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Blutstillung mittels Tourniquet in der präklinischen Notfallmedizin

Hemostasis with a tourniquet in preclinical emergency medicine

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An Erratum to this article was published on 26 July 2013

Zusammenfassung

Hintergrund

Bisher galt der Einsatz von Tourniquets aufgrund der häufig beobachteten Nebenwirkungen und Komplikation als obsolet und wurde, wenn überhaupt, nur als Ultima ratio bei lebensbedrohlichen Extremitätenblutungen nach dem Motto „life before limb“ eingesetzt. Gründe für die Nebenwirkungen und Komplikationen waren v. a. Anwendungsfehler sowie der Einsatz schlecht konstruierter Produkte.

Aktuelle Situation

Der Verlust einer Extremität aufgrund eines Tourniquet-Einsatzes stellt eine Rarität dar. Mittlerweile werfen die positiven Erfahrungen des Militärs bei den Konflikten im Irak und in Afghanistan ein neues Licht auf diese Form der Blutstillung. Bei einem protokollbasierten rationalen Einsatz bewährter und getesteter Tourniquets durch trainierte Anwender kann die Verwendung von Tourniquets bei einer Anlagedauer von bis zu 2 h als eine sichere, schnelle und v. a. lebensrettende Maßnahme eingestuft werden. Dies wird durch die aktuelle Datenlage belegt.

Schlussfolgerungen

Zukünftig sollten deshalb im zivilen Rettungsdienst industriell gefertigte Tourniquets vorgehalten und SOP-basiert eingesetzt werden. Die wichtigste Maßnahme, um mögliche Komplikationen abzuwenden, ist die Schulung des medizinischen Personals in der korrekten Anwendung sowie die Durchführung eines regelmäßigen Trainings. Für Spezialeinheiten der Behörden (SEK/MEK, GSG9, etc.) ist es sinnvoll, in taktischer Einsatzmedizin ausgebildetes Personal innerhalb der Einheiten einzusetzen, welches in einer „Care-under-Fire-Situation“ eine massive Extremitätenblutung mittels Tourniquet kontrollieren kann, noch bevor der Patient an den Rettungsdienst übergeben und durch diesen weiterbehandelt wird. Speziell für die taktische Verwundetenversorgung wurden in Deutschland bereits Richtlinien durch die TREMA e. V (Tactical Rescue & Emergency Medicine Association) ausgearbeitet.

Abstract

Background

Until recently the use of tourniquets was considered to be obsolete due to the known side effects and complications. Tourniquet application was seen as a last resort to stop life-threatening extremity bleeding by placing “life before limb”. In the past the main reasons for complications were application errors and the use of poorly designed products.

Present situation

The actual loss of a limb due to tourniquet use is a rarity and now the positive experiences of the military conflicts in Iraq and Afghanistan are throwing a new light on this method to “stop the bleeding”. The SOP-based application of modern trusted and tested tourniquets by trained users for a period up to 2 h is considered to be a fast, safe and life-saving procedure.

Conclusions

This evidence is reflected by the current data; therefore, the civilian emergency services should be provided with commercially manufactured tourniquets. To prevent potential complications it is important that civilian medical personnel are regularly trained in the correct SOP-based use of tourniquets. Special police units should have personnel trained in tactical combat casualty care in the units who can control massive limb bleeding in a “care under fire” situation by tourniquet use before the civilian emergency medical services take over casualty care. In Germany the Tactical Rescue and Emergency Medicine Association (TREMA) has developed specific guidelines for tactical casualty care.

