Tourniquets

BACKGROUND: Just over 200 years ago, surgeons were puzzled that the use of the tourniquet to control hemorrhage as common sense during surgery was a relatively recent development. Within the last 20 years, much progress has been made to controlling hemorrhage in the prehospital context. Then, as now, it was surprising that progress on something that appeared obvious had occurred only recently , begging the question how controlling blood loss was common sense in a surgical context, but not for emergency treatment. METHODS: This article is a historical survey of the evolution of the medical understanding of hemorrhage along with technological response. RESULTS: The danger of blood loss had historically been consistently underestimated as physicians looked at other explanations for symptoms of how the human body responded to trauma. As the danger from hemorrhage became apparent, even obvious, responsibility for hemorrhage control was delegated down from the surgeon to the paramedic and eventually to individual service members and civilian bystanders with training to " stop the bleed. " CONCLUSION: Hippocratic medicine assumed that blood diffused centrifugally into periphery through arteries. William Harvey's observation in 1615 that blood ran through a closed circulatory system gradually transformed conventional wisdom about blood loss, leading to the development of the tourniquet about a century later by Jean-Louis Petit, which made amputation of limbs survivable. However , physicians were cautious about their application during the First World War over concerns over effects on patient recovery. Hemorrhage had generally been seen as symptom to be managed until the patient would be seen by a surgeon who would stop the bleeding. More thorough collection and analysis of data related to case histories of soldiers wounded during the Vietnam Conflict transformed how surgeons understood the importance to hemorrhage leading to development of the doctrine of Tactical Combat Casualty Care in the late 1990s. (J Trauma Acute Care Surg. 2018;85: S13–S17.

Given the recent success of emergency tourniquets, limb exsanguination is no longer the most common cause of preventable death on the battlefield; hemorrhage amenable to truncal tourniquets now is. The purpose of the present study is to discuss the gaps today in battlefield hemorrhage control and candidate solutions in order to stimulate the advancement of prehospital combat casualty care. A literature review, a market survey of candidate devices, a request for devices, and an analysis of the current situation regarding battlefield hemorrhage control were performed. Hemorrhage control for wounds in the junction between the trunk and the limbs and neck is a care gap in the current war, and, of these, the pelvic (including buttock and groin proximal to the inguinal ligament) area is the most common. Historical and recent reports give background information indicating that truncal tourniquets are plausible devices for controlling junctional hemorrhage on the battlefield. A request for ...

Les vagues d’attentats en France depuis les années 1980 ont apporté à la pratique civile l’expérience du polymorphisme des mécanismes vulnérants physiques et psychiques du terrorisme. Les enseignements tirés des confl its militaires de la prise en charge de nombreuses victimes dans les premières minutes sont à diffuser à tous les professionnels de santé et largement à la population. Les objectifs des “gestes qui sauvent” sont simples, clairs, et leurs applications permettent de limiter le nombre de morts évitables (sauver) et les conséquences des blessures (mieux sauver). Dans ces situations, l’hémorragie est la première cause de mortalité, à stopper idéalement dans les dix premières minutes dites de “platine” ou dans la “demi-heure hémorragique” faisant le pronostic vital.

Dengue haemorrhagic fever (DHF), a public problem in most of the tropical countries of South-East Asia, is diagnosed on the basis of demonstrating an increased capillary permeability and thrombocytopenia with concurrent haemoconcentration. Tourniquet test has been recommended as the initial screening procedure of patients with suspected DHF, particularly grade I DHF. The objective of the present study was to study the value of this test as an indicator of haemorrhagic tendencies in patients of DHF. One hundred and ten adult patients hospitalized with DHF during outbreak of DHF in 1996 in north India were prospectively studied. The diagnosis of DHF was considered on the basis of haemoconcentration > 20%, evidence of transudation, or presence of shock along with thrombocytopenia. A tourniquet test was conducted in these cases in the standard method. Of the 110 patients of DHF studied, 62 patients (56.4%) had bleeding but tourniquet test was positive in only half of these patients. ...

Perioperative blood loss during total knee arthroplasty can be significant, with magnitudes typically ranging from 300 mL to 1 L, with occasional reports of up to 2 L. The resultant anemia can lead to severe complications, such as higher rates of postoperative infection, slower physical recovery, increased length of hospital stay, and increased morbidity and mortality. Although blood transfusions are now screened to a greater extent than in the past, they still carry the inherent risks of clerical error, infection, and immunologic reactions, all of which drive the need to develop alternative blood management strategies. Thorough patient evaluation is essential to individualize care through dedicated blood management and conservation pathways in order to maximize efficacy and avoid associated complications. Interventions may be implemented preoperatively, intraoperatively, and postoperatively.

The amount of blood loss in a primary cemented total knee arthroplasty (TKA) seems to vary in different reported studies. We carried out a prospective study to determine the factors affecting the peri-operative blood loss, hidden blood loss and blood transfusion requirements in a primary cemented total knee arthroplasty. The factors analysed were gender, diagnosis, tourniquet time and body mass index (BMI). We included a total of 66 consecutive patients who underwent primary TKA by a single surgeon (A.M). There was significantly more peri-operative blood loss in male patients than in females (p=0.001, Student’s t test). The patients with rheumatoid arthritis did not show any statistical difference in peri-operative blood loss compared with that in patients with osteoarthritis. The tourniquet time and the surgical time showed a positive correlation with peri-operative blood loss. The BMI did not show any correlation with peri-operative blood loss. The incidence of blood transfusion was significantly higher in patients with rheumatoid knees as their pre-operative haemoglobin value was low. The amount of hidden blood loss in our series was 38%. We concluded that gender and tourniquet time plays a role in blood loss in TKA, but diagnosis (advanced osteoarthritis [OA] or rheumatoid arthritis (RA) does not. The blood transfusion depends on both pre-operative haemoglobin value and intra-operative blood loss. The post-operative transfusion trigger can be brought to 8.0 g% in a haemodynamically stable patient. La quantité de perte de sang dans une prothèse totale du genou de première intention cimentée est variable suivant les différentes études. Nous avons réalisé une étude prospective pour déterminer quels étaient les facteurs de la perte sanguine péri-opératoire et quels étaient les facteurs qui entraient dans la nécessité d’une transfusion, après une prothèse totale du genou de première intention. Les facteurs analysés ont été le sexe, le diagnostic, l’utilisation d’un garrot, le BMI. Nous avons inclus dans cette étude, 66 patients consécutifs, opérés par le même chirurgien (A.M.). Il y a eu une de façon significative une augmentation des pertes sanguines péri-opératoires chez les patients de sexe masculin (p=0.001, Student’s t test). Les patients présentant une arthrite rhumatoïde n’ont pas montré de différences significatives dans la perte de sang, comparés aux patients opérés pour gonarthrose. Le temps de garrot et le temps opératoire sont en corrélation avec les pertes de sang péri-opératoires, l’augmentation du BMI ne semble pas avoir de corrélation avec la perte sanguine. L’incidence des transfusions est de façon significative plus élevée chez les patients opérés pour arthrite rhumatoïde du genou et dont l’hémoglobine préopératoire était basse. Nous pouvons en conclure que le sexe et le temps de garrot ont une responsabilité dans la perte de sang dans la prothèse totale du genou mais, certainement pas l’étiologie. La nécessité de transfusion dépend du taux d’hémoglobine pré-opératoire et des pertes sanguines per-opératoires. Une transfusion peut être pratiquée pour 8.0 g% chez un patient haemodynamiquement stable.