Humans have always tried to find ways to help the human body survive and recover. For this purpose, they found healthy eating habits, herbs to treat and prevent diseases, and also medical instruments to use in the medical treatment of the patients. Such an instrument that humans have been using for centuries is a Tourniquet cuff. It has been reported that in the fourth century BC, Alexander the Great’s military campaigns included the use of tourniquets to control the bleeding of wounded soldiers.
These tourniquets were made of bronze and leather was used for comfort. Romans used these tourniquets mostly during amputations to control the bleeding. Even in history when most of the men died in battles due to loss of so much blood to cause death, Sir Gilbert Blane who instituted health reforms in the royal navy once asked every man in the battle to carry his own tourniquet so that in case of an injury, the soldier could use it to stop the bleeding before receiving medical care.
Thigh tourniquet used by Romans in 199 BCE – 500 CE
Types of tourniquets
A tourniquet is a device that is used to stop the flow of blood by applying pressure to a limb or extremity. There are three types of tourniquet cuffs. The simplest type of handmade tourniquet cuffs can be made using a rope and a stick. Some types of tourniquets cuffs are as follows
These silicone ring tourniquets or elastic ring tourniquets do not require any wires, tubes, or electricity. These tourniquets are available in several sizes and by determining the patient’s blood pressure and limb circumference, the ideal tourniquet can be found for the patient. Another tourniquet used is called a pneumatic tourniquet. These double-cuff pneumatic tourniquets are used in surgeries to limit the blood flow from a limb. The majority of surgical tourniquets are placed by two persons on the patient’s limb where one person is responsible for holding the patient’s limb while the other places the device on the limb.
Zimmer tourniquet cuffs
Emergency tourniquets are used to stop the bleeding before hospital care is given. These are usually applied by first aid responders or the injured person himself. These tourniquets are applied to the injured limb and tightened to occlude the blood vessels which helps to control bleeding. These emergency tourniquets can be lifesaving as this help to stop the blood flow till proper medical care is given to the patient.
Silicone ring auto-transfusion tourniquet
A silicone ring auto-transfusion tourniquet (SRT/ ATT/ EED) or surgical auto-transfusion tourniquet consists of a stockinet, a silicone ring, and pull straps. These tourniquet cuffs help to stabilize a patient in the operating room or in emergency medicine. This is used until further treatment is applied.
Combat application tourniquet
The Combat application tourniquet (CAT) has been adopted by militaries and emergency personnel all around the world. It was developed by Ted Westmoreland. A small tourniquet is provided to soldiers that can be self-applied. It is used by the U.S. military, by NHS ambulance service, and Fire and rescue services in the UK.
Combat application tourniquet (CAT)
A tourniquet is used in rehabilitation settings to restrict arterial blood flow at a consistent and safe pressure for a short period of time during low-intensity exercise to increase muscle size and strength.
Uses of tourniquets
The most important use of tourniquet cuffs is to stop the life-threatening flow of blood to save a patient’s life. These are used as a bleeding control method by many emergency medical services till proper medical care is provided to the patient.
Tourniquets are used in knee replacement surgery to reduce the blood flow to the knee. These are also used in amputation to help surgeons in blood-free operations.
What are tourniquets made of?
Tourniquets can be made even using a rope and a stick. Romans used these tourniquets that were made of narrow straps of bronze and used leather for comfort. Tourniquets were made of a simple garrot and a twisting rod to tighten them until 1718 when a French surgeon, Jean Louis Petit developed a screw device to control the flow of blood at surgical sites. In the 2000s, Noam Gavriely, a professor of medicine and former emergency physician created the silicon ring tourniquet or elastic tourniquet which is made of an elastic ring made of silicone, stockinet, and for the purpose of rolling the device onto the limb, he used pull straps made of ribbon. Single and double cuffs are also used as per the requirement of the condition.
