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domingo, 27 de marzo de 2016

TOURNIQUET LAST INFORMATION / CAT COMBAT APPLICATION TOURNIQUET tm

CAT COMBAT APPLICATION TOURNIQUET tm
•Un sangrado importante de una extremidad es la causa más frecuente de muertes prevenibles por una lesión

El Torniquete 


Es un dispositivo que detiene el flujo de sangre.  


Si se aplica correctamente, el torniquete detiene el flujo arterial a la extremidad y a la herida.


Limitar la pérdida de sangre puede prevenir que el   paciente entre en shock y posteriormente la muerte.





El retorno del torniquete. Lo que aprendimos de la guerra llevó a vidas salvadas en Boston


Una década después de la invasión de Irak, parece bastante claro que las aventuras militares que siguieron allí y en Afganistán han hecho más daño que bien. Miles de millones de dólares se gastaron miles de vidas perdidas, y dos regiones son ahora más estable que cuando llegamos.Pero la tragedia de ayer en Boston nos ha dado una razón para estar agradecido: el torniquete.Después de dos bombas de cocina estresantes enviados metralla a través de la multitud en la línea de muy acabado maratón como los IED que se han cobrado tantas vidas de los soldados-se habló mucho de las extremidades perdidas.Un día después de los ataques, sin embargo, sólo unos cuantos habían en realidad sido amputada: cuatro en el Hospital General de Massachusetts, cinco en el Boston Medical Center, y uno en el Hospital Brigham y de la Mujer. El recuento total de víctimas fue aún menor, a sólo tres muertes hasta el momento. Los que sobrevivieron podría tener torniquetes de agradecimiento: Los informes indican que los socorristas utilizaron cinturones, cuerdas de seguridad, arrancaron la ropa y la ropa incluso estrenar para unir las heridas de las víctimas de explosiones.Hace sólo unas semanas, un grupo de funcionarios de la FBI, Colegio Americano de Cirujanos, y la policía y las organizaciones de bomberos publicó el "Consenso de Hartford" en la forma de responder a los incidentes con víctimas masivas, como el tiroteo en Newtown, Connecticut. Su conclusión principal: La primera causa de muerte prevenible en estas situaciones es la pérdida de sangre, y la mejor manera de detener la pérdida de sangre es aplicar correctamente un torniquete.Usted no pensaría ese hecho tendría reiteración. Pero torniquetes pasó de moda hace mucho tiempo, y sólo recientemente han hecho una reaparición. De acuerdo con la American Journal of Surgery, fueron prohibidas en la práctica después de la Segunda Guerra Mundial, cuando chapuza aplicaciones bandas atadas con demasiada fuerza o demasiado sueltas llevado a más muertes y extremidades perdidas, no menos. Los torniquetes fueron utilizadas sólo ocasionalmente en las guerras de Corea y Vietnam; Estudios posteriores demostraron que podían haber evitado entre siete y 19 por ciento de las muertes en Vietnam.El ejército comenzó a entrar en razón sobre torniquetes en la década de 1990, cuando las fuerzas especiales en Somalia encontró que los utilicen correctamente salvó varias vidas. Por último, en 2003, los nuevos diseños de torniquete fueron probados para operaciones de combate en Irak y recomendados para una cuestión común a los soldados. Un estudio de 2008 de un hospital de Bagdad encontró que la tasa de supervivencia con el uso del torniquete fue del 87 por ciento.Ahora, torniquetes están haciendo poco a poco su camino de regreso a la medicina de emergencia civil también. Director médico de la Clínica Mayo Trauma Center Donald Jenkins, quien se retiró de una carrera de 24 años en la Fuerza Aérea en 2008 y ahora dirige el Instituto Nacional de Trauma, estima que un poco más de la mitad de las ambulancias llevan ahora torniquetes y debidamente capacitar al personal para utilizarlos."Después de décadas de predicando que torniquetes son malos, se podía ver cómo iba a tomar tiempo para que algo como esto a hundirse", dice Jenkins. "Los torniquetes salvaron vidas en este bombardeo de Boston, y va a aumentar el uso de ellos en otros lugares."Como suele suceder, los investigadores del Centro Médico de Boston ya habían tomado nota de la marea girando hacia torniquete en el campo de batalla, y llevó a cabo un estudio sobre las víctimas del tiroteo de civiles entre 1999 y 2006 que llegaron a una conclusión similar: Cuando se utiliza correctamente, torniquetes de trabajo, y más socorristas deberían utilizarlos. El autor del estudio, Jeffrey Kalish, dice que muchas ambulancias locales al menos llevan un tubo de goma para ese propósito.



