of Tourniquet Application

  • Be familiar with a tourniquet that has been proven in studies to be effective, rather than using an improvised device.
  • Tourniquet must completely and consistently occlude arterial blood flow (both in legs and arms.)
  • There is an inverse relationship between tourniquet width and the minimal pressure required to occlude blood flow. As width increases, the amount of tissue that must be compressed increases, requiring an increased effort to produce tension.
  • As the width increases, the strap tends to bow, transmitting more pressure to the center rather than the edges and therefore reducing functional width.
  • If the tourniquet is ineffective it should be tightened or repositioned. If still ineffective (unlikely) the health care provider my consider a second tourniquet placed proximal to the first.
  • The time of application should be recorded and handed over to the receiving emergency department staff.


Again these are just highlights from the article, read through it yourself and let us all know in the comments what you think about tourniquet use in the civilian pre-hospital setting.

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  • J

    This is interesting because Art of Manliness had an article on tourniquet use a couple days ago.

    The way I read it, there appears to be some contradicting information in there compared to this article. For instance, the AOM article favors wider banded tourniquets. I seem to recall also reading that a complete amputation is not necessarily an indicator for a TQ.

    There still seems to be a lack of consensus on when to use TQ’s. This is from the perspective of someone outside the medical community who has had just a few first aid classes.

  • Mike

    J I also read that article on Art of Manliness and I think the difference in information lies from the varied experiences of the authors. The AOM article was written by a Combat Medic who was deployed to Iraq, while the article here was written by academics. In my experience with pre-hospial medicine, doctors are always more hesitant with TQ’s, and other interventions done by EMTs and Paramedics. Maybe its becase they are smarter or maybe its their lack of experience in the field, but I’ve alsways felt as if doctors don’t really trust EMS personell.

  • Jason

    Orange County EMT’s accreditation course actually teaches that if elevation of the limb and if 3 gauzes are soaked through, the EMT should apply a tourniquet. At least in OC it is seen that since there is so many hospitals in the county, with the 4 trauma centers spread pretty evenly, it would take less than 15 minutes to be at any hospital.

    • JJustin

      It’s the same for Florida’s EMT training as well. I just got certified EMT-B, and my instructor told us about direct pressure, but he said it’s currently not part of the state’s protocols for training so we didn’t really go too much into it.

      *I should add, from what I gathered (correct me if I am wrong, I am new to the pre-hospital field,) its a relatively new idea using tourniquets in the civilian field–there was someone in my class retaking it from only two years earlier who had learned direct pressure and NOT using tourniquets.

  • Ditto on the old six hour rule. Recent experience has contradicted this assumption.

    No amputations resulted from the tourniquet use in the study. Yes, there have been amputations, but they result from the original wound, not by tourniquet use. Applications of longer than six hours have been recorded with minimal nerve damage and virtually no muscle damage, certainly none to the level indicating amputation.

  • dreyson stadterman

    awesome article just adding more into the steel trap that is my head.


    The prehospital care journal Journal of Emergency Medical Services also addressed this recently in an article largely advocating for the continued development and trial of TQ use in the civilian prehospital setting.
    If not for the research conducted by the Army Medical Department this turnover of outdated protocols would have never been pursued.

  • Ian Delmar

    Both articles bring great insight into the debate over use of the TQ in the civilian, prehospital setting.

    I have never had to use a TQ, fortunately, both as an EMT and as a soldier to treat a patient. I have found, though, that there are very few situations that would require a tourniquet in the pre-hospital field, simply because there are not many scenarios that are likely to occur that warrant it in the civilian arena (this of course depends on the region you work in).

    I believe that one should always have as many tools as possible on hand and be well versed in them – hence a tourniquet should still be a treatment option. However, in my opinion, you should be cautious in treatment applications. If you can solve a symptom or presentation more simply, why use a more complicated treatment that has more complications attached to it?

  • Cory Heimark

    Well I will tell everyone having used tourniquets in combat, having taught tourniquet use to pre-hospital responders as well as tactical operators such as Sheriff and Police Officers there is a time and a place for everything.

    I have seen experienced combat medics fail at putting tourniquets on. I have seen experienced ranger infantrymen use tourniquets quickly, safely and effectively.

    The problem/ dilemma/ debate over tourniquet use stems from (in my experience) Surgeons/ Providers who often stay too much in a clinical mindset and the amount of patients presented with tourniquets improperly placed.

