TOURNIQUETS.pptx

pneumatic tourniquets

1. THE TYPES OF TOURNIQUETS AND THE GENERAL PRINCIPLES OF THEIR APPLICATION PRESENTATION BY KUNAL SHRIVASTAVA

2. ORIGINS OF THE WORD: The word tourniquet is derived from French,meaning ‘to turn’. Term coined by Jean Louis Petit in 1718.  Joseph Lister first employed it to provide a bloodless field in 1873. Johann von Esmarch then made a bandage - Flat & woven from India rubber. Complication:Associated with nerve palsies. Harvey Cushing in 1904 -pneumatic Tourniquet, the most basic of its kind-The primordial modern tourniquet.

3. A tourniquet is a constricting or compressing device used to control venous and arterial circulation to an extremity for a period of time. Pressure is applied circumferentially upon the skin and underlying tissues of a limb; this pressure is transferred to the walls of vessels, causing them to become temporarily occluded.

4. TYPES: 1)EMERGENCY TOURNIQUET. 2)SURGICAL TOURNIQUET. Surgical tourniquets are frequently used in orthopedic surgery while emergency tourniquets are limited to emergency situations to control blood loss.

5. THE EMERGENCY TOURNIQUET(C.A.T) The Combat Application Tourniquet (C-A-T) is used by the U.S. and British military to provide soldiers a small, effective tourniquet in field combat situations, and is also in use by NHS ambulance services, and some UK fire and rescue services

6. THE SURGICAL TOURNIQUET Surgical tourniquets are available for operations around the upper and lower limbs.

7. TYPES OF SURGICAL TOURNIQUETS MANUAL (OPERATION): 1)PNEUMATIC. 2)ESMARCH. 3)MARTIN SHEET RUBBER BANDAGE. AUTOMATIC.

8. HOW TO APPLY THE SURGICAL TOURNIQUET A tourniquet is a potentially dangerous instrument that must be used with proper knowledge and care. The upper arm or the thigh is wrapped with several thicknesses of smoothly applied cast padding.

9. All air is first withdrawn from the tourniquet before application A gauze bandage is then wrapped around it to prevent its slipping during action. The extremity is elevated for 2 minutes, or the blood is expressed by a sterile sheet rubber bandage or a cotton elastic bandage. The tourniquet should be inflated quickly to prevent filling of the superficial veins before the arterial blood flow has been occluded.

10. HOW TO APPLY IN AN OBESE PATIENT In obese patients, an assistant manually grasps the flesh of the extremity just distal to the level of tourniquet application and firmly pulls this loose tissue distally. Traction on the soft tissue is maintained while the padding and tourniquet are applied, and the latter is secured.

11. TOURNIQUET PRESSURE The exact pressure to which the tourniquet should be inflated has not been determined. The correct pressure depends on the age of the patient, the blood pressure, and the size of the extremity. Tourniquet pressures of 135 to 255 mm Hg for the upper extremity and 175 to 305 mm Hg for the lower extremity were satisfactory for maintaining hemostasis.

12. BRAITHWAIT AND KLENERMAN’S MODIFICATION OF BRUNER’S TEN RULES FOR TOURNIQUET APPLICATION APPLICATION Apply only to a healthy limb or with caution to an unhealthy limb SIZE OF TOURNIQUET Arm, 10 cm; leg, 15 cm or wider in large legs SITE OF APPLICATION Upper arm; mid/upper thigh ideally PADDING At least two layers of orthopaedic wool SKIN PREPARATION Occlude to prevent soaking of wool. Use 50-100 mm Hg above systolic for the arm; double systolic for the thigh; or arm 200-250 mm Hg, leg 250-350 mm Hg (large cuffs are recommended for larger limbs instead of increasing pressure) TIME Absolute maximum 3 hr (recovers in 5-7 days) generally not to exceed 2 hr TEMPERATURE Avoid heating (e.g., hot lights), cool if feasible, and keep tissues moist DOCUMENTATION Duration and pressure at least weekly calibration and against mercury manometer or test maintenance gauge; maintenance every 3 months

13. THE AUTOMATIC TOURNIQUET Automatic tourniquet systems are capable of providing safety features that are not possible in older mechanical tourniquets. These systems can monitor the cuff inflation time as well as regulate the cuff pressure to a known pressure throughout the surgical procedure. Some microprocessor controlled tourniquets are capable of calculating the proper pressure to ensure complete blood occlusion in about 30 seconds. This assists the operating room staff in deciding what the tourniquet pressure should be set at on a per-patient basis.

