The Life-Saving Evolution of Tourniquet Use: From Battlefield to EMS

The use of tourniquets has transformed trauma care, moving from a once-feared intervention to a cornerstone of life-saving strategies, both on the battlefield and in civilian emergency response.

Navy Captain (Ret.) Dr. Frank Butler, the architect of Tactical Combat Casualty Care (TCCC), helped shift the perception of tourniquets in the 1990s.

Earlier trauma care teachings viewed tourniquets as dangerous due to the risk of limb loss. However, research from past conflicts, and practical experience, revealed that failure to control extremity bleeding was a leading cause of preventable death.

With the rise of TCCC in military settings, particularly during the wars in Afghanistan and Iraq, the widespread adoption of tourniquets helped save thousands of lives by controlling life-threatening hemorrhage early.

This success led to updated guidelines emphasizing tourniquet conversion, replacing the tourniquet with other bleeding control methods within two hours to avoid complications when possible.

Despite its military success, civilian EMS was initially slow to adopt tourniquet use. That changed following the Hartford Consensus and the creation of the Stop the Bleed campaign after the Sandy Hook tragedy.

These efforts brought battlefield lessons to the civilian sector, empowering both the public and EMS providers to take swift action in bleeding emergencies.

The key takeaway for EMS providers is clear:

👉 Uncontrolled bleeding is a time-sensitive emergency

👉 Tourniquets, when used correctly, are a safe and essential tool in prehospital care

👉 Every EMS provider should be trained, equipped, and ready to use a tourniquet when needed

For a deeper dive into the history, science, and best practices behind tourniquet use, you can read the full article here: 

The Evolution of Tourniquet Use in Trauma Care by Public Safety Group, 2025

EMS Environmental Emergencies - Lightning Related Incidents

Each year, lightning-related fatalities surpass those caused by tornadoes, hurricanes, and earthquakes combined, highlighting the frequency and severity of these incidents. 

However, lightning strike injuries are often an underestimated component of environmental emergencies that EMS Providers must be prepared to handle. 

Lightning strikes not only present unique mechanisms of trauma but can also lead to high morbidity and sudden fatalities. These incidents demand rapid, informed, and skillful response due to their sudden and unpredictable nature.

EMS Providers play a crucial role as the first line of care in such emergencies, especially given that lightning strikes often occur in remote or outdoor areas where specialized medical assistance is not immediately available. 

Recognizing lightning as the second most common storm-related cause of death - surpassed only by flash floods - emphasizes the need for comprehensive training and awareness.

Mechanisms of Lightning Injury

The mechanisms of injury (MOI) are multifaceted, ranging from direct strikes to complex indirect effects like ground current and blast injuries. 

These factors make understanding the nature of lightning-related incidents vital for effective prehospital management and prevention of complications.

EMS providers must understand the primary mechanisms of injury associated with lightning strikes to properly assess and manage patients:

Direct Hit: Occurs when a person is directly struck by lightning, most often in open spaces such as fields or meadows.

Splash Lightning: Lightning can strike an object and "splash" or jump to another nearby object or person, following the path of least resistance.

Ground Current: The most frequent cause of injury, where lightning hits the ground nearby, and the electrical current radiates outward. If someone is within this radius, the current can pass through or over the body.

Blast Injury: The rapid expansion of air from a lightning strike can create an explosive force, causing secondary trauma.

Contact Injury: Occurs when a person is touching an object that conducts electricity, such as a wire fence or a corded phone.

Signs and Symptoms of Lightning Injury

Lightning strikes can present with a range of symptoms, including:

Cardiac / Respiratory Arrest: Immediate life-threatening emergencies.

Neurological Impacts: Loss of consciousness, seizures, paralysis, and balance issues.

Burns: Typically minor due to the "flashover" effect where current passes over the body.

Sensory Disturbances: Temporary blindness or deafness.

Trauma: Injuries resulting from being thrown by the force of a strike.

