Athena Vale
Tourniquets are used to stop blood flow and prevent life-threatening external bleeding. They are also used when drawing blood or during surgery. However, their use is not without risk. Complications from tourniquet use can range from mild to severe, and in some cases, they can even cause death. While tourniquets can be extremely useful in preventing blood loss, they can also cause nerve damage, muscle damage, tissue necrosis and ischemia, paralysis, severe pain, and compartment syndrome. The risk of damage increases the longer a tourniquet is left on, with research showing that leaving a tourniquet on for more than 2 hours can cause permanent damage.
| Characteristics | Values |
|---|---|
| Use of tourniquets | Can result in temporary or permanent injury to underlying nerves, muscles, blood vessels and soft tissues |
| Can cause nerve and muscle damage, tissue necrosis and ischemia, paralysis, severe pain, and compartment syndrome | |
| Can cause pressure-related damage to skin and subcutaneous tissues | |
| Can cause digital necrosis | |
| Can cause reperfusion injury | |
| Can cause post-tourniquet syndrome | |
| Can cause histologic changes in the muscle beneath the tourniquet | |
| Can cause systemic effects | |
| Can be used in orthopaedic surgery to safely provide blood-free surgical fields | |
| Can be used in blood flow restriction (BFR) therapy to reduce muscular atrophy, increase muscle strength, and stimulate bone growth | |
| Can be used to stop blood flow and prevent life-threatening external bleeding | |
| Can be used when drawing blood or during surgery | |
| Can be used in extremity surgery to reduce blood loss and improve surgical visualization | |
| Can be used in pre-hospital settings, especially in the military environment | |
| Should not be left on for more than 2 hours | |
| Ice packs can prevent or reduce tissue damage |
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What You'll Learn
Tourniquet use exceeding two hours can cause muscle damage
Tourniquets are essential in preventing life-threatening blood loss, especially in pre-hospital settings. They are commonly used in orthopaedic surgery to provide a blood-free surgical field. However, their use carries risks, including nerve damage, muscle damage, tissue necrosis, and ischemia.
The use of tourniquets exceeding two hours can cause muscle damage. Histologic changes in the muscle beneath the tourniquet occur after two hours of application, and similar changes can occur in the distal ischemic muscle after four hours. These changes include an increase in inflammatory cells, focal fibre necrosis, and signs of hyaline degeneration. Prolonged ischemia can lead to permanent muscle damage and necrosis, the death of body tissue due to oxygen deprivation.
The severity of muscle damage depends on the duration of ischemia and the underlying condition of the muscle. Muscle ischemia, or lack of blood supply, results in hypoxia, acidosis, and increased capillary permeability, leading to metabolic changes and cell damage. The sudden release of toxins, such as lactic acid and creatinine phosphokinase, upon cuff deflation can further contribute to systemic effects.
Additionally, reperfusion injury, or ischemia-reperfusion injury (IRI), occurs when blood supply returns to the tissue after a period of ischemia. This can lead to post-tourniquet syndrome, characterised by edema, swelling, and limb weakness. While this syndrome typically resolves within one to six weeks, it underscores the importance of minimising tourniquet application time to prevent complications.
To mitigate the risks associated with tourniquet use, it is crucial to adhere to time limits of less than two hours and ensure proper training in tourniquet application and conversion techniques. Understanding the indications for tourniquet use and frequent reassessment of its necessity are also essential to prevent unnecessary morbidity and optimise patient outcomes.
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Compartment syndrome and post-tourniquet syndrome
Compartment syndrome is a rare but serious complication of tourniquet use. It occurs when there is a buildup of pressure in the space between the muscles, known as the compartment, due to swelling or bleeding. The compartment is the area between the two fascia layers of a muscle group, and the increase in pressure can result in swelling and pain that cannot be alleviated by narcotics. Other symptoms include muscle weakness, paresthesia, decreased or absent pulses, tense skin over the limb, and irreversible paralysis. Patients with a previous history of compartment syndrome symptoms or McArdle's disease are at a higher risk of developing compartment syndrome after tourniquet use.
The use of a tourniquet can also lead to post-tourniquet syndrome, which is characterized by edema (swelling) and limb weakness. It typically resolves within one to six weeks. Post-tourniquet syndrome is caused by the return of blood flow to the limb after the release of the tourniquet, resulting in an increase in blood flow to restore the normal acid-base balance in the tissue. This can lead to additional swelling and prolonged bleeding from the surgical wound. Other symptoms include stiffness, pallor, numbness, and weakness without paralysis.
To prevent compartment syndrome and post-tourniquet syndrome, it is important to minimize tourniquet time and avoid solid cast placement prior to tourniquet cuff depressurization. Additionally, a preoperative evaluation of the patient's personal and family history should be conducted to identify any previous compartment syndrome-like symptoms.
Although tourniquets are effective in preventing life-threatening blood loss, their use carries risks, including nerve and muscle damage, tissue necrosis, and ischemia. It is crucial to apply tourniquets properly and to be aware of the time limits to prevent potential injuries.
