Various widths of rubber suitable for use as a tourniquet
By Lizzie Bennett
Many things can befall us that can cause massive, life threatening blood loss. Gunshot wounds, stabbings, road accidents, the list is almost endless. Even something that appears to be a small nick can be fatal if that small nick perforates a blood vessel.
Blood can come out of a human body at an amazing speed, and the first choice you have to make is whether or not there is any point at all even trying to control the situation. That may sound harsh, but your decision can make the difference between life and death for others involved in the event, or even your own future survival if you use everything you have trying to save someone who has no hope of survival.
In order for the heart to pump it has to have adequate pressure, and this is supplied by the veins and arteries of the body. It’s a closed system. If that system is breached the blood pressure starts to drop which has an almost immediate effect on the heart. It’s also possible that air enters via a severed vessel and that an embolism occurs, causing death.
So, the name of the game is to keep the blood pressure at a working level. Arterial blood is under much greater pressure than venous blood, so a person will bleed out from a severed artery much more quickly than they will from a severed vein. Job number one therefore is to decide if all the blood you are seeing is arterial or venous, because that makes a difference to what happens next.
Arterial blood is full of oxygen, it is bright red and will be leaving the body in spurts that roughly coincide with the persons pulse. When the blood spurts get weaker the pulse is getting weaker, it’s that simple. The pressure of arterial blood means a person of average height who had an arterial bleed could spray the ceiling of an average room quite easily.
Arterial blood leaving a body from even a very small wound will be fatal if it is not dealt with, the force of the heart beating will force blood out of the wound until there is not enough pressure to maintain the heart beat and the person dies.
In an emergency situation the best thing you can do is get apply a tourniquet if you can. If not try to get the wound above the level of the heart which slows blood loss down a little, and apply pressure…for a long time.
As an example, just removing an arterial cannula after surgery, and bearing in mind the cannula is less than 2mm in diameter, pressure needs to be maintained on the site for 15 minutes in order to be sure that the little hole has clotted off.
A tourniquet can be made of anything, but the best ones have some give in them. A bicycle tyre inner tube is ideal, as is any other piece of stretchy rubber like material. It’s a good idea to have one in your emergency kit. Unlike the elastic,velcro or clasp ended tourniquets in medical kits an inner tube will be suitable for legs as well as arms. Cut it so it’s no longer a circle, and you’re done. all non-clasp tourniquets should be double knotted into place when used on a limb.
Clasp type tourniquet. Note the short length
As I said a tourniquet can be made of anything as long as you can pull it tight enough and secure it in order to stem the flow of blood. We have had patients turn up with tourniquets made of belts,elastic hair ties, a necktie and the leg off a pair of mechanics coveralls…they all did the job required of them and did it reasonably well.
The tourniquet should be secured above the wound and tightened until the blood flow stops completely or is little more than an ooze. If you get to that stage, don’t mess with anything, you’re doing well.
Look at the blood and see if you can identify if it is arterial or venous, if its arterial the tourniquet needs to be left in place longer than normal as mentioned previously. The problem is applying a tourniquet for extended periods not only stops blood flow from the severed vessel, it prevents blood flow from undamaged vessels getting to the general area, this can cause tissue necrosis. Should you be dealing with a traumatic amputation forget about the type of blood,you’ll have both and it become a moot point.
So, the blood loss from a serious leg wound can be stopped by the application of a tourniquet but all blood flow to the leg is also stopped, including the blood flow to undamaged parts of the leg. This can actually cause so much tissue death that the limb may be lost.
In a controlled situation where a tourniquet is used in an operating theatre the surgeon is informed when the tourniquet has been on for 30 minutes, then again at the hour mark. From that point the ‘tourniquet time’ is announced every ten minutes. The ideal is to have the tourniquet released ASAP, but life is not always ideal is it?
Make a note mentally if not physically of the time the tourniquet went on. During the hour you need to get a dressing in place…a good one. The dressing needs to be the cleanest stuff you have available. this should not be a pressure dressing. I will cover how to make a decent pressure dressing in a while.
Tourniquets in hospitals are pneumatic, they are blown up with air from a cylinder, this means that when the time comes to let it down it can be done in a very controlled fashion, bit at a time which hopefully preserves the integrity of any clot formation as only a little blood is let back into the limb each time a little more air is let out of the tourniquet.
