Management of Field Tourniquets in the ED

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All trauma patients who arrive to the ED with a field tourniquet in place on an extremity should have the following done:

  1. If the patient is being transported directly to the OR for definitive care within 10-15 min after ED arrival the field tourniquet can be taken down in the OR.
  2. For patients undergoing full trauma team evaluation in the ED and not being taken directly to the OR the field tourniquet should be taken down, and replaced or removed as part of the secondary survey.
    1. Primary survey
    2. Secondary survey
      • Takedown tourniquet
      • Assess injury, bleeding
      • Replace with pneumatic/surgical OR tourniquet if necessary

Prior to field tourniquet takedown, adequate vascular access must be obtained. Blood products, hemostatic agents, and pneumatic/surgical OR tourniquet(s) should all be available at the bedside.  Pneumatic/surgical OR tourniquet(s) are available in the trauma cart along with a sphygmomanometer bulb inflator device.  Larger size OR tourniquets are in a plastic bin on the shelf in the resuscitation hallway.

Field tourniquet application time and takedown time should be noted in the chart flowsheet. If the field tourniquet is replaced with a pneumatic/surgical OR tourniquet the inflation time and pressure (mmHg) should be recorded in the trauma flowsheet.

Process for tourniquet removal/replacement

  • Assemble pneumatic/surgical OR tourniquets at the bedside and ensure sphygmomanometer bulb and gauge are functioning. Choose the widest cuff possible that reasonably encircle the extremity as a wider bladder is able to occlude arterial blood flow at a lower inflation pressure. (1)
  • Conduct a pre-briefing with trauma team to coordinate monitoring, vital sign acquisition, and fluid management with nursing and key providers.
  • Under the supervision of the Trauma/ED attending release and remove the field tourniquet.
  • Assess for continued arterial or uncontrolled venous bleeding. If arterial or uncontrolled venous bleeding is present, place the appropriately sized pneumatic/surgical OR tourniquet proximal to the wound and inflate. The ideal tourniquet pressure has not been determined. A reasonable guideline is (2);
    • 50 mmHg above the patient’s systolic blood pressure for upper extremities.
    • 100 mmHg above the patient’s systolic blood pressure for lower extremities.

* Higher inflation pressures may be required if bleeding is not controlled using this guideline

  • Document the removal time of the field tourniquet and reapplication time of the pneumatic tourniquet (if applicable).
  • Proceed with clinical care/imaging studies with the goal of rapid transport to the OR for definitive management.
  • If the pneumatic tourniquet has been inflated for greater than 60 min the attending trauma surgeon may elect to briefly deflate and re-inflate the tourniquet to limit the risk for acidosis, local tissue damage, and compartment syndrome from ongoing ischemia.