of modern tourniquets and hemostatic dressings on
the battlefield and aggressive training of all levels of
responders in their effective use. 4
As noted earlier, deaths from extremity hemorrhage
can largely be prevented by early use of tourniquets.
Because of their effectiveness at hemorrhage control and the speed with which they can be applied,
tourniquets are the best option for temporary control of life-threatening extremity hemorrhage in
the tactical environment when under fire. This concept can apply as well in the civilian arena, with its
increasing number of mass casualty or active shooter
events. These concepts become especially applicable in terrorist-style bombing events on our home
soil. Direct pressure and gauze compression dressings can be effective; however, the lack of dedicated
personnel to apply continuous direct pressure, a less-than-secure environment, and extremity injuries
that could lead to exsanguination are all indications
for rapid tourniquet application. In routine emergency medical services (EMS) care, the so-called
pressure dressing for massive external hemorrhage
is frequently inadequate and only effective when
continuous direct manual compression is applied.
Because of the personnel constraints on most civilian
EMS runs, tourniquets and hemostatic dressings are
both medically and logistically beneficial. 5 Despite
the overwhelming evidence of benefit from the military experience, recent data indicate that only a few
EMS systems are using recommended commercially
manufactured tourniquets and hemostatic dressings
for exsanguinating hemorrhage.
This situation continues despite numerous mili-
tary publications documenting the lifesaving benefit
and low incidence of complications from prehospital
tourniquets and hemostatic dressings used in combat
casualties. Although it is somewhat obvious, tourni-
quets are most effective in saving lives when applied
early, before the individual has gone into shock
from blood loss. Although tourniquet use has been
discouraged by EMS systems in the past because of
concerns about ischemic damage to the extremity, this
complication is actually very rarely seen. Prolonged
use of a tourniquet can potentially result in amputa-
tion, but saving the life of the individual must always
take precedence if the tourniquet cannot be removed.
Because of their proven lifesaving value, tourniquets
are now ubiquitous on the modern battlefield, yet adop-
tion has been slow in many civilian EMS systems.
Although limited, there are reports that the
adoption of the military practice of tourniquets and
hemostatic dressings into civilian EMS and emergency
medicine practice is increasing. One of the key con-
cepts that emerged was placing the hemorrhage control
devices in the hands of not only all medical provid-
ers, but also the much more numerous nonmedical
first-responding personnel. In the civilian sector, many
police officers and firefighters now carry these devices,
making them widely and rapidly available. Effective
training in, and use of, hemorrhage control devices
by nonmedical personnel has been a critical element
in reducing preventable deaths.
In patients with severe extremity bleeding,
hemorrhage control is a priority. Most extremity
injuries do not require tourniquets, but patients with
life-threatening bleeding do require a tourniquet. As
in most trauma situations, over-triage is acceptable,
as tourniquets found not to be needed can be safely
removed on arrival at a hospital. The following descrip-
tions are provided as examples of trauma victims for
whom tourniquet use is appropriate:
• There is pulsatile or steady bleeding from the
•Blood is pooling on the ground.
• The overlying clothes are soaked with blood.
•Bandages or makeshift bandages used to cover
the wound are ineffective and steadily becoming
soaked with blood.
• There is a traumatic amputation of the arm or leg.
One of the most important lessons learned in the last 14 years of
war is that using tourniquets and hemostatic dressings as soon as
possible after injury is absolutely lifesaving.