Key Treatment Principles

Scene Safety: Ensure the scene is safe, as lightning can strike the same area more than once.

Basic Life Support (BLS): Be prepared for prolonged rescue breathing and CPR as needed.

Comprehensive Examination: Conduct a thorough assessment of the patient and treat injuries accordingly.

Continuous Monitoring: Keep a close watch for any changes in the patient's condition.

Evacuation: Transport any individual struck by lightning for further evaluation and care.

Prevention Tips for Lightening Safety

EMS Providers should be aware of preventive strategies to minimize lightning injuries:

Seek Shelter: In urban areas, take refuge in buildings (avoid small sheds) or vehicles. The motto “When thunder roars, go indoors” underscores the urgency.

In outdoor areas, select locations surrounded by a uniform stand of trees or low, rolling terrain.

Understand Risk Areas: Recognize that while some outdoor locations are safer than others, no place outside is completely safe during a lightning storm.

Monitor Weather: Be aware of local weather patterns and avoid exposure to known risk zones during storms.

Avoid High-Risk Locations:

• Elevated areas such as peaks, ridges, and hills
• Isolated tall objects (e.g., single trees)
• Open fields or meadows
• Large bodies of water and shorelines
• Shallow cave entrances or overhangs
• Previously struck areas
• Long conductors like wire fences, pipes, or wet ropes

Insulate and Disperse: When moving to a safer location is impractical:

Insulate yourself from ground current by crouching in the lightning position (heels together, minimizing contact with the ground).

Encourage group members to spread out to minimize the risk of multiple casualties.

In Conclusion

EMS Providers should be equipped with the knowledge to recognize the broad spectrum of signs and symptoms that can accompany lightning injuries, from cardiac arrest and neurological damage to less apparent conditions like temporary blindness or minor burns. 

The potential for cardiac and respiratory arrest underscores the necessity of timely and proficient Basic Life Support (BLS). Additionally, ensuring scene safety is paramount, as lightning can strike the same location more than once, posing a continued threat to both the patient and the responder.

Given the unpredictable nature of storms, EMS teams must be adept at prevention, risk assessment, and patient education to minimize exposure and injury rates. 

By understanding these principles and preventive measures, EMS Providers can effectively manage and mitigate the risks associated with lightning injuries during environmental emergencies.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Gookin, J. (2011) Backcountry Lightning Risk Management. NOLS. Accessed October 24, 2024

Grayson, S. & Gandy, W. (2011) Environmental Emergencies. EMS World Online. Accessed November 8, 2024.

Limmer, D., O'Keefe, M. F., & Dickinson, E. T. (2020) Emergency Care (13th Ed) - Chapter 31: Environmental Emergencies. Accessed November 8, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Oglesbee, S. (2014) Considerations When Assessing & Treating Patients with Lightning Injuries. Journal of Emergency Medical Services. Accessed October 26, 2024

Osmosis (ND) Environmental Emergencies. Elsevier. Accessed October 8, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Schimelpfenig, T. (2021) NOLS Wilderness Medicine (7th Ed). Mechanicsburg, Pennsylvania: Stackpole Books

EMS In the News - Whole Blood in the Field: The Next Frontier of ‘What’s Actually Impossible?’”,

Jonathon Feit discusses the concept of challenging established norms and the perception of what is “practical” or “possible” in the field of emergency medical care, specifically concerning the use of whole blood in prehospital settings.

Feit critiques the statement from a September 2024 Journal of Trauma and Acute Care Surgery article that suggested “low-titer O whole blood (LTOWB) is the only practical solution prehospital.” 

Feit argues that this mindset limits innovation by implying that alternatives are not feasible, when history has shown that what is considered “impossible” often becomes routine with technological advancements.

Drawing parallels from science fiction scenarios that have turned into reality (like brain-computer interfaces and real-time data sharing), Feit suggests that the same principles could apply to portable blood testing and administration in the field. 

