Who invented the tourniquet

Nowadays, most tourniquets are of the pneumatic design. In this paper, we focus mainly on surgical and pneumatic tourniquets. In some cases the use of the tourniquet is a luxury while in others, the surgery is impossible without it, such as delicate surgeries in the hand.

Bunnell statement should be considered: "Hand surgery without tourniquet is like repairing a clock in an ink container" 9. The use of the tourniquet helps to create a bloodless field in surgery, results in better surgeon visualization, and, theoretically, reduces the time of surgery At least one study in knee arthroscopy 11 and one systematic review on upper limb surgery 12 concluded that the tourniquet does not reduce the time of surgery.

In the past, it was mentioned that the tourniquet must be wrapped on the uppermost part of the limb, but nowadays use of a forearm 13 , leg 14 , wrist 15 , and ankle 16 tourniquets has gained popularity. Some studies have reached the conclusion that forearm tourniquets are more endurable in comparison to arm tourniquets. Also, ankle tourniquets are more comfortable than leg tourniquets 14 , 17 , 18 while some have concluded that in the upper limbs there is no difference between the arm and forearm 19 , The skin beneath the tourniquet must be protected by enough layers as a protector.

Tourniquet efficacy is reduced with increasing the number of padding layers and it has been suggested that the number should be no more than two The protector can be made of wool, cotton, stocking band, or reconstructed material and there is no difference among them Stocking band maybe somewhat better for the lower limb Care should be taken to keep washing liquid from penetrating beneath the tourniquet at the time of preparation of the limb because it can lead to severe dermal reactions 23 or loss of a partial or full thickness area of the skin 24 , This risk is higher in children and the elderly 26 and occurs mostly with alcohol containing solutions To prevent this, a sterile towel, a piece of plastic, a surgical glove, or premade instruments 28 may be used under the tourniquet.

To empty the limb of blood, it is kept upright for two minutes or an elastic band is used. One study concluded that the time of up righting doesn't differ in 5, 15, 30, 45 seconds, and minutes The methods of limb blood draining have been compared to each other as well with the Esmarch method and blood sucking equal for surgeon convenience in practice and were better than just up righting alone Lower pressure is needed with wider tourniquet cuffs Nowadays, with the appearance of the concept of limb occlusion pressure, any single formula for measuring tourniquet pressure may not be useful.

Limb occlusion pressure is the minimum pressure in some special time with a special cuff to a special part of a particular limb that results in the disappearance of limb pulse Advanced tourniquets have instruments for measuring this pressure but a security border must be added to be sure of its efficacy.

Still some systems adjust tourniquet pressure according to systolic pressure It has been suggested that in a healthy person less than 50 years old, it is better not to use a tourniquet for more than two hours.

Two hours has a logical basis, since after this time of ischemia, progressive venous acidosis will occur in the region the tourniquet effects If the operation is predicted to be more than 3 hours long, then breathing time must be considered and after 2 hours, as a routine practice, the tourniquet is released for half an hour However, it takes 40 minutes for the limb to return to the normal metabolic state. One study reached the conclusion that the transient reperfusion course may not be useful By utilizing double tourniquet cuffs and intermittent discontinuance of one, the safe time of the tourniquet can be prolonged up to 4 hours Coldness reduces the effect of ischemia in tissues, so it is justifiable that cooling the limb is along with an increase in the safe time of the tourniquet, which has been confirmed in animal 39 and human 40 studies but making tissues cold during the surgery is not simple or practical.

Considering the role of antibiotics before the surgery to control infections, it seems logical that they should be prescribed before inflating the tourniquet and the time of injection has been mentioned as 20 41 , 5 42 , 2 43 , and 1 44 minutes before inflation. However, another study concluded that antibiotic prescriptions before inflating the tourniquet do not seem to have any superiority to antibiotic injection after inflation A recent clinical trial compared prophylactic antibiotic use before and after tourniquet inflation in lower limb surgeries.

They concluded that in the "before group" the risk of infection and the time of complete healing of the wound had increased and patient satisfaction was lowered A famous complication is tourniquet pain that may be the result of mechanical pressure and ischemia reperfusion mechanism Surely the central nervous system may also be involved One study concluded that pain is not related to cuff width and tourniquet pressure 46 but another still says that the use of lower width cuffs results in milder pain, which is induced for a longer time Using lidocaine with edible gabapentin 49 , ketamine 50 , dexamethasone, and ketorolac 51 may lead to more efficient pain reduction.

