Massive hemorrhage is one of the leading causes of death in motor vehicle-related trauma, and with only minutes to death from a significant arterial bleed, the reality is that a percentage of salvageable casualties will die from potentially compressible bleeds prior to emergency services arriving. The authorities in the United States have recognized this fact in regard to active shooter scenarios and terrorist mass-casualty incidents, and have instituted the bystander “Stop The Bleed” campaign aimed at empowering the civilian first-responder in such a scenario to save lives (Homeland Security, 2015).
While an active shooter event or mass-casualty terrorist incident remains an unfortunate possibility in our current world climate, a far more likely instance in which the life-saving skills of massive hemorrhage control might be required is a motor vehicle accident.
As per the Stop The Bleed infographic above, if external bleeding can be seen, and you have decided to act to stop it (considering the danger of the situation and risk of potential blood-borne virus exposure) the initial technique is firm, direct pressure to the wound. Research shows that the maximum pressure achievable with a firm pressure dressing will be around 90mmHg (Naimer 2000), which will be enough to control most bleeding from the low-pressure venous system.
However, if the bleeding is from a severed artery, a pressure dressing alone may not be enough to stop it. Normal peak pressures in the arteries of an adult range from 120-140 mmHg, and under duress or in pain, such as a casualty situation, may exceed 200 mmHg. Looking at those numbers, it can be seen that a firm pressure dressing may be inadequate to control bleeding, and an arterial tourniquet might be appropriate. This tourniquet should be placed around 5-10cm (2-4 inches) above the level of the injury on an arterially bleeding limb.
If a commercially made arterial tourniquet is available, then the problem is solved fairly easily by the skilled first-responder following the steps below:
The life-saving application of an arterial tourniquet by two appropriately trained police officers can be seen in the video below.
The only problem with this is how many of us (aside from me) carry an arterial touniquet in their car boot and work backpack? Not many, I’m sure. So is it possible to improvise an arterial tourniquet from readily available materials, and if so, how?
The answer is yes, and the key to improvising a successful arterial tourniquet lies in the use of a windlass device. A review of all of the tourniquets placed on amputated or arterially bleeding limbs after the Boston Marathon bombing showed that all were improvised, none used a windlass, and assessed that most, if not all, were largely ineffective (King DR 2015; Kragh JF 2015). The failure lay in the lack of windlass device, with the improvised tourniquets being items of clothing or belts tied tightly around limbs as illustrated below:
This is not intended to discredit the first responders at the Boston Marathon; their rapid and decisive actions in treating and evacuating the wounded unquestionably saved many lives. The issue, however, with applying an improvised tourniquet to a limb—one that cuts off the venous system but is not tight enough to occlude the arterial system—is that blood will continue to flow into the injured limb, so the wound will continue to bleed, and the remaining blood will be trapped in the limb as illustrated below. This has the unwanted effect of increasing the pressure in the injured limb and actually worsening the prognosis for the casualty.
Research has demonstrated that 99 percent of improvised tourniquets without a windlass will fail to effectively stop arterial bleeding (Altamirano MP 2015), and even with a windlass, around 30 percent of tourniquets will fail (Altamirano MP 2015). The choice of improvised windlass is also crucial, as items such as pencils and small craft sticks have been demonstrated to break 75-80 percent of the time before sufficient pressure has been applied to a tourniquet to occlude arterial blood flow (Kragh JF 2015).
With all of that in mind, I wanted to see whether I could improvise an effective tourniquet from items I had in the boot of my car, to simulate common things that would be readily at hand in a car crash scenario.
Using a length of an old towel and a jack handle, I was able to fabricate an improvised arterial tourniquet that, within 45 seconds, occluded the blood flow to one of my legs (proven by an absence of palpable foot pulses). The technique was as follows:
I certainly appreciate that, as a trial of one, done on myself, this experiment holds no scientific credibility (for the science behind improvised tourniquets, please see Altamirano et al. 2015 and Kragh et al. 2015). This was not the point of the exercise; it was simply to demonstrate that an effective arterial tourniquet could be rapidly fabricated and applied in a car crash scenario with items that would be readily available. The goal of this article is to seed the thought in the reader’s mind of what might be used to fabricate an effective tourniquet in an extreme situation where commercially available medical equipment is not at hand.
The choices of equipment one can use for an improvised tourniquet are almost limitless. However, for it to have the best chance of working, a tight band, ideally of 5 centimeter (2 inch) width, needs to be wrapped around the limb, approximately 5-10 centimeters (2-4 inches) above the site of arterial bleeding, and a windlass of appropriate strength must then be used to tighten the device. The windlass must then be held under tension until emergency services arrive to take over, or an effective solution to locking it in place can be fabricated.
It must be noted that this improvised tourniquet was extremely painful when applied to the tension required to occlude arterial flow. The use of such an improvised device would be in extremis only, however, when the chips are down, having the skills to fabricate and apply one might just save a life!
Of course, a better solution to the problem would be to have an appropriately stocked car medical kit. For the contents of such a kit, as compiled by a former special operations soldier and current TacMed Australia colleague of mine, please click on this link.
As always, comments and questions are welcome.
Kind regards, Dan Pronk
References:
Altamirano MP, KJ, Aden JK, Dubick MA 2015, ‘Role of the Windlass in Improvised Tourniquet Use on a Manikin Hemorrhage Model’, Journal of Special Operations Medicine, vol. 15, no. 2, pp. 42-46.
HomelandSecurity 2015, ‘Stop The Bleed’, viewed 10 December 2015,<http://www.dhs.gov/sites/default/files/images/oha/infographic_stopthebleed_02.jpg%3E.
King DR, LA, Ramly EP, BostonTraumaCollaborative 2015, ‘Tourniquet use at the Boston Marathon bombing: Lost in translation’, The Journal of Trauma and Acute Care Surgery, vol. 78, no. 3, pp. 594-599.
Kragh JF, WT, Aden JK, Dubick MA, Baer DG 2015, ‘Which Improvised Tourniquet Windlasses Work Well and Which Ones Won’t?’, Wilderness and Environmental Medicine, vol. 26, no. 3, pp. 401-405.
Naimer, S, Chemla, F 2000, ‘Elastic adhesive dressing treatment of bleeding wounds in trauma victims’, American Journal of Emergency Medicine, vol. 18, pp. 816-819.
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