4-9. DETERMINING IF A TOURNIQUET IS REQUIRED
A tourniquet is a constricting band placed around an extremity to stop arterial bleeding by stopping blood circulation to the part of the limb below (distal to) the tourniquet. A tourniquet is only used on an arm, forearm, thigh, or leg when there is a danger of the casualty bleeding to death.
WARNING: A tourniquet is not used for wounds to the head, neck, or trunk (chest and abdominal area).
a. Wound on an Extremity. Bleeding from a major artery of the thigh, lower leg, arm, or forearm and bleeding from multiple arteries may prove to be beyond control by the methods discussed in Section II. If you have applied a pressure dressing and firm hand pressure, but the dressing has become soaked with blood and the wound continues to bleed, apply a tourniquet.
NOTE: The tactical situation may not allow the time or safety for conventional methods of controlling the bleeding if you are under fire. The recommended means to control bleeding while under fire is a rapidly applied tourniquet. Tourniquets may be left in place for two hours without major complications.
REMEMBER If you are unable to control bleeding except with a tourniquet, it is better to sacrifice a limb than to lose a life due to excessive bleeding.
(1) An amputation may be complete (the limb is completely severed) or partial (the two parts of the limb remain connected by some skin or other tissue). Both require a tourniquet. Both involve bleeding from multiple arteries and are beyond control by the methods discussed in Section II.
(2) A person whose has suffered an amputation of the arm, forearm, thigh or leg may not be bleeding severely when first discovered, but a tourniquet should be applied anyway. Lack of bleeding is due to the body’s normal defenses (contraction and spasm of blood vessels) because of the amputation. However, bleeding will start when the blood vessels relax or if the clot is knocked loose while moving the casualty.
4-10. APPLYING A COMBAT APPLICATION TOURNIQUET
A Combat Application Tourniquet (CAT) (figure 4-6) is the tourniquet of choice. It is effective and can be applied quickly. Use the CAT from the soldier’s Improved First Aid Kit (IFAK). Procedures for applying the CAT are given below.
NOTE: The Combat Application Tourniquet in figure 4-6 is shown in its one-handed application configuration. The CAT is delivered in this configuration and is the recommended storage configuration.
(1) Remove the CAT from its pouch.
(2) Slide the wounded extremity through the loop formed by the tourniquet band (figure 4-7A).
(3) Position the CAT so the tourniquet band is two inches above the wound.
(5) Adhere the tourniquet band around the limb (figure 4-7C).
NOTE: Do not adhere the tourniquet band past the rod-locking clip.
(6) Twist the windlass rod to tighten the tourniquet band (figure 4-7D). Continue tightening until the bright red arterial bleeding has stopped and the distal pulse is eliminated. The darker bleeding from the veins may continue draining for a while.
(7) Place the windlass rod inside the rod-locking clip, locking the rod in place and keeping the tourniquet from untwisting (figure 4-7E).
(8) Check to make sure that the arterial bleeding has not started again and the distal pulse is still absent. If arterial bleeding has resumed or the pulse is present, remove the windlass rod from the clip, tighten the tourniquet band until the bleeding and/or pulse are absent, and replace the rod in the clip.
(9) Adhere the end of the tourniquet band over the rod, inside the clip, and fully around the limb (figure 4-7F).
(10) Secure the windlass rod and tourniquet band with the rod-securing strap. The CAT is now properly applied and the casualty is ready for transport. If the casualty is not to be transported at this time, check the tourniquet periodically.
b. Two-Handed Application. The two-handed application is normally used for the lower extremity when greater pressure is needed to stop the bleeding. The two-handed application is always used when the tourniquet is applied to the casualty’s thigh. The two-handed application is also used if the tourniquet band has become dirty since the friction buckle locks the band in place and help to prevent loosening during transportation.
NOTE: The CAT friction buckle is used with the two-handed application, but is not normally used with the one-handed application.
(1) Remove the CAT from its pouch.
(2) Route the tourniquet band around the casualty’s limb so that the band is two inches above the wound.
(3) Pass the red tip of the tourniquet band through the inside slit of the friction buckle (figure 4-8A) and pull the tourniquet band tight.
(4) Pass the red tip of the tourniquet band through the outside slit of the friction buckle (figure 4-8B). The friction buckle will lock the tourniquet band in place.
NOTE: When the tourniquet band is pulled tight and secured, no more than three fingers will fit between the tourniquet band and the limb.
(6) Twist the windlass rod using both hands to tighten the tourniquet band (figure 4-8D). Continue tightening until the bright red arterial bleeding has stopped and the distal pulse is eliminated. The darker bleeding from the veins may continue for a while.
(7) Place the windlass rod inside the rod-locking clip, locking the rod in place and keeping the tourniquet from untwisting (figure 4-8E).
(8) Check to make sure that the arterial bleeding has not started again and the distal pulse is still absent.
(a) If arterial bleeding has resumed or the pulse is present, apply a second tourniquet proximal to the first tourniquet.
(b) If a second tourniquet is applied, reassess to make sure the arterial bleeding is controlled and the distal pulse is absent. Do not remove the first tourniquet.
(c) If the second tourniquet does not control the arterial bleeding, transport the casualty as soon as possible.
(9) Secure the windlass rod and tourniquet band with the rod-securing strap (figure 4-8F). The CAT is now properly applied and the casualty is ready for transport. If the casualty is not to be transported at this time, check the tourniquet periodically.
c. Storing the Combat Application Tourniquet. Follow the following procedures if you need to store an opened Combat Application Tourniquet.