Technologies like “lab on a chip” and advancements in portable diagnostics challenge the idea that comprehensive blood management must be confined to hospitals. He encourages a reevaluation of these limitations, emphasizing that once-novel ideas in EMS - such as electronic patient care reporting (ePCR) and voice-controlled systems - are now standard.

The core message is that innovation should not be constrained by what has “always been done.” Instead, Feit calls for pushing boundaries and exploring new solutions, especially when it comes to potentially life-saving interventions like administering whole blood in the prehospital environment.

For more information, access the full article here.

EMS Emergencies - Pediatric Patients

EMS providers need to be well-prepared to handle pediatric emergencies as they require specialized knowledge and skills due to the unique needs of children.

Here are some key points they should know:

1. Respiratory Distress: Children commonly present with respiratory distress due to conditions such as asthma, bronchiolitis, or croup. EMS providers should be proficient in assessing respiratory status, administering oxygen, and managing airway obstructions.

2. Febrile Seizures: Febrile seizures are common in young children and are often frightening for caregivers. EMS providers should know how to assess and manage febrile seizures, including ensuring adequate ventilation and preventing injury during the seizure.

3. Trauma: Children are at risk for various types of trauma, including falls, burns, and motor vehicle accidents. EMS providers should be skilled in assessing and managing pediatric trauma, including immobilization techniques and pain management.

4. Sepsis: Sepsis can be challenging to recognize in children, as symptoms may be nonspecific. EMS providers should be vigilant for signs of sepsis, such as fever, tachycardia, and altered mental status, and be prepared to initiate early treatment.

5. Anaphylaxis: Allergic reactions, including anaphylaxis, can occur in children due to food allergies, insect stings, or medications. EMS providers should be trained in recognizing anaphylaxis and administering epinephrine as needed.

6. Dehydration: Children are at increased risk for dehydration due to factors such as vomiting, diarrhea, or fever. EMS providers should be skilled in assessing hydration status and administering fluids as needed, especially in cases of severe dehydration.

7. Seizures: Seizures can occur in children due to various causes, including epilepsy or febrile illnesses. EMS providers should know how to assess and manage seizures, including protecting the child from injury and administering appropriate medications if necessary.

8. Poisoning: Accidental poisoning is a common pediatric emergency. EMS providers should be familiar with common toxins and their effects on children, as well as appropriate decontamination and treatment measures.

9. Cardiac Arrest: While less common in children than in adults, cardiac arrest can still occur due to various causes, including congenital heart defects or respiratory failure. EMS providers should be proficient in pediatric CPR and advanced life support techniques.

10. Communication & Family Support: Effective communication with caregivers is essential in pediatric emergencies. EMS providers should be skilled in providing clear and compassionate communication, as well as offering support to families during stressful situations.

By being knowledgeable about these common pediatric emergencies and having the necessary skills to assess and manage them effectively, EMS providers can play a crucial role in providing optimal care for children in emergency situations.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Equipment - Traction Splints Addendum

For open femur fractures, it is essential to follow the principles of advanced trauma life support (ATLS) and local trauma management protocols.

These protocols typically recommend initial hemorrhage control, wound care, and expedited transport to a trauma center for definitive care.

According to the organization, International Trauma Life Support (ITLS), they advocate for the use of traction devices for open midshaft femur fractures.

ITLS reports the use of a traction device for open midshaft femur fractures can help reduce the risk of neurovascular injuries and alleviate patient pain. It highlights the importance of considering the patient's extrication and transportation needs when selecting a traction device.

In situations where the patient will be transported by air, the ITLS update suggests that a HARE traction splint may be preferred over a Sager traction splint. This is likely due to the design and ease of application of the HARE traction splint, which may be better suited for air transport scenarios.

It's important to note that guidelines and recommendations can vary across different organizations and regions. Therefore, it's crucial to consider the specific guidelines and protocols established by your local EMS authority or trauma organization when managing open midshaft femur fractures.