Tourniquets are made using Velcro and some are made of stretchy material. The disposable cuff is also used that are one-time use cuffs and can be thrown away after use. The technology used in the manufacturing of tourniquet cuffs started from simple cloth bands wrapped tightly around limbs and improved with the development of mechanical screw tourniquets, non-pneumatic Esmarch tourniquets, and microprocessor-controlled pneumatic tourniquets. A tourniquet cuff price varies according to the type and size of the tourniquet cuffs used.
What can be the possible side effects of using tourniquets?
Several side effects are associated with the use of tourniquet cuffs. These side effects can happen because of very high or very low pressure. These problems can also occur due to prolonged use of the tourniquet cuffs. Some of the side effects associated with the use of tourniquet cuffs are as follows
Tourniquet inflation causes an increase in the patient’s heart rate, and systolic, and diastolic pressures after 30 to 60 minutes of inflation. These changes do not go away until tourniquet deflation which is a critical process of its effects on the central venous pressure and mean arterial pressures. Tourniquet deflation can cause a sudden drop in central venous pressure and mean arterial pressures that can cause cardiac arrests in some patients after tourniquet deflation. These problems often happen to patients with poor cardiac function.
Respiratory changes are often seen during the deflation stage and are rare. The cause of these effects is the transient increase in end-tidal carbon dioxide tension due to the efflux of hypercapnic venous blood and metabolites into the systematic circulation.
Changes in body temperature have been reported during the tourniquet inflation and deflation stages. Tourniquet inflation causes the body temperature to increase and the temperature falls during tourniquet deflation. During surgery, this sudden fall in temperature can be reduced by maintaining core body normothermia.
Patients can experience a dull, tight, and aching sensation at the site of the tourniquet application. Several techniques like the application of EMLA cream, infiltration with local anesthetics, use of wider cuff with lower inflation pressure, epinephrine along with local anesthetics in the spinal block, and the addition of opioids, and clonidine have been tried to reduce this pain but none of these helps to provide successful pain relief. Ketamine, Dexmedetomidine, magnesium sulfate, and clonidine remifentanil infusions have also not shown any positive results in successfully providing tourniquet pain relief. The only successful method of tourniquet pain relief is tourniquet deflation.
The use of tourniquet cuffs can cause skin abrasions, blisters, bruising, and breaks. Chemical injuries to the skin and subcutaneous tissues under the tourniquet cuffs can also cause discomfort for the patient. Tourniquet cuffs can cause damage to a person’s skin because of the pressure. It is more common in old patients who have delicate skin and subcutaneous tissues. It can also happen to people who are diabetic.
The use of a tourniquet can cause mild loss of function and even paralysis. Also, intraoperative bleeding can also happen because of the following reasons:
• An under-pressurized cuff
• Improper cuff selection
• Loosely applied cuff
• Calcified vessels
• Too slow inflation of the tourniquet cuffs
• Too slow deflation of the tourniquet cuffs
• Insufficient exsanguination
Nerves and tissue injury
The use of tourniquets in orthopedic surgery can help in surgery by providing blood-free surgical fields but these can cause temporary and permanent injury to the underlying muscles and blood vessels. Nerves and soft tissues. However, with recent advances in the technology used in tourniquet production, these problems are decreasing.
Apart from the side effects mentioned above, extreme care should be taken in the tourniquet application of people who already have any medical condition to reduce the risk of any problem. The people with the following diseases should be carefully monitored and taken care of during tourniquet application.
• People who have sickle cell disease
• People having severe crush injury
• Diabetic neuropathic patients
• People having severe peripheral vascular disease
• Patients who have a history of deep vein thrombosis and pulmonary embolism
Tourniquet cuffs have a long history and have been used for centuries for various reasons. They may have changed technology and appearance but they still provide many benefits most importantly in surgeries and emergency situations. When used properly, tourniquet cuffs can be lifesaving and help in saving a patient’s blood which is extremely important. However, there are certain risks associated with the use of these tourniquet cuffs that should be taken care of. Therefore it is highly significant to be aware of the threats that the use of tourniquet cuffs pose. These complications are certainly rare but if they happen they can be disastrous.