Over the years I have come to understand that there are a few phrases that should make you STOP and THINK before you do anything else. I picked this up while flying around in different areas of the country where I saw that some areas have great and aggressive thinkers/doers, while others seem to be predisposed to questionable decision making.
Keeping a calm/cool head once you arrive to these situations is key. It is key so that you can focus on some of those subtle clues or have the wherewithal to hit the pause button when you hear/see certain things. The other team may have missed the cues, after all they were in the mix for a bit before you got there, and it is understandable that to err is human.
Here is the phrase, that to this day, makes me stop and think:
“The patient has a GSW to his leg and we cannot get the bleeding stopped…”
“Why is there not a tourniquet in place?”
The patient laying there was a 20-ish year old male, shot by “I don’t know” somewhere near “I don’t know.” The entrance wound is mid-femur, entrance and exit are clearly identified – mostly by the amount of bleeding present – as evident by the amount of saturation of the gauze bandage around his leg. Did the team not think the patient needed one? Are they wrapped up in the old school mentality of “tourniquets are last?”
In 2025, it may even be considered careless to see extremity hemorrhage without a tourniquet in place, but there was once a time when placing tourniquets was considered a “last resort.” Unfortunately, there are those who still believe this to be the norm. But this mentality is several decades old. Over the last 20 years, mostly due to the lessons learned from the Global War on Terrorism, the use of tourniquets has become quite mainstream. The placement of tourniquets for extremity hemorrhage has moved from the end of the treatment algorithm to very near the top. There are still astute recommendations to attempt less invasive means of hemorrhage control first (e.g. direct pressure).
But the pendulum may have swung too far the other direction. Whereas they used to be considered the “last resort” for hemorrhage control, there is some newer research that is asking if we are putting them on when it is not indicated. Remember, these devices are indicated for life threatening arterial hemorrhage not amenable to any other hemorrhage control efforts.
In January 2025, the European Journal of Trauma Emergency Surgery looked at 11 years (2011-2021) of data of prehospital tourniquet application by paramedic/physician air and ground teams in Australia. They posit that the increase in prehospital tourniquet use is from tourniquet application when it was not indicated.1 For example, isolated venous bleeding and open fractures. 86 patients underwent 88 tourniquet placements.1 70% of the cases had a tourniquet placed without any attempt to control hemorrhage by a less invasive means with no arterial injury identified.1 77% of the tourniquet applications were deemed non-indicated.1 That is, not indicated by their protocol: life threatening arterial hemorrhage from penetrating trauma or amputation of an extremity that cannot be controlled by direct pressure, wound packing, etc.
In 13% of the non-indicated applications, arterial damage was discovered during surgery that was directly related to the tourniquet placement. 35% required nerve repairs.1 9 of these patients required an amputation, only 2 of which were directly related to the primary injury.1 75% of the amputations were attributed to a prolonged tourniquet time that rendered the tissues unsalvageable. This is in stark contrast to the data from the GWOT in which no amputations were attributed to tourniquet placement alone. The military also has training and provision for conversion of tourniquets to pressure dressings as soon as possible, as soon as the situation allows.
As Josh from Alert Medic 1 recently posted, a patient who has life threatening arterial hemorrhage from an extremity will likely exsanguinate before EMS/FD arrives. These are high pressure, large diameter arteries through which a patient can bleed out in as little as 3-4 minutes. By the time EMS/FD arrives, if the patient has perfusing pressures and rhythms, it is prudent to perhaps try wound packing and direct pressure BEFORE moving on to tourniquet placement. This brings up a very important point… Civilian training and “Stop the Bleed” initiatives are essential to preventing death from extremity hemorrhage. They may be the true “first responder.”
Hard Signs of Vascular Injury:3
Hard signs of vascular injury include those assessment findings for which there should be no hesitation for intervention.
Pulsatile bleeding, the classic spurting bleeding that is often seen and described with arterial bleeding.
Expanding hematoma or swelling that is seen over seconds to minutes. This is severe arterial bleeding that is happening under the skin, commonly seen with humerus and femur fractures with no breakage of the skin.
Audible bruit/palpable thrill, which are best described as being able to hear blood flow with a stethoscope, which is called bruit, or being able to feel the blood flowing from a disrupted vessel by palpation (thrill).
Pulse Deficit
Soft Signs of Vascular Trauma3
The soft signs of vascular trauma include those assessment findings that are highly suspicious for vascular injury that require further investigation and a high index of suspicion for life-threatening hemorrhage.