 Ni Boston Medical Center en Boston, ni servicios médicos de emergencia han respondido a las preguntas sobre cómo se utilizaron los torniquetes después de los atentados de maratón, así que todavía no pueden confirmar su eficacia. No sería la primera vez, sin embargo, que el asesinato en el extranjero ha salvado vidas en casa: los avances médicos en tiempos de guerra se han traducido siempre en la vida civil (centros de trauma completo de especialistas comenzaron a establecerse en las ciudades, por ejemplo, después de que habían trabajado a gran efecto en Vietnam). Últimos conflictos de Estados Unidos también se han mejorado las técnicas para reparar los tejidos y nervios que han impedido que las amputaciones en los quirófanos de todo el país.Ese tipo de financiación de la investigación tiende a secarse cuando los soldados regresan a casa. Sin embargo, cientos de miles de personas mueren a causa de las lesiones traumáticas cada año, y Jenkins dice que enormes brechas aún permanecen en nuestro conocimiento de cómo tratarlos. El Instituto Nacional de Trauma ha estado haciendo campaña para obtener más dinero a la investigación del trauma, que no telar tan grande en la conciencia pública como muchas enfermedades hacen."Hemos gastado millones sobre el VIH / SIDA y el cáncer de mama, y ​​estamos viendo las tasas de supervivencia no se puede creer. La gente está sobreviviendo a mucho mayores extensiones de hoy porque tenemos centros de accidente cerebrovascular y coronaria que han demostrado a través de estudios clínicos aleatorizados lo que funciona" Jenkins dice. "Eso es todo lo que espera para suceder en el trauma. Usted puede resolver el problema, y ​​podemos aprender mucho, sólo tenemos que aplicar los recursos para hacerlo. Simplemente no podemos conseguir la atención de cualquiera que este es un problema enorme."Quizás Boston creará ese tipo de atención. Actos internos de violencia masiva parecen ser la amenaza de esta década, después de todo, y que no deberían tener una guerra para detener la hemorragia.
CAT COMBAT APPLICATION TOURNIQUET tm

Reviving a Life Saver, the Tourniquet

 



FAKE TOURNIQUET 


Torniquete Táctico C.A.T. (Combat Application Tourniquet). Torniquete oficial de la armada de E.U. 100% efectivo para ocluir sangrado tanto en extremidades superiores como inferiores. Incluye un área para registrar por escrito la hora de colocacion.



CAT COMBAT APPLICATION TOURNIQUET


Tourniquets
            A. Prehospital tourniquet use shown to have significant beneficial effect on blood loss, shock, and mortality without increased risk for amputation or conversion to higher amputation levels1
            B. Application of tourniquets taught as part of echelon I (self-aid, buddy care) course to all military personnel
            C. Combat Application Tourniquet System (CATS) tourniquet (see figure 12figure 13) is most frequently used military field tourniquet and is supplied in individual first aid kits (IFAKs)
            D. Tourniquets should be applied to upper thigh or upper arm for extremity injuries
            E. Tourniquets best removed in operating room and may be replaced with standard pneumatic tourniquets
            F. Coordination of tourniquet removal with resuscitating anesthesiologist or traumatologist is imperative, as systemic response to blood redistributing in limb and reperfusion of blood-starved tissues releasing cellular damage by-products is expected 
USE of CAT COMBAT APPLICATION TOURNIQUET tm