In addition, suddenly letting blood rush into a leg all at once can cause a catastrophic drop in blood pressure and actually cause the heart to stop beating.
In the wild as it were you and your patient will not be so fortunate as to have a pneumatic tourniquet, but, if your tourniquet is made of something stretchy you can still let a little blood back into the area rather than having it all flood in at once.
Slide your finger under the tourniquet and pull it upwards releasing some of the pressure. Gently let it down back into place after about 10 seconds. move an inch around and do it again. Keep going until you have moved right around the tourniquet. This relieves the pressure on the skin and allows capillary blood flow and as you move around you will be decompressing any underlying blood vessels for a few seconds allowing blood flow back into the limb. 10 seconds is not long, but you have to think that the blood you are letting in can’t get back out once the tourniquet is back in place. Relaxing the pressure for too long can cause engorgement of the blood vessels leading to further damage.
That done have a look at the dressing. Is there ooze? A huge patch of bright red blood? a patch of darker red blood?
Bright red blood is arterial blood so leave the tourniquet in place. If the blood is darker but still coming out at a rate more than an ooze, leave the tourniquet in place. If the wound is oozing, prepare a pressure dressing and when you’re ready with the dressing and it’s in position undo the 2nd knot holding the tourniquet in place and take one end of the material in each hand close to the first knot, keeping a steady tension on the material. Very slowly release the tension and the knot will loosen. When its fully loose leave it in position in case you need to use it again.
Watch the dressing for blood.
If the first small releases of the tourniquet required it to be left for a longer period you have to consider the time the limb has been without a blood supply. Wait no more than another 30 minutes before using your fingers to release a little pressure as you did before.
In the 90 minutes or so that the tourniquet has been in place the patient would have stabilized a little if the wound is survivable. What you do next depends entirely on the situation you are in. If help is on the way and the victim will be taken to a surgical centre leave the tourniquet in place. Losing a limb due to tourniquet pressure would be awful, but losing your life because it was taken off would be a travesty.
If however you know no help is coming, but it will be at some point, ie when you fail to return home from your hike, ditto above.
If you are in a worst case scenario, where no help is ever coming you have some very tough decisions to make. You need to consider how you will facilitate the removal of a dead limb should that be the outcome.
In such a situation there is little choice in my opinion, but to proceed with the best pressure dressing you can and release the tourniquet. You and your casualty may decide something different, and that is your right.
Again, if you are dealing with an amputation it’s a moot point, leave the tourniquet in place.
In this worse case scenario you are going to need a very good pressure dressing.
The idea of a pressure dressing is obviously to exert pressure. The type of dressing varies with the type of wound. For example a gunshot wound where you can see the hole would benefit from a tampon inside the wound, and a regular pressure dressing strapped on top.
Tampons are idea for penetrating wounds as the expand in all directions maintaining an even pressure. Applicator tampons are best as the applicator slides easily into the wound and leaves the tampon untouched and therefore less likely to be contaminated. This reduces the chance of infection.
I hate to keep on with the feminine hygiene products, but sanitary pads make excellent pressure dressings. The key is they way it is stuck down. Tape should be wide and very sticky, duct tape is ideal. The tape should extend several inches on all sides of the dressing.
Start with one long piece of tape to hold the dressing in place. The other strips of tape should be put on as follows:
A long strip along each of the long sides of the dressing extending several inches beyond the end of the dressing, then one long strip up the middle of the dressing.
Strips across the dressing COVERING THE LONG STRIPS COMPLETELY. These should also extend beyond the edges of the dressing by a couple of inches.
Now if you’ve used any kind of impermeable tape you will not see blood coming through the dressing, this is just the way it is. Watch for the ends of the tape unsticking due to moisture or ooze coming out from under the tape.
In most cases that are survivable 90 minutes of tourniquet and a decent pressure dressing will suffice.
Avoid moving the casualty for as long as possible, even an extra few hours of immobility can help stabilize the situation.
Coping with massive blood loss is never easy, coping with it in emergency situations is sometimes impossible. In a situation where you know medical help is not going to arrive tough decisions have to be made, and only those involved can make them.
That sounds like a cop out but it’s not. It’s impossible to cover all scenarios, and the knowledge of the rescuer as well as the general health and fitness of the casualty all have a bearing on the outcome.