    The GO time for tourniquet use starts and stops with a single question “Is it necessary to save the life?” To answer you have to consider several factors. 1. Type and location of wound/ injury 2. Means to treat injury/ control bleeding (i.e. bandages, elevation, pressure, air splints, tourniquets and hemostatic agents) 3. Distance to definitive care (i.e. hospital, trauma center, helipad, aid station, etc) 4. Supplies available

    Loss of blood has been the #1 cause for traumatic death in the past 11 years of war. It has not been the #1 cause of death that pre-hospital care providers have responded to in the US. Enter in the time and place. I work and have worked with several paramedics in several states as well as first responders, firefighter/ EMT’s and Tactical medics. I can probably think of less than 5 that do not carry a tourniquet somewhere in their kit/ equipment/ response gear. I know tons of veterans that either still serve, have ended their service or were injured that keep tourniquets available for the “oh Sh!t” moment.

    Tourniquets are a tool. They won’t work in all instances. I have packed wounds with gauze and wrapped with elastic bandages and transported patients both in combat and stateside with great success. I have not yet applied a tourniquet in a life/ death situation stateside but I do know people that have. I relate it to the surgical cric, I know medics/ paramedics with 20 years of experience that have never cric’d and I know some that have only a few years of experience that have cric’d often.

    You can’t use a tourniquet in areas such as the neck/ groin for obvious reason. For limbs there is lots of supportive evidence that proves it’s success. The consideration for use of tourniquet really stemmed from “getting off the X” and Care under Fire. Exposing yourself for the least amount of time to provide life saving aid and prepare to evacuate the casualty. There are many different opinions on whether a tourniquet could have saved the life of a soldier during the “Black Hawk Down” encounter. I know a retired MSG who is alive today because of the use of a “ratchet strap tourniquet” after a road side bomb blew off his leg within a block or two of his compound.

    It still takes training, practice, familiarity with the equipment. There are lots of types of tourniquets out there. the CAT is a “ONE TIME USE ONLY” tourniquet, and the velcro becomes ineffective with a major bleeding wound, but it does work.

    Pre-hospital care providers (i.e. EMT’s, Paramedics, Fire Medics, etc) are often under scrutiny because they really work under a Medical Director (Provider) within their facility or in support of their service. Providers are not Pre-Hospital Experts. They are used to having many advanced tools at their disposal in a clinical environment. Registered Nurses are paid more than Paramedics and never intubate, fail at IV’s often, often do not interpret Cardiac Rhythms and only push medications once ordered/ directed by a Provider. Paramedics have standing orders to deliver certain medications, and interpret Cardiac Rhythms as well as apply critical thinking in the absence of the Provider.

    In Summary, I would consider tourniquet use appropriate anywhere in the US. I’d urge the use in rural areas, mountainous areas, tactical scenarios and anywhere with the possibility of delayed transport. Most built up areas of the US allow for patients to be transported to a definitive care facility (hospital or trauma center) within 10 – 15 minutes, and with areas that are covered by flight service there are many areas that have fast transport times even in rural areas. The transport times do not eliminate the consideration for a tourniquet, but do decrease the percentage of times used because other tools can be applied effectively (pressure point manipulation, pressure bandages, and even air splints for services that still carry those types of equipment). Hemostatic agents have become more beneficial in Pre-Hospital care than tourniquets but again a tourniquet is an appropriate tool for use and often a judgement call by the provider based upon other injuries, concern for life and other factors discussed above. Just like a good knife, lock picks, and a flashlight…..there is a time and a place and tourniquets should never be just ruled out as ineffective, or inappropriate……My 2 cents. Thanks for raising the discussion Bryan, as so often we are afraid to discuss the tools that we like or think have a purpose and discard them for the favor of the general population or what some Academic expert has decided (even though they’ve never been 3 days from a hospital and had an 11 person mascal that presented with more than 17 different body parts) and an aid bag half empty of supplies with no resupply

  • Daniel H

    The general rule of thumb I was taught in wilderness first aid classes was “direct pressure, elevate limb, indirect pressure, TQ”. If you can’t stop the bleeding with pushing on it or raising the limb above the level of the heart, press hard over the artery leading to the bleeding (closer to the body), as a last resort, apply a TQ. In the trauma content of my BSN program, the use of TQs was encouraged when it was likely that bloodloss would end life; I’ve read very few scientific reports that would discourage me from using a TQ, and I keep one in my POV at all times.