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Literatur

  1. Kragh JF Jr, Swan KG, Mabry RL et al (2011) Historical review of emergency tourniquet use to stop bleeding. Am J Sur 203(2):242–252

    Article  Google Scholar 

  2. Tourniquet Recommendations from USAISR 28 July 2004, http://www.delfimedical.com/8-usaisr-tourniquet-recomendation.pdf?SiteID=d1d7441a-c53c-473f-a3f8-3b6b92c9c516&V=0

  3. Beekley AC, Sebesta JA, Blackbourne LH et al (2008) Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control. J Trauma 64(2):S28–S37

    Article  PubMed  Google Scholar 

  4. Childers R, Tolentino JC, Leasiolagi J et al (2011) Tourniquets exposed to the Afghanistan combat environment have decreased efficacy and increased breakage compared to unexposed tourniquets. Mil Med 176(12):1400–1403

    PubMed  Google Scholar 

  5. Kalish J, Burke P, Feldman J et al (2008) The return of tourniquets: original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries. JEMS 33(8):44–54

    PubMed  Google Scholar 

  6. Kragh JF Jr, Littrel ML, Jones JA et al (2011) Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med 41(6):590–597

    Article  PubMed  Google Scholar 

  7. Doyle GS, Taillac PP (2008) Tourniqutes: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care 12:241–256

    Article  PubMed  Google Scholar 

  8. Kragh JF Jr, O’Neill ML, Walters TJ et al (2011) Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: research, history, and reconciling advocates and abolitionists. Mil Med 176(7):817–823

    PubMed  Google Scholar 

  9. Kragh JF Jr, Walters TJ, Baer DG (2008) Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 64(2 Suppl):S38–S49

    Article  PubMed  Google Scholar 

  10. Kragh JF Jr, O’Neill ML, Walters TJ (2011) The military emergency tourniquet program’s lessons learned with devices and designs. Mil Med 176(10):1144–1152

    PubMed  Google Scholar 

  11. Brodie S, Hodgetts TJ, Ollerton J et al (2007) Tourniquet use in combat trauma: UK military experience. J R Army Med Corps 153(4):310–313

    Article  PubMed  Google Scholar 

  12. Kragh JF Jr (2010) Use of tourniquets and their effects on limb function in the modern combat environment. Foot Ankle Clin 15(1):23–40

    Article  PubMed  Google Scholar 

  13. Lakstein D, Blumenfeld A, Sokolov T et al (2003) Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 54(Suppl 5):S221–S225

    PubMed  Google Scholar 

  14. Lee C, Porter KM, Hodgetts TJ (2007) Tourniquet use in the civilian prehospital setting. Emerg Med J 24(8):584–587

    Article  PubMed  CAS  Google Scholar 

  15. Champion HR, Bellamy RF, Roberts CP et al (2003) A profile of combat injury. J Trauma 54(Suppl 5):S13–S19

    PubMed  Google Scholar 

  16. Majno G (1991) The healing hand: man and wound in the ancient world. Commonwealth Fund Publications

  17. Parker PJ, Clasper J (2007) The military tourniquet. J R Army Med Corps 153(1):10–15

    PubMed  CAS  Google Scholar 

  18. Richey SL (2007) Tourniquets for the control of traumatic hemorrhage: a review of the literature. World J Emerg Surg 2:28

    Article  PubMed  Google Scholar 

  19. Maury AC, Roy WS (2002) A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance. J Hand Surg Br 27(4):359–360

    Article  PubMed  CAS  Google Scholar 

  20. Taylor DM, Vater GM, Parker PJ (2011) An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage. J Trauma 71:591–595

    Article  PubMed  Google Scholar 

  21. Walters TJ, Wenke JC, Baer DA (2004) Research on tourniquet related injury for combat casualty care. ftp://ftp.rta.nato.int/Pubfulltext/RTO/MP/RTO-MP-HFM-109///MP-HFM-109-P33.pdf

  22. Lechner R, Achatz G, Hauer T et al (2010) Verletzungsmuster und – ursachen in modernen Kriegen. Unfallchirurg 113:106–113

    Article  PubMed  CAS  Google Scholar 

  23. Fischer C, Josse F, Helm M (2010) „Stop the bleeding“! Neue Aspekte der Blutstillung aus dem zivilen und militärischen Bereich. Notfall Rettungsmed 13:384–392