USE of CAT COMBAT APPLICATION TOURNIQUET tm


Prehospital Tourniquet Use – A review of the current literature
PHTLS
Lance E. Stuke, M.D. MPH
Background:
The use of extremity tourniquets for exsanguinating limb trauma has remained controversial throughout history. The ancient Romans were likely the first to use battlefield  tourniquets and their basic use has evolved little over the years, although many commercially available brands are replacing the folded cravats used previously. Tourniquets were issued in Civil War surgical sets and it was during this conflict that enthusiasm over their use diminished, likely due to the ischemic complications associated with prolonged delays from their application to definitive care.1 The use of tourniquets has been slowly increasing in military campaigns since the Vietnam War but it wasn’t until the recent experience in the Iraq and Afghanistan conflicts that widespread tourniquet use has been accepted as standard of care in the military. 
A review of civilian extremity trauma from 1994-99 noted that 86% of patients who died from an isolated exsanguinating penetrating limb injury had signs of life at the scene but had no discernible pulse or blood pressure upon arrival to the hospital.2 No patient in their study had a prehospital tourniquet placed by EMS personnel. Several factors account for the reluctance of EMS personnel to use tourniquets. These factors include the perceived complications of nerve injury and deep vein clot formation and the notion that limb ischemia could increase the risk of future amputation. Since the publication of these initial reports, civilian use of tourniquets is becoming accepted as standard of care, primarily due to the data derived from the recent military experience in Iraq and Afghanistan.
            The 6th Edition of the PHTLS textbook endorses the use of tourniquets if external bleeding cannot be controlled by direct pressure. It also notes that elevation of an extremity and compression on a pressure point proximal to the injured site are not proven methods of hemorrhage control and are not endorsed by PHTLS. The 6th edition endorsement of tourniquet use is based on several small published studies demonstrating benefit as well as early evidence arising at the time from the Iraq conflict. Since the publishing of the 6th edition, significant additional data has appeared in the trauma surgical literature to support the use of tourniquets. We will review these new studies in an effort to keep PHTLS providers abreast of the latest literature on this subject.  


CAT COMBAT APPLICATION TOURNIQUET tm
Literature Review:
            The first large study to retrospectively review tourniquet use by the U.S. military in Iraq was published in the Journal of Trauma by Beekley, et al.3 The authors reviewed their experience during 2004 in Iraq. This was relatively early in the conflict and widespread tourniquet use among military personnel was still in its infancy. The authors reviewed 67 patients who had prehospital tourniquets placed and another 98 patients with severe extremity trauma who did not have tourniquet placement. The average tourniquet time was 70 minutes (range 5-210 minutes). While a survival benefit to tourniquet use was not demonstrated in this initial study, the authors found that among the most severely injured patients (Injury Severity Score > 15) prehospital tourniquet use significantly improved hemorrhage control. No early adverse outcomes from tourniquet use were noted among the survivors. The authors discuss the challenges faced by providers in the combat environment and recognize that documentation of successful hemorrhage control, tourniquet application time, and vital signs was often inadequate. Furthermore, a comprehensive military trauma database was still under development so hospital records were often suboptimal. This study is significant in that it demonstrated that battlefield tourniquets can safely be applied by prehospital personnel with no significant side-effects. Critics point out the retrospective nature of the study as well as the author’s admitted difficulty in data collection early in the war. As data gathering methods improved over the next several years, future research would expand on this early study



            The next two articles are from the prospectively gathered trauma database by the U.S. military in Iraq.4,5 The articles represent the work from a single combat hospital in Baghdad and cover a span of seven months, March to October 2006. During this time, 2,838 patients were admitted with major limb trauma of which 8% (232 patients) had 428 tourniquets placed on 309 limbs. Some patients had multiple limbs injured, while others had an additional tourniquet placed on the same limb if the initial placement did not adequately control hemorrhage.  The average tourniquet time was 1.3 hours.
            The first article from this prospective database was published in the Journal of Trauma and evaluated complications associated with tourniquet use.4  Four patients had nerve palsies diagnosed at the level of the tourniquet, three of which improved within a day. Only one patient had mild persistence of his nerve palsy at 6 days. Seven patients had skin pinching, blisters, abrasions, or bruises in the area directly under the tourniquet. Ten blood clots were noted although the surgeons attributed these to be secondary to the injury itself and not to tourniquet use. No patient developed a pulmonary embolus. There was no apparent association between tourniquet time and the development of clots, nerve palsies, pain, or myonecrosis. Nine fasciotomies were done, but all were prophylactic to prevent compartment syndrome and no cases of compartment syndrome were noted from tourniquet use. Nearly all tourniquets were properly positioned (97%). The low rate of complications noted in this study compares favorably with other prior studies from as far back as World War II which all demonstrate little or no morbidity associated with tourniquet placement. 