    “Registered Nurses are paid more than Paramedics and never intubate, fail at IV’s often, often do not interpret Cardiac Rhythms and only push medications once ordered/ directed by a Provider. Paramedics have standing orders to deliver certain medications, and interpret Cardiac Rhythms as well as apply critical thinking in the absence of the Provider.”

    Not trying to start a flame-war; just wanted to clarify your statement. The RNs in your area may have pitiful practice skills, but in my area, each of your points is void. RNs with ACLS certification routinely intubate patients in “code” situations in smaller hospitals and in pre-hospital care, most RNs have very high success rates with IV starts (and some are trained to start central-IVs), all RNs are trained in (at the very least) basic EKG interpretation in their schooling and utilize it to identify heart problems/medication side-effects/treatment results, RNs operate under standing-orders to administer drugs in a “code” or pre-hospital situation in the same manner as an EMT-P, and “critical thinking” is one of the key tenants of nursing; but, you’re right, RNs are paid more than EMT-Ps. For the level of service EMT-Ps provide, their compensation should be on-line with that of an associate-degree-RN. I’m not entirely sure where your mini-rant about RNs came from in your post, but I hope I cleared some things up for the readers.

  • Cory Heimark

    Daniel, it was no rant on RN’s. I am not against RN’s. I am against the fact that we pay medical professionals based upon schooling. So an RN with a BSN gets paid more than a Paramedic with/ without an associates. We don’t pay for the skills set. I know RN’s that are very capable of intubating, that are very capable of interpreting rhythms, that are very capable of initiating an IV. I’ve worked in rural hospitals where the RN tries to give an IV once or twice and then the charge nurse or the paramedic gives one. I teach ACLS with some RN’s. My point is not against the use of RN’s, it was merely that Paramedics bread and butter is pre-hospital care and the management of critical patients. You won’t see an RN in a pre-hospital setting unless it is in flight service. I have been deployed with RN’s that could not take the role of a PA or Provider and yet I have watched Paramedics do it often. RN’s serve a role, but a rarely is it to apply a tourniquet. I would dare say you cannot say “most” RN’s have a high success rate with IV starts because in most locations RN’s don’t generally start IV’s a med tech does. Central lines (IV’s) are a clinical tool and have no basis in pre-hospital care, however it is a skill, but yet I’ve seen those same nurses freak out when they see an EJ (external jugular) IV. ACLS certification gives basic training but unless professionals are routinely involved in critical care environments they do not use their skills or apply the critical thinking (this applies to Paramedics, RN’s, PA’s and Providers alike). I have seen RN’s in several hospitals address foley’s or IV’s without assessing airways. This is not a failure in what they were taught, it is a failure in applying what they were taught. I have been called to put on a C collar for a patient who was C-Spine cleared in an ER but on the care ward the nurse decided the patient needed a C collar (I believed a C Collar was a basic skill much like IV’s)

    I was not attacking or making blanket statements about who can do what type of skill, I was identifying that often literature, scientific evidence and expert opinion still become subjective based upon the individuals training/ experience and environment. I worked at a hospital where very few people saw critical patients or trauma, so naturally those skills were difficult to maintain. I have watched professionals be trained on defibrillators only to forget how to turn it on a week later.
    Just as combat medics should be experts at tourniquet use, all of these skills are perishable. Just because you did it in school, or one time at a conference, or practiced on yourself does not mean you can do it when it really counts. This stuff takes practice, takes time in order to apply it when it is really needed, when adrenaline is heightened.

    I have trained people in the dark, with strobe lights, loud music, blind folds and other distracters to apply tourniquets and other devices on themselves and others. I have run drills much like we would at an active range to prepare for malfunctions. Just like IO devices and the many other tools out there in the medical realm the important thing is that those providing care use what works, know their limits and don’t fake their capability.

    As with all things there is a time and a place (the theme I expressed in my previous post). A time for a Nurse, a time for a medic, a time for a tourniquet, a time for a bandage or pressure, even a time for antibiotics. I have often said Medicine is as much an art as it is a science. You can’t always look at a lab value to determine what is wrong with your patient, sometimes you just have to look at them and understand that something isn’t right. (Trust your gut) make a choice and take action.
    It is proven that when someone needs CPR (at a supermarket, mall, etc) even with a crowd gathered around that has several people trained it is only 1 or 2 people that will rise to the occasion to help. Much as we learned in the civil war that of those that would pull the trigger of a rifle, not all would aim to kill. Sometimes having a tool is still not the answer, the human factor comes in to play, the murphy factor comes in to play. I saw many people freak out when the original Quik Clot was used, surgeons especially. Most everyone that did not like it or did not want it used was concerned about the heat factor and the damage it would cause to the tissue. Quik clot was a tool, and I’ve seen it save lives. It wasn’t the best tool, but at the time it was the best hemostatic type agent available. Fear does a thing to a person, until we learn and understand the appropriate use for a device or a tool. We all learn to drive at some point and yet despite a basic and standard skill set that involves a written and hands on test not everyone is a success, and not everyone can handle a NASCAR race for that matter. The Human factor is a variable that still influences the tools of the trade.