Neural injuries are most often reported in the upper limb but may occur in the lower limb as well. Neural injuries consist of a spectrum from simple paresthesia to permanent paralysis. These are not common. In a large study, their incidence was reported 0.

Serious injuries may be caused by improper function of the tourniquet gauge 53 and some tourniquets have been found to apply even 54 mmHg more pressure to the limb than what was indicated.

The inaccuracy of a tourniquet gauge is not a rare event. On the contrary, it is common. Some cases of fatal pulmonary emboli have been reported after the Esmarch band for draining the blood from the limb. Most of them were after trauma 56 , 57 but it has been reported after elective surgeries Most arterial injuries occur after a tourniquet is used in knee joint replacement surgery and are the result of indirect injury and thrombosis, especially in the limbs with previous blood flow problems The tourniquet has caused a compartment syndrome in some cases 60 - Pulmonary embolisms are a rare complication after tourniquet use that may occur before 64 or after 65 , 66 deflation.

Controversy exists about the role of the tourniquet in causing deep venous thrombosis and pulmonary emboli. Most studies had been about knee arthroplasty. One group believes that this risk does not increase 67 but other studies do not agree 67 - The mechanism of this injury by tourniquet has been proposed to be venous stasis, endothelial injury, and platelet aggregation 71 - Tourniquets may increase blood pressure, probably because of autonomous nervous system changes 74 and, especially, in children, it may induce hyperthermia.

Pulmonary gas exchange disorder may occur a few hours after tourniquet deflation and in the safe time limit of tourniquet time After deflation pulse and end tidal Co 2 increases to reach a peak after 5 minutes and after 15 minutes returns to the normal range.

These are usually benign changes but in patients with cardiovascular or intracranial problems, they may become important. In these cases with hemodynamic and end tidal volume monitoring, quick liquid injection with hyperventilation for minutes after deflation is recommended Since tourniquet use leads to ischemia in the limb, though temporarily it is arguable that it can affect the results of surgery for a fracture.

One study on tibia fractures treated with plate and screws did not show any harmful effects from tourniquets Another study on the same topic in which statistical analysis was not performed and did not show great differences between the two groups except some skin blisters in the tourniquet group Despite this, the authors recommended against tourniquet use.

Another study on fibula fractures concluded that tourniquet use would increase the risk of wound infection A systematic review of the tourniquet in leg and ankle surgery showed that by avoiding tourniquet use, postoperative pain, limb edema, infection, and deep vein thrombosis decreased Actually, with a high probability the postoperative pain would decrease if a tourniquet were not used 77 , 81 - Although, this is not confirmed in all studies Tourniquet use when reaming the canal of the fractured tibia for placing intramedullary nails is absolutely contraindicated 85 , since it may lead to severe burning bone necrosis 86 , 87 , though this has been questioned by at least one study One study concluded that in multiple trauma patients, whose femur fracture was treated by intramedullary nail, tourniquet use for other lower limb fractures might increase pulmonary morbidity Tourniquet use with sickle cell anemia is controversial.

Tourniquets cause hemostasis, acidosis, and hypoxia in the tissues distal to the tourniquet and all these situations are directly related to sickling of blood cells in sickle cell patients. This is not confirmed in practice and a new study reviewing previous studies concluded that by taking precautionary measures and prior readiness, a tourniquet can be used in these patients with proportional safety As authors mention, this topic has not been studied largely and many of the published articles were case reports.

Not many studies have been performed on tourniquet use in children 91 - 93 to the best of our knowledge. In fact, the principles are not much different from adults. A recent paper repeats adult recommendations 91 that have already been mentioned previously A recent case report referred to the sudden and harmful effects of tourniquet use in two children even with pressures only 50 mmHg higher than patient systolic pressure and emphasized the need for special criteria for children Peripheral vascular diseases in which end limb pulses are not palpable are relative contraindications for tourniquet use.

The use of tourniquets in patients who have congenital susceptibility for nerve compression is contraindicated. Use of tourniquets in neuropathies, systemic lupus erythematosus, underlying coagulation disorders, and cachectic patients must be done with caution Tourniquet use in limb surgery is not without risk and though very sophisticated devices have developed, the risk has not been omitted.