    Article  Google Scholar 

  24. Fludger S, Bell A (2009) Tourniquet application in a rural Queensland HEMS environment. Air Med J 28(6):291–293

    Article  PubMed  Google Scholar 

  25. Horlocker TT, Hebl JR, Gali B et al (2006) Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg 102(3):950–955

    Article  PubMed  Google Scholar 

  26. Deutsche Gesellschaft für Unfallchirurgie (DGU) (2012) Jahresbericht 2012. http://www.traumaregister.de/images/stories/downloads/jahresberichte/tr-dgu-jahresbericht_2012.pdf

  27. Shaw JA, Murray DG (1982) The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh. J Bone Joint Surg Am 64(8):1148–1152

    PubMed  CAS  Google Scholar 

  28. Crenshaw AG, Hargens AR, Gershuni DH et al (1988) Wide tourniquet cuffs more effective at lower inflation pressures. Acta Orthop Scand 59(4):447–451

    Article  PubMed  CAS  Google Scholar 

  29. Pedowitz RA, Gershuni DH, Schmidt AH et al (1991) Muscle injury induced beneath and distal to a pneumatic tourniquet: a quantitative study of effects of tourniquet pressure and duration. J Hand Surg 16A:610–621

    Google Scholar 

  30. Pedowitz RA, Fridén J, Thornell L-E (1992) Skeletal muscle injury induced by a pneumatic tourniquet: an enzyme- and immuno-histochemical study in rabbits. J Surg Res 52:243–250

    Article  PubMed  CAS  Google Scholar 

  31. Worland RL, Arredondo J, Angles F et al (1997) Thigh pain following tourniquet application in simultaneous bilateral total knee replacement. J Arthroplasty 12(8):848–852

    Article  PubMed  CAS  Google Scholar 

  32. Orban JC, Levraut J, Gindre S et al (2006) Effects of acetylcysteine and ischaemic preconditioning on muscular function and postoperative pain after orthopaedic surgery using a pneumatic tourniquet. Eur J Anaesthesiol 23(12):1025–1030

    Article  PubMed  CAS  Google Scholar 

  33. Swanson AB, Livengood LC, Sattel AB (1991) Local hypothermia to prolong safe tourniquet time. Clin Orthop 264:200–208

    PubMed  Google Scholar 

  34. Irving GA, Noakes TD (1985) The protective role of local hypothermia in tourniquet-induced ischemia of muscle. J Bone Joint Surg 67B:297–301

    Google Scholar 

  35. Husum H, Gilbert M, Wisborg T et al (2004) Prehospital tourniquets: there should be no controversy. J Trauma 56(1):214–215

    Article  PubMed  Google Scholar 

  36. Wakai A, Wang JH, Winter DC et al (2001) Tourniquet-induced systemic inflammatory response in extremity surgery. J Trauma 51:922–926

    Article  PubMed  CAS  Google Scholar 

  37. Graham B, Breault MJ, McEwen JA et al (1993) Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs. Clin Orthop 286:257–261

    PubMed  Google Scholar 

  38. Jarrett PM, Ritchie IK, Albadran L et al (2004) Do thigh tourniquets contribute to the formation of intraoperative venous emboli? Acta Orthop Belg 70(3):253–259

    PubMed  Google Scholar 

  39. Hirota K, Hashimoto H, Kabara S et al (2001) The relationship between pneumatic tourniquet time and the amount of pulmonary emboli in patients undergoing knee arthroscopic surgeries. Anesth Analg 93(3):776–780

    Article  PubMed  CAS  Google Scholar 

  40. Angus PD, Nakielny R, Goodrum DT (1983) The pneumatic tourniquet and deep venous thrombosis. J Bone Joint Surg Br 65(3):336–339

    PubMed  CAS  Google Scholar 

  41. Patterson S, Klenerman L (1979) The effect of pneumatic tourniquets on the ultrastructure of skeletal muscle. J Bone Joint Surg Br 61-B:178–183