History of moderate hemorrhage at the scene, which usually comes in the form of a first responder or bystander reporting a massive amount of blood on the scene.
Penetrating wound(s) in proximity to vascular structures.
Diminished pulse distal to the injury.
Non-expanding hematoma.
Extremity peripheral nerve deficit.
“Why is there only one tourniquet?”
The patient is a young 22 year old male who has suffered a traumatic amputation of his right leg at the knee. The epicondyle is exposed and the flesh around the wound is ragged. Initial responders placed a single tourniquet on the thigh and have been unable to stop the hemorrhage. “It has slowed down. But we can’t get it to stop.”
A common misconception is that one tourniquet will get the job done, but this is not always the case. Josh from Alert Medic 1 gave an outstanding overview of the CAT tourniquet at the Shock Trauma EMS Conference in Baltimore this year. In that talk he broke down a huge misunderstanding of the way that device was intended to work.
The inner band, what actually tightens when you spin the windlass, is one inch wide. The minimum acceptable width for a tourniquet. The problem with this is the amount of pressure that it takes to occlude the femoral artery is often much higher than what can be generated by a single, inch-wide tourniquet. To get deeper on this, research “limb occlusion pressure.” To combat this problem there are a couple of options. 1.) Place another tourniquet proximal to the first one with no space in between them. This increases the surface area that is being compressed and has a better chance of meeting the occlusion pressure required to stop bleeding. 2.) Use a wider tourniquet, like the SAM tourniquet. This may not fix it alone, and may still require the placement of two tourniquets in order to control the bleeding. In my personal practice, I use two tourniquets for placement on the thigh and a single tourniquet for the arms and below the knee.
Another interesting episode comes from the One’s Ready Podcast. In this episode they interview Scott Zastrow, a GWOT OG 18D turned PA. He highlights some of the flawed thinking about tourniquet placement:
“Did you know this tourniquet is not tight enough?”
A farmer had his arm tangled in the drive shaft of a bush hog. The FD and EMS team were able to extricate him, and had a tourniquet in place. The man is writhing in pain and he continues to bleed heavily despite a seemingly properly placed tourniquet.
When the device is reassessed it was found that the tourniquet had failed to stop the bleeding because there was still slack in the strap. The medic was able to fit a whole finger underneath the strap. When asked, the initial responder noted that the patient was in considerable pain during tourniquet application and he stopped twisting the windlass because of the pain.
These are two common failures in tourniquet application: 1.) The strap is not tight enough. 2.) The windlass is not turned until all distal hemorrhage ceases. These are simple issues to defeat in training and practice. The strap is the most important step. Otherwise the strap bunches and twists as the operator spins the windlass, rendering the device completely ineffective.
Pain from tourniquet placement is intense. If you have practiced putting them on your teammates you hear the wailing and feel the squirming before the device is tight enough to stop the peripheral pulse. It is very unnerving to hurt someone as you attempt to help them. Stop the bleeding and begin pain management as soon as you can.
Close-Out
Tourniquets are essential to controlling life threatening hemorrhage. Like anything else we do in medicine, they have complications associated with them and we have to be deliberate in selecting the patients that receive the treatment. A graduated response to serious hemorrhage is also prudent. Like we were taught in EMT school, move from the least invasive treatment to the most invasive treatment. Wound packing and direct pressure represent the first steps of that graduated response. This is of course without the obvious hard signs of vascular trauma and arterial hemorrhage… in that case a tourniquet need be the first thing you reach for.
References:
Hedger DJ, Smith M, Weaver N, Bendall J, Balogh ZJ. Increasing prehospital tourniquet use attributed to non-indicated use: an 11-year retrospective study. Eur J Trauma Emerg Surg. 2025 Jan 24;51(1):71. doi: 10.1007/s00068-024-02716-3. PMID: 39856364; PMCID: PMC11762000.
2. Ko YC, Tsai TY, Wu CK, Lin KW, Hsieh MJ, Lu TP, Matsuyama T, Chiang WC, Ma MH. Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis. World J Emerg Surg. 2024 Mar 19;19(1):10. doi: 10.1186/s13017-024-00536-9. PMID: 38504263; PMCID: PMC10949629.
3. Feliciano DV, Moore FA, Moore EE, West MA, Davis JW, Cocanour CS, Kozar RA, McIntyre RC Jr. Evaluation and management of peripheral vascular injury. Part 1. Western Trauma Association/critical decisions in trauma. J Trauma. 2011 Jun;70(6):1551-6. doi: 10.1097/TA.0b013e31821b5bdd. PMID: 21817992.