Bibliography

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Davis, D. D., Ginglen, J. G., Kwon, Y. H., & Kahwaji, C. I. (2023) EMS Traction Splint. StatPearls. https://pubmed.ncbi.nlm.nih.gov/29939619/ Accessed February 19, 2023

International Trauma Life Support (2011) Utilization of Traction Splints with Open Femur Fracture. https://www.itrauma.org/.../UtilizationofTractionSplintsw... Accessed November 14, 2023

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

The Bone School (ND) Femoral Shaft Fractures. http://www.boneschool.com/lower-limb/hip/femur-fractures/femoral-shaft-fractures Accessed February 19, 2024

EMS Trauma Emergencies - Le Fort Fractures

EMS Providers should be familiar with Le Fort fractures as they are severe injuries to the facial bones that require immediate attention.

There are three main types of Le Fort fractures, each affecting different parts of the face. Here's what EMS providers should know about them:

Le Fort I Fracture (Horizontal Maxillary Fracture):

This fracture involves a horizontal separation of the maxilla (upper jaw) from the rest of the face.

Mechanism of injury often involves a blow to the front of the face, such as a dashboard impact in a motor vehicle accident.

Signs and symptoms may include:

- Pain and tenderness in the upper jaw region.

- Mobility or instability of the teeth.

- Numbness or tingling in the upper lip or gums.

Complications can include airway compromise due to displacement of the maxilla.

Le Fort II Fracture (Pyramidal Fracture):

This fracture involves separation of the central portion of the face from the skull, including the nasal bones, ethmoid bone, and maxilla.

Mechanism of injury often involves a high-energy impact to the middle third of the face, such as a direct blow to the nose or cheekbones.

Signs and symptoms may include:

- Swelling and deformity of the mid-face.

- Crepitus (grinding sensation) upon palpation.

- Periorbital ecchymosis (bruising around the eyes).

- CSF (cerebrospinal fluid) rhinorrhea or otorrhea, if there is associated skull base fracture.

Complications can include orbital and ocular injuries, as well as CSF leakage which may lead to increased risk of meningitis.

Le Fort III Fracture (Transverse Fracture):

This fracture involves separation of the entire facial skeleton from the skull, including the zygomatic arches, orbits, and nasal bones.

Mechanism of injury often involves a severe, high-velocity impact to the face, such as a fall from height or a significant blunt force trauma.

Signs and symptoms may include:

- Gross facial deformity with flattening of the mid-face.

- Bilateral periorbital ecchymosis (raccoon eyes).

- Subconjunctival hemorrhage.

- Epistaxis (nosebleed).

Complications can include severe facial disfigurement, orbital compartment syndrome, and optic nerve injuries leading to visual impairment or blindness.

The concept of Le Fort fractures was developed by a French surgeon named René Le Fort. René Le Fort conducted extensive anatomical studies on the human skull in the early 20th century. 

In 1901, he published his findings on patterns of fractures involving the mid-face region, which came to be known as Le Fort fractures. His work laid the foundation for understanding and classifying these severe injuries to the facial bones.

For EMS providers, prompt recognition and stabilization of patients with Le Fort fractures are crucial. Management typically involves securing the airway, controlling bleeding, and providing pain management while transporting the patient to an appropriate medical facility for further evaluation and treatment by a maxillofacial surgeon or a trauma specialist. 

Additionally, EMS providers should be vigilant for associated injuries, particularly to the cervical spine and head, given the mechanism of injury typically associated with these fractures.

Further Reading:

Alexander, M. & Belle, R (2012) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). New Jersey: Pearson. 

Bledsoe, B. E., Cherry, R. A. & Porter, R. S. (2023) Paramedic Care: Principles and Practice Volume 1 (6th Ed). New Jersey: Pearson. 

Brown, C. A., III., & Walls, R. M. (2023) The Walls Manual of Emergency Airway Management (6th Ed). Pennsylvania: Lippincott Williams & Wilkins. 

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). New Jersey. Pearson Education. 