    Google Scholar 

  42. Chambers LW, Green DJ, Sample K et al (2006) Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraqi Freedom: one unit’s Experience. J Trauma 61(4):824–830

    Article  PubMed  Google Scholar 

  43. Heppenstall RB, Balderston R, Goodwin C (1979) Pathophysiologic effects distal to a tourniquet in the dog. J Trauma 19(4):234–238

    Article  PubMed  CAS  Google Scholar 

  44. Walters TJ, Mabry RL (2005) Issues related to the use of tourniquets on the battlefield. Mil Med 170(9):770–775

    PubMed  Google Scholar 

  45. Dorlac WC, DeBakey ME, Holcomb JB et al (2005) Mortality from isolated civilian penetrating extremity injury. J Trauma 59(1):217–222

    Article  PubMed  CAS  Google Scholar 

  46. Bellamy RF (1984) The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 149(2):55–62

    PubMed  CAS  Google Scholar 

  47. Kelly C, Creagh T, Grace PA et al (1992) Regional hypothermia protects against tourniquet neuropathy. Eur J Vasc Surg 6:288–292

    Article  PubMed  CAS  Google Scholar 

  48. Kragh JF, Walters TJ, Baer DG et al (2009) Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 249(1):1–7

    Article  PubMed  Google Scholar 

  49. Rossaint R, Bouillon B, Cerny V et al (2010) Management of bleeding following major trauma: an updated European guideline. Crit Care 14:R52

    Article  PubMed  Google Scholar 

  50. Swan KG Jr, Wright DS, Barbagiovanni SS et al (2009) Tourniquets revisited. J Trauma 66(3):672–675

    Article  PubMed  Google Scholar 

  51. Ficke JR, Pollak AN (2007) Extremity war injuries: development of clinical treatment principles. J Am Acad Orthop Surg 15(10):590–5

    PubMed  Google Scholar 

  52. King RB, Filips D, Blitz S et al (2006) Evaluation of possible tourniquet systems for use in the Canadian forces. J Trauma 60:1061–1071

    Article  PubMed  Google Scholar 

  53. Walters TJ, Wenke JC, Kauvar DS et al (2005) Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care 9(4):416–422

    Article  PubMed  Google Scholar 

  54. Walters TJ, Wenke JC, Greydanus DJ et al (2005) Laboratory evaluation of battlefield tourniquets in human volunteers, http://www.dtic.mil/dtic/tr/fulltext/u2/a441140.pdf

  55. (o A) (o J) Tactical Combat Casualty Guidelines, 17 September 2012, http://www.health.mil/Education_And_Training/TCCC.aspx

  56. Deutsche Gesellschaft für Unfallchirurgie (DGU) (2011) S3-Leitlinie „Polytrauma/Schwerverletzten-Behandlung“. http://www.awmf.org/leitlinien/detail/ll/012-019.html

  57. Walters TJ, Kragh JF, Baer DG (2008) Influence of fiber-type composition on recovery from tourniquet-induced skeletal muscle ischemia-reperfusion injury. Appl Physiol Nutr Metab 33(2):272–281

    Article  PubMed  Google Scholar 

  58. Kam P, Kavanagh R, Yoong F et al (2001) The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia 56(6):534–545

    Article  PubMed  CAS  Google Scholar 

  59. Konrad G, Markmiller M, Lenich A et al (2005) Tourniquets may increase postoperative swelling and pain after internal fixation of ankle fractures. Clin Orthop Relat Res 433:189–194

    Article  PubMed  Google Scholar 

  60. Ochoa J, Danta G, Fowler TJ et al (1971) Nature of the nerve lesion caused by a pneumatic tourniquet. Nature 233:265–266

    Article  PubMed  CAS  Google Scholar 

  61. Brömme HJ, Loertzer H, Akcetin Z (2002) Der postischämische Reperfusionsschaden – biochemische und methodische Grundlagen. Urologe 41:159–163