            The next article, published in Annals of Surgery, represents the first prospectively gathered data to demonstrate the survival benefit of tourniquet use.5 The authors first note five patients who met eligibility criteria for prehospital tourniquet placement who did not receive a tourniquet for various reasons. All five patients were alive in the field, bled to death in the presence of fellow soldiers, and arrived at the hospital 10-15 minutes later without vital signs.  The authors conclude those deaths could have been prevented with early tourniquet placement. They also note that timing is critical to tourniquet placement.  The patient must have a tourniquet in place before the onset of shock. Patients with a tourniquet placed in the absence of shock had a 90% survival rate versus a 10% survival rate in those whose tourniquet was placed after development of shock. The median time to placement after injury was 10 minutes and placement should be done prior to extrication from the vehicle and transport to the hospital.
            The final study to review is a continuation of the previous two papers from the same combat support hospital in Iraq.6 The authors conducted this study to see if their initial data supporting the use of tourniquets held up as more patients were enrolled in the study over time. The study population included 499 total patients, with 862 tourniquets applied on 651 limbs. A survival advantage was noted in patients who had a tourniquet applied early, before the onset of shock (96% before vs 4% after). Furthermore, a survival benefit was noted in patients with prehospital application of a tourniquet versus hospital application (89% vs 78% hospital). Complications associated with tourniquet placement, such as nerve palsies, remained extremely low in this study as well (< 1.5%). The authors conclude that early tourniquet application, before the onset of shock, saves lives with little to no associated complications.
Summary:
-          Prehospital tourniquets are indicated if direct pressure or a pressure dressing fails to control hemorrhage.
-          The tourniquet should be placed prior to extrication and prior to transport. There is a clear survival advantage if placement is done prior to the onset of shock.
-          The tourniquet is tightened until hemorrhage ceases. An additional tourniquet can be placed next to the first tourniquet if bleeding control is inadequate following placement of the first tourniquet.
-          The patient should be transported to a hospital with immediate surgical capabilities whenever possible.
-          The time of tourniquet application should be documented and relayed to the trauma team upon arrival at the hospital.
-          There are few, if any, significant complications attributed to tourniquet use. It is a safe procedure, should be performed by all EMS personnel, and saves lives.


PHTLS Recommendation:
            PHTLS recommends the placement of tourniquets by EMS personnel if direct pressure fails to control extremity hemorrhage.


Bibliography:
  1. Doyle GS and Taillac PP. Tourniquets: A review of current use with proposals for expanded prehospital use. Prehospital Emergency Care. 2008; 12: 241-256.
  2. Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. Journal of Trauma. 2005;59: 217-222.
  3. Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes. Journal of Trauma. 2008; 64: S28-S37.
  4. Kragh JF, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. Journal of Trauma. 2008;64: S38-S50.
  5. Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery. 2009;249: 1-7.
  6. Kragh JF, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. Journal of Emergency Medicine. 2009. Article in press.
           
           




TOURNIQUET LAST INFORMATION / CAT COMBAT APPLICATION TOURNIQUET tm


Tourniquet Safety & Efficacy / CAT COMBAT APPLICATION TOURNIQUET tm

PHTLS Recommendation:
            PHTLS recommends the placement of tourniquets by EMS personnel if direct pressure fails to control extremity hemorrhage.

Full document
Reviews of current literature on prehospital tourniquet use  (Word document)


Official Spanish Army Kit


MILITARES ESPAÑOLES USAN EL TORNIQUETE COMO PIEZA ELEMENTAL DE SU EQUIPO DE PROTECCIÓN.

"Nadie debe morir por un sangrado descontrolado" Consenso Hartford Curso B-Con-PHTLS


El Torniquete
es un dispositivo que detiene el flujo de sangre.
Si se aplica correctamente, el torniquete detiene el flujo arterial a la extremidad y a la herida.
Limitar la pérdida de sangre puede prevenir que el paciente entre en shock y posteriormente la muerte.http://goo.gl/uwZGy8