EMS Trauma Emergencies - Epidural & Subdural Hematomas

EMS providers should have a good understanding of epidural and subdural hematomas, as prompt recognition and management are crucial.

An epidural hematoma occurs when blood accumulates between the skull and the outer layer of the brain (dura mater). It is typically caused by a traumatic head injury, such as a skull fracture that damages the middle meningeal artery.

Examples of causes include motor vehicle accidents, falls, or assaults.

A subdural hematoma, on the other hand, is the accumulation of blood between the dura mater and the brain. It can result from a direct blow to the head or rotational forces causing tearing of the bridging veins.

Causes can include falls, sports injuries, shaken baby syndrome, or head trauma in older adults due to minor falls.

In both cases, the accumulation of blood can lead to increased pressure on the brain, potentially causing neurological deficits.

EMS Providers should be aware of the signs and symptoms, such as severe headache, altered mental status, focal neurological deficits, or changes in consciousness.

Prompt transportation to a trauma center is essential for definitive diagnosis and surgical intervention, if necessary.

Remember, this information is not a substitute for medical advice. If you suspect a head injury, it's important to consult with a healthcare professional for proper evaluation and management.

#PreHospitalCare #TraumaEmergencies #EpiduralHematoma #SubduralHematoma #NeurologicalDeficits

EMS Trauma Emergencies - Le Fort Fractures

Emergency Medical Services (EMS) providers need to be well-prepared to assess and manage facial injuries including Le Fort Fractures. These injuries can result from various mechanisms, such as motor vehicle accidents, falls, or assaults. 

Recognizing and managing them appropriately is crucial to ensure the best possible outcome for the patient. Here's what EMS providers need to know:

Assessment:

Start by assessing the patient's airway, breathing, and circulation (ABCs).

Be vigilant for signs of life-threatening injuries, such as airway compromise, respiratory distress, or severe bleeding.

Examine the face for deformities, swelling, and visible fractures.

La Forte Fractures:

La Forte fractures are complex facial fractures that involve the upper jaw (maxilla). They are classified into three types: Le Fort I, Le Fort II, and Le Fort III. These fractures may not always be obvious from the outside.

Le Fort I Fracture (Horizontal Fracture):

This fracture separates the maxilla from the rest of the face. The midface may be mobile, and the upper teeth may be mobile or displaced.

The patient may have pain in the upper jaw, and there may be bruising or swelling around the cheek and upper lip.

Le Fort II Fracture (Pyramidal Fracture):

This fracture involves the central part of the maxilla and extends up to the nasal bones.

The patient may have a floating midface, with mobility and deformity of the nose and upper jaw.

There may be a change in the appearance of the eyes, such as raccoon eyes (bruising around the eyes) or epistaxis (nosebleeds).

Le Fort III Fracture (Transverse Fracture):

This is the most severe and involves the entire midface, including the orbits (eye sockets).

The patient may have widely separated eyes, called telecanthus.

Check for visual disturbances or signs of injury to the eyes.

Management:

Focus on maintaining the airway and ensuring adequate ventilation. Patients with severe facial injuries can experience airway compromise due to swelling and bleeding.

Stabilize any obvious fractures with gentle manual pressure, if necessary.

Control any bleeding by applying direct pressure with sterile dressings.

Provide pain management as needed.

Transport the patient to the nearest appropriate medical facility, preferably one with a trauma center and maxillofacial surgery capabilities.

Continuous monitoring of vital signs is essential during transport.

Precautions:

Handle facial fractures with care to avoid worsening the injuries or causing further damage.

Avoid pressure on the eyes or the nose.

Immobilize the head and neck, especially if there is concern about cervical spine injuries.

Remember that prompt and appropriate care is crucial in managing facial injuries, as they can impact the patient's ability to breathe, see, eat, and speak. 

Always follow local protocols and guidelines, and communicate effectively with the receiving hospital to ensure the best possible outcome for the patient.

#TraumaEmergencies #LeFortFractures #PreHospitalCare #EMS