(1) Pass the red tip of the tourniquet band through the inside slit in the friction buckle.
(2) Pull six inches of the tourniquet band through the slit, fold the tourniquet band back, and adhere the tourniquet band to itself (figure 4-9A).
(3) Flatten the loop formed by the tourniquet band, placing the friction buckle in the middle of the flattened tourniquet band (figure 4-9B).
(4) Fold the CAT in half so the friction buckle is at one end (figure 4-9C).
(5) The CAT is now ready to be placed in your medical equipment set or other container.
4-11. APPLYING AN IMPROVISED TOURNIQUET
In the absence of a specially designed tourniquet such as the CAT, a tourniquet may be made from a strong, pliable material such as gauze, a muslin bandage, or a strip of material torn from clothing. An improvised tourniquet is used with a rigid stick-like object to act as the windlass rod. To minimize skin damage, ensure that the improvised tourniquet is at least two inches wide.
a. Gather Materials for Making a Tourniquet.
(1) Tourniquet band. You need a band of strong, pliable material that is at least two inches wide when folded and will retain this width after being tightened. A folded muslin bandage (usually called a cravat), a folded handkerchief, or a folded strip of clothing will do. A belt, rope, strap from load bearing equipment (LBE), roller gauze, or a torn sleeve can also be used. Do not use wire or shoestrings as a tourniquet band. A wide tourniquet will protect the tissue beneath the tourniquet when it is tightened. If a very narrow tourniquet is used, the nerves and blood vessels beneath the tourniquet may be seriously damaged.
NOTE: Figure 4-10 illustrates how to fold material into a cravat. The square material is cut in half along the diagonal (base) to form two triangular bandages. Each triangular bandage can be made into a cravat.
(2) Rigid windlass. A rigid windlass is needed to tighten the tourniquet band. A windless device can be made by placing seven or eight tongue depressors together, one on top of the other, and wrapping duct tape around the tongue depressors. You can make this device prior to the mission and keep it in your aid bag. If you do not have such a windlass, a strong rigid object can be used as shown in figures 4-12 and 4-13.
(3) Securing materials. Additional material is needed to secure the rigid windlass once the tourniquet band has been tightened. A piece of cloth or cravat similar to the tourniquet band can serve as securing material.
b. Select the Tourniquet Site. Select a site two to four inches above the edge of the wound or amputation site.
(1) If the wound or amputation site is in the upper arm or thigh, select a site that is two to four inches above the edge of the wound or amputation site.
(2) If the wound or amputation is below the elbow or knee, initially select a site two inches above the edge of the wound or amputation site. If an improvised tourniquet applied below the knee or elbow is unsuccessful at stopping the bleeding, apply a second tourniquet two to four inches above the joint (knee or elbow). Do not remove the first tourniquet until the second tourniquet has been applied.
CAUTION: Do not place a tourniquet over a joint or over a fracture site.
c. Apply the Improvised Tourniquet.
(1) Place the tourniquet band material around the tourniquet site.
(2) Tie the band with a half-knot (the same as the first part of tying a shoe) (figure 4-11).
(3) Place the windlass on top of the half-knot.
(4) Tie a full knot (square knot) over the windlass (figure 4-12).
(5) Twist the windlass (figure 4-13) either clockwise or counterclockwise until the tourniquet is tight and the bright red bleeding has stopped. Bright red blood is from a severed artery. Generally, darker blood is from a vein. Dark blood may continue to ooze even after the tourniquet has been properly applied. When the tactical situation permits, check for a pulse below the tourniquet. There should be no pulse below the tourniquet. If a pulse still exists, try to tighten the tourniquet more. If tightening the tourniquet does not eliminate the distal pulse, apply a second tourniquet just above the original one, tighten it, and recheck the pulse.
(6) Wrap a piece of securing material, such as a cravat or torn strip of clothing, around the limb. Then wrap the ends of the material around one end of the windlass so that the windlass is secured and the tourniquet band will not unwind.
NOTE: Tape from your aid bag can be used to secure the windlass in stead of a strip of material or cravat.
7) Tie the tails of the securing material in a nonslip knot (figure 4-14).
Figure 4-15 shows improvised tourniquets applied to amputations of the legs.
Write a “T” and the time of application on the casualty’s skin with an indelible marker. The “T” alerts medical personnel that a tourniquet has been applied. The Combat Application Tourniquet (CAT) has a place on the securing strap where you can record the time of application instead of writing the time on the casualty’s skin.
4-13. DRESSING AN AMPUTATION
After the tourniquet has been applied to an amputation of the arm or leg, place a dressing made of soft, absorbent material over the end of the stump and secure the dressing with bandages. The dressing will help to prevent additional contamination of the wound. It will also help to protect the wound from additional injury.
4-14. MONITORING A CASUALTY WITH A TOURNIQUET IN PLACE
Take measures to ensure that the tourniquet is performing its function.
a. When the tactical situation permits, check the casualty for a pulse distal to tourniquet. If a pulse is present, attempt to tighten the tourniquet more or apply another tourniquet side-by-side and proximal (above) to the existing tourniquet. This measure will help to prevent a compartment syndrome or expanding hematoma from threatening the viability of the extremity.
b. If a tourniquet applied below the knee or elbow does not control the arterial bleeding, apply another tourniquet two inches above the joint.
c. Do not cover the tourniquet. Leave the tourniquet in full view so medical personnel can locate it quickly.
d. Any time you move the casualty, recheck the tourniquet to make sure it is still controlling the bleeding.