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Tourniquet-induced nerve compression injuries
The risk for permanent damage increases the longer a tourniquet is left on. The nerves in an extremity are responsible for communicating with the brain about the environment. A person with nerve damage may be unable to feel pressure, pain, heat, or cold on the skin over the damaged nerves. Because the brain uses nerves to signal the muscles to move, nerve damage may result in periodic or even permanent immobility.
The most common complication of tourniquet use is nerve damage. Nerve injury can range from mild transient loss of function to permanent, irreversible damage. Symptoms of nerve injury include an inability to detect pain, heat, cold, or pressure over the skin along the source of the nerve; and a sluggishness or inability to move large or small muscles upon command. Limb paralysis is also referred to as nerve paralysis or tourniquet paralysis syndrome. When this occurs, all motor nerves distal to the cuff are affected, resulting in a temporary or permanent inability to move the extremity.
Tourniquets can also cause muscle damage, tissue necrosis, and ischemia, paralysis, severe pain, and compartment syndrome. If a tourniquet is left on for too long, nerve and tissue damage can occur. Tourniquets can cause a lack of blood supply and oxygen to tissues, causing ischemia and necrosis. Tourniquet muscle damage can occur from extensive pressure, prolonged use, and ischemia.
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Muscle damage caused by pressure, prolonged use, and ischemia
Tourniquets are used to stop blood flow and prevent life-threatening external bleeding. They can also be used when drawing blood or during surgery. While tourniquets are a life-saving tool, their use is not without risk.
Muscle damage can occur when tourniquets are used for long durations or at extreme pressures. The risk of muscle damage is caused by extensive pressure, prolonged use, and ischemia. Ischemia leads to tissue hypoxia and acidosis, which can cause muscle damage. Muscle is more susceptible to ischemic damage than nerves. Histologic changes in the muscle beneath the tourniquet occur after 2 hours of tourniquet time, but similar changes can occur in the distal ischemic muscle after 4 hours of tourniquet use. The combination of muscle ischemia, edema, and microvascular congestion contributes to post-tourniquet syndrome, which includes edema, stiffness, pallor, weakness without paralysis, and subjective numbness of the extremity without objective anesthesia.
Direct pressure and mechanical deformation contribute to increased severity of muscle damage under the cuff. These changes include an increase in the number of inflammatory cells in the perivascular space, focal fiber necrosis, and signs of hyaline degeneration. Muscle damage may also release myoglobin, which can collect in the collecting tubules of the kidney, leading to renal failure.
The prolonged use of a tourniquet can also cause tissue ischemia and necrosis, post-tourniquet syndrome, and nerve and muscle damage. If a tourniquet is left on for too long, nerve and tissue damage can occur due to a lack of blood supply and oxygen to the tissues. Research has shown that a tourniquet left on for more than 2 hours can cause permanent damage, although damage can occur in less time depending on the situation.
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Pre-hospital tourniquet use and the need for guidelines
The use of tourniquets in pre-hospital settings has been on the rise, especially in emergency situations to control severe bleeding and restrict blood flow to the affected area. While tourniquets are an effective intervention for controlling extremity haemorrhage, their prolonged application poses inherent risks of complications.
Tourniquets can cause nerve and muscle damage, tissue necrosis, ischemia, paralysis, severe pain, and compartment syndrome. Nerve injury is the most common complication from tourniquet use, ranging from mild transient loss of function to permanent, irreversible damage. The extent of nerve damage can result in a temporary or permanent inability to move the extremity.
The risk of permanent damage increases the longer a tourniquet is left on. Research has shown that a tourniquet left on for more than 2 hours can cause permanent damage, with muscle damage occurring from extensive pressure, prolonged use, and ischemia. Post-tourniquet syndrome, characterised by edema and limb weakness, can also occur after reperfusion.
The design and application of pre-hospital tourniquets differ from classical surgical tourniquets, necessitating the development of guidelines for admitting patients to the hospital with pre-applied tourniquets. These guidelines would provide a framework for understanding the differences between pre-hospital and surgical tourniquets, ensuring safe and effective use, and improving patient outcomes.
Recent studies have examined the effectiveness and safety of pre-hospital tourniquet use, finding that early application before the onset of shock is strongly associated with increased survival. The latest United States national guidelines for field triage of injured patients include active bleeding and the use of tourniquets as criteria for recognizing a high risk of serious injury.
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Frequently asked questions
Yes, tourniquets can cause muscle damage. Histologic changes in the muscle beneath the tourniquet occur after 2 hours of tourniquet time, but similar changes can occur in the distal ischemic muscle after 4 hours of tourniquet use.
Tourniquet muscle damage can occur from extensive pressure, prolonged use, and ischemia. The risk for permanent damage increases the longer the tourniquet is left on.
Symptoms of muscle damage include swelling, stiffness, pallor, weakness, and numbness of the extremity.
To prevent muscle damage, it is recommended that tourniquets are not left on for longer than 2 hours. Ice packs can also help prevent or reduce tissue damage.
