Tourniquets go from combat to kids

(Scott Foresman/Wikimedia Commons)
(Scott Foresman/Wikimedia Commons)
In the aftermath of the Boston Marathon bombings, first responders did whatever they could to help victims. For many of those injured, tourniquets proved to be the difference between saving and losing a limb—or a life.

“There’s no doubt that tourniquets played a key role in treating the bombing victims,” says Boston Children’s Hospital Trauma Center Director David Mooney, MD.

Two children who were later treated at Boston Children’s had tourniquets applied at the site of the tragedy. One arrived with extensive lacerations caused by one of the two detonated bombs. The other was in worse condition, having suffered blood vessel damage among other problems. Both children are doing better, although one will require further treatment.

Dating back to Roman times, a simple tourniquet, encircling a limb just above a wound, was the go-to method to stop bleeding. Since then, tourniquets have been used on the battlefield and in emergency rooms and operating rooms. However, had the bombings taken place 10 or 15 years ago, those wounded might not have been treated with tourniquets, Mooney believes. In those more recent years, tourniquets were out of favor over fears that they could cause nerve damage, blood clots, ischemia and other problems. Instead, clinicians were taught to simply apply direct pressure to halt bleeding.

A recent study in the Annals of Surgery found those concerns to be largely unfounded. In addition, the experiences of soldiers over the past 10 years in Iraq and Afghanistan strongly indicate that tourniquets can be highly effective when used properly.

Combat injuries, Mooney notes, have “changed from shooting injuries to injuries caused by improvised explosive devices (IEDs).” Like the bombs used in Boston, IEDs are detonated on or in the ground, and they are loaded with shrapnel, which causes lower-extremity injuries. Because of the increase in serious lower-body wounds suffered on the battlefield, Mooney reports that the use of tourniquets in the military is now “standard practice. Most every soldier is given a tourniquet and is trained on how to use it.”

Proper use of a tourniquet is central to success. “A tourniquet must be applied tight enough, so the bleeding stops,” Mooney explains. In some situations, a second tourniquet is needed. But tourniquets must not be left on for too long. “When we see a patient with a tourniquet, the clock is ticking,” Mooney says. “We know that this person has a severe injury, and we get them to the operating room as quickly as possible.”

On Marathon Monday, the 260+ victims were only minutes away from Boston Children’s and the city’s other trauma centers, so tourniquets applied at the finish line could be removed within an appropriate amount of time, and the people who were severely injured could be brought quickly into surgery. In the case of the two children with tourniquets who came to Boston Children’s, Mooney reports that “they were in the OR within minutes.”

The successful use of tourniquets on these two young patients is instructive and encouraging, but many questions remain about the impact the devices have on pediatric patients. There is a wealth of information on how tourniquets help those hurt in combat and on injured civilian adults, but very little data on children.

In situations like the marathon bombings, Mooney says, “we’ve been forced to use ‘combat therapy’ on kids, but we don’t know the long-term effects.” For example, if a child treated with a tourniquet develops a problem with an arm or leg as they grow older, how can we tell if the tourniquet was to blame? “There may never be enough kids to study for us to really know the impact,” Mooney says.