Guide to Tourniquet Application: Essential Techniques for Controlling Massive Bleeding in Extremities


Tourniquet application is vital in Tactical Combat Casualty Care (TCCC) and pre-hospital trauma situations. Serving as a first-line intervention for uncontrolled haemorrhage from extremity wounds, this life-saving measure is grounded in robust evidence and historical success. This guide delves into the understanding, application, and effective use of tourniquets, paying close attention to safety measures, the “high and tight” philosophy, and the challenges presented by double bone areas.

Section 1 – Understanding Tourniquets:

The primary function of a tourniquet is to stem the flow of blood from an extremity wound, buying precious time for advanced medical care to be administered. A tourniquet can quite literally be the difference between life and death[^1^].

Section 2 – Safe and Effective Use of Tourniquets:

The key to effective tourniquet use is placing it correctly. It should be applied directly to the skin, approximately two inches above the injury site, but not over a joint[^2^]. Once in place, the windlass or tension device should be tightened until the bleeding stops. Despite common misconceptions, tourniquets applied correctly for a short duration in a pre-hospital setting do not pose a significant risk of limb loss[^3^].

Section 3 – The “High and Tight” Philosophy:

The “high and tight” approach suggests applying the tourniquet as high on the limb as possible, effectively stemming bleeding from all potential sites below the application point. This philosophy has been especially useful in high-stress scenarios or when injuries are not clearly visible, ensuring that no critical injury points are missed.

Section 4 – The Challenge of Double Bone Areas:

Double bone areas, such as the forearm and lower leg (areas with two parallel bones – the radius and ulna in the forearm, and the tibia and fibula in the lower leg), pose a challenge for tourniquet application. The compressibility of these areas is reduced due to the anatomical structure, making it difficult for a tourniquet to occlude blood flow[^4^] effectively. As such, injuries to these areas should be treated with direct pressure or hemostatic dressings, and a tourniquet should be applied above the joint if these measures fail.

Section 5 – Conclusion:

Mastering the safe and effective use of tourniquets is essential to pre-hospital and battlefield medicine. Ongoing training and evidence-based updates on tourniquet use can help healthcare providers save lives in the field.

[^1^]: Kragh Jr JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1-7.
[^2^]: Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2):S28-S37.
[^3^]: Kragh Jr

JF, Cooper A, Aden JK, et al. Survey of trauma registry data on tourniquet use in pediatric war casualties. Pediatr Emerg Care. 2012;28(12):1361-1365.
[^4^]: King DR, van der Wilden G, Kragh Jr JF, Blackbourne LH. Forward assessment of 79 prehospital battlefield tourniquets used in the current war. J Spec Oper Med. 2012;12(4):33-38.

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