  • Interesting. In my civilian Search and Rescue training we were basically universally told tourniquets are a bad ideas. They were highly discouraged. Maybe they are just trying to mitigate incompatibly, which is fine with me as I like the searching more than the rescuing. 🙂 For non-medial types like myself I find it infinitely tiring listening to the EMTs argue over the best way to put on a band-aid. Its similar to the 1911/glock flights on the interewebz.

  • Ian Delmar

    @ ExtremeTolerance: Hmmmm that is interesting. I could see why potentially since you may have much longer transport times than others in EMS, and after 6 hours the limb is essentially dead and has to be amputated.

    We can all agree I think that TQs have a specific time and place for their use, but to avoid it unless it is a life or death situation.

  • GorillaMedic

    As a working paramedic, I can tell you that the whole thought-process behind using TQs in the prehospital civilian setting has changed quite a bit over the last ten years. Research does seem to support it, and our classes and protocols have changed as well. I’ve applied TQs in several settings with good effect. Essentially, if my patient has life-threatening bleeding that can not be controlled by direct pressure and pressure dressing, then a TQ is most likely indicated (sound judgement needs to be applied). In every instance I’ve applied it, the patient has been in the hands of an ER physician or trauma surgeon within thirty minutes and they can surgically control the bleeding (clamp an artery, cauterize bleeders, etc.). The patient stays alive, and importantly, avoids the complications associated with losing a LOT of blood.

    If a hospital was not readily available, I’d be more reticent to use a TQ. But if the bleeding won’t stop (large GSW, severed artery, stab wounds, etc.) it sure can be a lifesaver.

    My 2¢ on the RN/paramedic pay debate: Most paramedics do indeed have the same or more education than RN. They have greater responsibility, I think, and similar levels of skill and knowledge (but in different fields; I know very little about how to maintain someone’s health long term or rehabilitate them). Our pay should be equivalent, but won’t be until EMS systems both recognize the value of a paramedic and change the way they get paid or budgeted by the public they serve. We have a long ways to go for that to happen.

  • Greg Natsch

    As an old medic, trained in ’74 and a licensed Paramedic since ’80, two words”Semper Gumby” . We were taught TK’s as a skill when others fail. In the civilian world it was a last resort.our training was based on Vietnam. Now due to OEF and OIF, the civilian world is more open to TQ’s. You can’t expect an overnight change and acceptance after years of “no”. It will take time for the civilian world to fully accept the concept and embrace it.its a cultural issue. I have two CAT in each of my packs. Remember the general in WarGames?
    “Hell I’d p*ss on a spark plug if I thought it would help”. Use them as directed, and instruct those who need the training. Keep an open mind and be able to articulate why you used a course of action or treatment. Let’s carry on.

  • IM Fletcher

    This is now a part of my duty kit. Its in my back country hunting and fishing gear as well.

  • Zach

    I personally had my first tourniquet experience a few weeks ago, using a SOFT-W tourniquet. Bear in mind that I finished 68W Combat Medic training about 2 months ago, and I am a Firefighter/Paramedic civilian side. The patient’s laceration was so significant that the first option was in fact to go straight to tourniquet, despite the fact the patient was no longer bleeding, for 2 very good reasons. #1, the patient was obviously hypovolemic and shocky, presenting with an extreme altered mentation. At the risk of losing any more blood, until an extensive exam proved there were no other injuries, a tourniquet was easy management of the patient. #2, if you study the physiology of the body’s response to massive hemmorhage, the vessels naturally constrict and ‘retract’ for lack of a better word, which is why TCCC shoots for “high and tight” during C.U.F. Like any distance runner, the body will eventually be unable to hold this for long, and there’s not determining factor as to when this will happen. There’s no fireworks, bells, or whistles that lets you know the patient’s body has relaxed and begun to finish bleeding out. Tourniquets, albeit painful, are a quick and easy hemmorhage management skill that should be sooner than later. And if I catch someone using pressure points, you should slap yourself. Think long term, not short term for the patient. Back to the patient, a quick TQ and exam with no further injury. Blood transfusions and fluid replacement was needed before he could be flown to a more appropriate facility. Don’t be afraid of tourniquets! I carry 4 CATs in my personal bag that follows me to my ambulance!