14. USES IN ORTHOPEDICS Replacement or revision of the joints of the knee, wrist, digits, hand, or elbow. Arthroscopy of the knee, elbow, wrist, hand, or digits. Bone grafts. Fractures of elbow, forearm, knee and leg. Hand surgeries. Graft and repair of lacerated tendons. Repair of traumatic nerve damage. Traumatic or non traumatic amputation. Podiatry.

15. PLASTIC AND RECONSTRUCTIVE SURGERY Repair of burn contractures. Excision of lesions or tumors of the limbs. Split - thickness skin grafts on burned patients. Amputations or replantations. Repair of bone, cartilage, tendons, nerves, or blood vessels. Resection of invasive tumors or lesions.

16. ANAESTHESIA In intravenous regional anesthesia (IVRA), local anesthesia and a bloodless operative field are produced by inflation of a dual - bladder tourniquet proximal to the operative site, followed by injection of a local anesthetic agent distal to the tourniquet.

17. USES OF TOURNIQUET IN EMERGENCY The non-surgical use of pneumatic compression devices is commonly directed toward manipulation of venous and arterial circulation for the purpose of reducing primary or secondary circulatory problems. External pneumatic calf compression is a preventive therapy for patients at risk for deep venous thrombosis. Knee - length inflatable plastic boots with an alternating pressure cycle are used to prevent sluggish venous blood flow. Military Anti-Shock Trousers (MAST suits) can be used for early treatment of hypovolemic shock in trauma victims.

18. COMPLICATIONS:

19. TOURNIQUET PARALYSIS Tourniquet paralysis can result from: (1) excessive pressure (2) insufficient pressure, resulting in passive congestion of the part, with hemorrhagic infiltration of the nerve. (3) keeping the tourniquet on too long. (4) application without consideration of the local anatomy.

20. The final decision on whether or not to use a tourniquet rests with the attending physician. A few possible contraindications that the physician may take into consideration are: Open fractures of the leg. Post - traumatic lengthy hand reconstruction. Severe crushing injuries—Elbow surgery (with concomittant excess swelling), Amputation of an ischaemic limb. Severe hypertension. Skin grafts (to help distinguish all bleeding points).

21. POST TOURNIQUET SYNDROME Post - tourniquet syndrome (PTS) is manifested by pronounced and, at times, prolonged postoperative swelling of the extremity. Approximately half of all post - tourniquet swelling is caused by blood returning to the limb after the release of the tourniquet (hyperemia). The remainder is the result of post ischemic reactive hyperemia, an additional increase of blood to restore normal acid - base balance in tissue.

22. The complication occurs in patients who have had tourniquets applied for a prolonged time and also in patients whose tourniquet cuff pressures were insufficient to prevent arterial inflow while preventing venous outflow. Post - tourniquet syndrome is characterized by edema, stiffness, pallor, weakness without paralysis, and subjective numbness without objective anesthesia.

23. OTHER COMPLICATIONS 1)Compartment syndrome. 2)Rhabdomyolysis. 3)Pulmonary emboli (rare complication). 4)Vascular complications can occur in patients with severe arteriosclerosis or prosthetic grafts. -Therefore, a tourniquet should not be applied over a prosthetic vascular graft.

24. PREVENTIVE MEASURES: Medication history :A patient's drug history should detect the routine ingestion of any drug that will influence clotting time or promote development of atherosclerotic vascular disease. Among these are steroids, aspirin, and birth control substances. History of hypertension . Clotting time . History of past thromboembolic occurrences . Evidence of arterial calcification .

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