    Article  PubMed  Google Scholar 

  62. Owens BD, Kragh JF, Wenke JC (2008) Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 64(2):295–299

    Article  PubMed  Google Scholar 

  63. Owens BD, Kragh JF Jr, Macaitis J et al (2007) Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 21(4):254–257

    Article  PubMed  Google Scholar 

  64. Naimer SA, Tanami M, Malichi A et al (2006) Control auf traumatic wound bleeding by compression with a compact elastic adhesive dressing. Mil Med 171(7):644–647

    PubMed  Google Scholar 

  65. Pillgram-Larsen J, Mellesmo S (1992) Not a tourniquet, but compressive dressing. Experience from 68 traumatic amputations after injuries from mines. http://www.dtic.mil/dtic/tr/fulltext/u2/a444895.pdf

  66. Tran TP, Tu H, Pipinos II et al (2011) Tourniquet-induced acute ischemia-reperfusion injury in mouse skeletal muscles: involvement of superoxide. Eur J Pharmacol 650:328–334

    Article  PubMed  CAS  Google Scholar 

  67. Eltzschig H, Eckle T (2011) Ischemia and reperfusion – from mechanism to translation. Nat Med 17(11):1391–1401

    Article  PubMed  CAS  Google Scholar 

  68. Lee YG, Park W, Kim SH (2010) A case of rhabdomyolysis with use of a pneumatic tourniquet during arthroscopic knee surgery. Korean J Intern Med 25:105–109

    Article  PubMed  Google Scholar 

  69. Estebe JP, Davies JM, Richebe P (2011) The pneumatic tourniquet: mechanical, ischaemia-reperfusion und systemic effects. Eur J Anaesthesiol 28:404–411

    Article  PubMed  Google Scholar 

  70. Finsen V, Kasseth AM (1997) Tourniquets in forefoot surgery. J Bone Joint Surg 79-B:99–101

    Google Scholar 

  71. Odinsson A, Finsen V (2001) The position of the tourniquet on the upper limb. J Bone Joint Surg 84-B:202–204

    Google Scholar 

  72. Arunakul R, Niempoog S (2011) Clinical experience in forearm tourniquet use. J Med Assoc Thai 94(Suppl 7):62–65

    Google Scholar 

  73. Hauschild S, Voß P, Witz S (2006) Präklinisches Management bei Explosions-verletzungen. Notfall Rettungsmed 9(5):453–472

    Article  Google Scholar 

  74. Rall JM, Cox JM, Songer A et al (2012) Comparison of novel hemostatic gauzes to Quickclot Combat Gauze in a standardized Swine Model of uncontrolled hemorrhage. Naval Medical Research Unit San Antonio, Technical Report # TR-2012-22

  75. Tactical Rescue & Emergency Medicine Association e. V. (TREMA) (o J) Richtlinien für TCCC 1.1, http://www.tremaonline.info/TREMA%20e.V.%20Guidelines%20TCCC%201.1.pdf

  76. Hodgetts TJ, Mahohey PF, Russel MQ et al (2006) ABC to <C>ABC: redifining the military trauma paradigm. Emerg Med J 23(10):745–746

    Article  PubMed  CAS  Google Scholar 

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S.W. Hauschild, G. Nöldge-Schomburg and J. Hoitz declare that they have no conflict of interest.

 

This article does not contain any studies with human or animal subjects.

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Authors and Affiliations

  1. Klinik und Poliklinik für Anästhesiologie und operative Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland

    S.W. Hauschild Oberfeldarzt d.R. & G. Nöldge-Schomburg

  2. Bundeswehrkrankenhaus Hamburg, Hamburg, Deutschland

    J. Hoitz

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  1. S.W. Hauschild Oberfeldarzt d.R.
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Hauschild, S., Nöldge-Schomburg, G. & Hoitz, J. Blutstillung mittels Tourniquet in der präklinischen Notfallmedizin. Notfall Rettungsmed 16, 291–304 (2013). https://doi.org/10.1007/s10049-013-1716-8

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