So its usage would take place with extreme caution. At present there is no evidence for discontinuation of tourniquet use in limb surgeries, but in some instances like children and patients with sickle cell anemia the need for further studies is obvious.

The authors declare their gratitude towards the kind personnel of the library of Kerman University of Medical Sciences for their cooperation in data gathering. Saied; Acquisition of data: Dr. Ayatollahi Mousavi, Dr. Arabnejad; Analysis and interpretation of data: Dr. Heshmati, Dr. Saied; Drafting of the manuscript: Dr.

Arabnejad, Dr. Heshmati; Critical revision of the manuscript for important intellectual content: Dr. Saied; Statistical analysis: Dr. Saied; Administrative, technical, and material support: Dr. Saied, Dr. Arabnejad; Study supervision: Dr. National Center for Biotechnology Information , U.

Iran Red Crescent Med J. Published online Feb Author information Article notes Copyright and License information Disclaimer. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4. This article has been cited by other articles in PMC. Abstract Context: A tourniquet is a device that is used frequently in most orthopaedic surgeries but this routine device can lead to serious complications so we decided to review and declare it for safe instruction and use.

Results: The use of tourniquet in orthopedic surgery can lead to serious but rare complications that can be prevented by its correct knowledge and use. Conclusions: At present, there is not enough evidence to discontinue the routine uses of tourniquets.

Keywords: Tourniquet, Orthopedic Surgeries, Limbs. Context Tourniquet is a device that prevents blood passage in the limbs and makes surgeries much easier. History The first recorded efforts to prevent arterial bleeding has been ascribed to Sushruta, the father of surgical art and science, in B. Types Generally, there are two types of tourniquets: surgery and emergency. Utilization In some cases the use of the tourniquet is a luxury while in others, the surgery is impossible without it, such as delicate surgeries in the hand.

Some Methods Have Been Suggested to Increase the Safe Time of Tourniquet If the operation is predicted to be more than 3 hours long, then breathing time must be considered and after 2 hours, as a routine practice, the tourniquet is released for half an hour Abdominal Aortic Tourniquet in position to block bleeding from shoulder.

A few weeks before the shooting in Alabama, the Abdominal Aortic Tourniquet saved a man in Afghanistan who was moments away from dying after losing both his legs in a blast from an improvised explosive device.

The man is now recovering with his family. Schwartz and Croushorn got the idea for an inflatable device at a medical conference in They soon began working with Westmoreland and testing early prototypes on themselves. In October , they applied for FDA approval, expecting the process to take three years. The U.

Army immediately ordered 60 tourniquets for combat medics in Afghanistan, with the first batch delivered to troops last summer.

Schwartz, Croushorn, and Westmoreland have each lost patients and friends to bleeding that could have been stopped with their invention. History of the tourniquet The first documented use of a tourniquet was not for preventing exsanguination—severe blood loss— but rather was used by Hindu physicians in the 6th century BCE to treat Greek troops bitten by snakes unfamiliar to physicians.

The turning of the tide Despite their widespread criticism, tourniquets returned to military use. Civilian EMS adoption Retrospective studies, along with the personal experiences of medics and resus teams in Iraq and Afghanistan, have resulted in a rethink of pre-hospital care in civilian trauma. References References Bellamy RF. Mil Med. J Am Coll Surg [Internet]. JAMA Surg. Tactical tourniquet: Surgical management must be within 3 hours.

Trauma Case Reports [Internet]. Forrest RD. Early history of wound treatment. J R Soc Med. Klenerman L. The Tourniquet Manual: Principles and Practice. London: Springer-Verlag; Mabry Tourniquet Use on the Battlefield. Services AM. Wolff L, Adkins Tourniquet problems in war injuries. Am J Surg. Tactical combat casualty care in the canadian forces: Lessons learned from the afghan Can J Surg. Army Medical Department Centre and Schools. Basic Medical Specialist Manual 91B.

First Revi. Washington, D. Government Printing Office; Carey Analysis of wounds incurred by U. J Trauma. United States army rangers in Somalia: An analysis of combat casualties on an urban battlefield. J ;49 3 — Prehospital Emerg Care. Ann Surg. Trauma United Kingdom. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian J Trauma Acute Care Surg. Tourniquet use at the Boston Marathon bombing: Lost in translation. J Trauma Acute Care Surg.