Hello. I am a PCP with the Ottawa Paramedic Service. I was wondering what your view on pre-hospital tourniquet removal is if there is no need for its application. I had a patient with a closed ankle fracture, (no bleeding) however, a bystander applied a combat style tourniquet on to "stop the internal bleeding". Tourniquet was on properly, no pedal pulse present. By the time we arrived the tourniquet had been on for around 45 minutes and the leg was purple and we did not remove it due to concerns of clot / other adverse outcome of removal. I was curious should something like this should happen again what action I should take. Should I call Base Hospital to authorize it's removal in each case or is there a certain window where it is safe to remove if it is applied unjustifiably? A brief explanation on the pathology would be much appreciated as well. Thank you!
There are minimal risks in removing the tourniquet of the specific patient care situation you portrayed in the 45 minute timeframe you mentioned. As you specified, the care goal is to perfuse the limb and prevent/reduce the extent of necrosis of tissue. As such, if the tourniquet has been left in place for 120 minutes and deemed not necessary, we recommend to remove the tourniquet without patching to a base hospital physician. Please note the patient may experience severe pain during reperfusion. You may need to consider analgesia. If the tourniquet has been left in place for 120 minutes or more, risks for acid base balance to shift in the limb and then move to the patient's system increases. We recommend patching to the BHP as there may be treatment plan recommendations outside of the ALS PCS that may be appropriate to assist mitigation of adverse events associated with acid/base balance, such as fluid bolus. As a separate note, we would like to provide more information regarding lower leg fracture and risks of hemorrhage, and specify that it is unlikely there will be an extensive bleed, should you find yourself in a similar situation and want to guide lay rescuers and healthcare providers.