  • MtnDoc8404

    I thought I would add my 2 pennies; as a combat corpsman serving with Marines previously, I have used CATs. I have always been weary of using them, but there have been situations where I have used them. I have also used QuickClot to help control serious hemorrhage as well. It was always my rule if possible to use direct pressure first, QuickClot, and then a TQ as a last resort. Each method has its own advantages and disadvantages. I have seen TQs save lives, but I believe that it takes good training and periodic refreshers to be truly effective while minimizing secondary injuries/impairments to the patient due to their use. I don’t believe anyone off the street with little/no training should attempt to apply a TQ. Again, just my 2 cents.

  • Jammin

    A good thing to do along with this article would be to post the PHTLS guidelines for civilian care, seeing as the TCCC guidelines are readily available for Military and tactical reference. Just a thought.

    • hueyrab

      I agree. TCCC and TECC guidelines both. The alleged controversy over the TQ use comes either from purposeful ignorance or inadvertant lack if knowlege. It is the first resort in specific situations calling for it, and a acouple of years ago NREMT has moved the TQ application in civilian setting up in the cretiria, if the wound is not amicable to direct pressure. A TCCC approved TQ is 100% effective, if applied properly. My 2 cents.

  • 940121

    First of all, sorry for my English, its not my native tongue.
    Tourniquets should be avoided if possible. There is a time and place for tourniquets, but you should think of them as the very last resort. While they stop the bleeding, they can cause reperfusion syndrome, after being applied for more than 1 hour (And that is stated clearly in the citated article).
    You should only apply them, if you cant save the limb, and you just want to stop the bleeding, or you dont have time for other, safer methods, but in that case, note that a TQ applied for more than 1 hour greatly increases the chance of reperfusion syndrome, which, in extreme cases can cost a patient his/her life. You don’t see these types of scenarios in civilian life. I do not say they can’t be useful, I just don’t think they are an EMTs best asset in civilian life, and they definitely, shouldn’t be taught as standard procedures for stopping a bleeding.
    This all being said, I don’t know the American standards for treating a bleeding wound, this is just what I was being taught in my home country at medical school, and EMT training. And it is also clearly written in the above mentioned article.

    Sources: I am a medical student, and in my free time, I work in an EMT.

  • Gentner91

    About two years ago I had the chance to use a CAT on scene. Im an EMT/Firefighter and currently going through school to become a Paramedic. Prior to this call I had taken PHTLS and a 24 hour course in TCCC. Originally we were dispatched for an “intoxicated male” who had punched a window in a pretty rural area of our township. After staging in the area for PD to secure the scene, I had arrived POV with our ALS echo unit. Standing outside were multiple friends of the patient, who were also intoxicated, that were trying to joke with us saying it wasn’t anything serious. PD made no indications that the injury was minor or life threatening. Upon entering the patients residence, we found the patient and his wife covered in blood with the wife trying to apply pressure to the injury. The patient showed obvious signs/symptoms of shock and was becoming slow at responding to questions. The patient had lacerated his brachial artery and despite two bath towels being wrapped around his injury prior to our arrival by family, continued to bleed profusely. I was able to apply the CAT proximal to the patients injury as our ambulance got on scene. The patient was then prepared for transport and while enroute to the hospital, the patients condition improved to the point where he was cracking jokes following IV access/bolus and oxygen administration. We also found out from the patient that prior to punching the window he had taken his daily dose of Warfarin. Later I found out that the patient made a full recovery without any deficits from the tourniquet use and his time from ER to surgery was within two hours of application. Having seen and used the CAT on scene first hand, Im a firm believer about tourniquet use in the prehospital setting. Obviously, this is something that needs to be taught well to help decrease the risks of injury from their use but there is more then enough evidence, be it from mass casualty incidents here in the states (Boston Marathon Bombing, Tucson Shooting etc) to OEF/OIF that tourniquets save lives and should be used. Since then, my local protocols have now changed in favor for tourniquet use and Michigan has even made it a requirement that every ambulance have a commercially made tourniquet available; Michigan is also providing those tourniquets for us.

  • Hermit

    Most of this article, and the comments, is/are out dated info.

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