2. History:-
• Term coined by “Jean Louis Petit” in 1718, to describe the action of
his screw device to stop haemorrhage.
• LISTER was the first surgeon to employ it to provide a bloodless field
for surgeries other than AMPUTATION.
• In 1873, Johann von Esmarch, Professor of surgery at Kiel and
Surgeon General to army, described the bandage which bears his
name.
• In 1904, pneumatic tourniquet was developed by Harvey Cushing.
• In 1980, James McEwen invented electronic tourniquet systems.
3. DEFINITION:-
• It is a constricting or compressing device used to control
venous and arterial circulation to an extremity distal to it for
period of time.
• Pressure is applied circumferentially upon the skin and
underlying tissues of limb; this pressure is transferred to the
walls of vessels, causing them to become temporarily
occluded.
5. Non Pneumatic:-
• It is permissible only in exceptional circumstances to use a non
pneumatic on an upper or lower limb.
• The DANGER with it is, whether straps or rubber bandage is that the
pressure exerted by them on the underlying tissues is unknown.
• Middleton and Varian (1974) illustrated that with Esmarch bandage
there is linear increase in pressure with each turn of bandage, to the
maximum of 900 mmHg in adults and 1015 mmHg in children.
• Esmarch is sterilized by autoclave.
6. Pneumatic Tourniquets:-
• Based on the same physical principles as BP cuffs but they are
stronger, their fastenings are more secure and they usually have a
stiff backing piece to maintain the effective width of inflated cuff.
• They could be divided in two types:-
1. Non – automatic
2. Automatic.
7. Contraindications to Exsanguination:-
• Sever Infection
• Tumor
• Proven or suspected DVT:-
In 1963, Austin reported two cases in which massive fatal
pulmonary embolism was precipitated by exsanguination with an
Esmarch bandage in presence of silent DVT.
8. Contraindication to use of Tourniquet:-
• Peripheral Vascular Disease
• Severe Crush Injuries
• Sickle Cell Disease
• Infection
• Compartment Syndrome
• Peripheral neuropathy.
• Poor skin condition.
10. Tourniquet pressures and time:-
• In upperlimb its is 50 mmHg plus to SBP.
• In lowerlimb it is twice the SBP.
• Time is 1.5 – 2 hours.
11. Tourniquet related complications:-
CONSEQUENCES OF TOURNIQUET
LOCALISED SYSTEMIC
Nerve injury Cardiovascular
Muscle injury Respiratory
Vascular injury Cerebral circulatory
Skin injury Haematological
Bleeding/hematoma Temperature changes
Tourniquet failure Metabolic
12. LOCAL
• Normal physiological conduction block in fifteen minutes
• NERVE INJURIES- 0.37%
1. The radial nerve, followed by the ulnar and median nerve in the upperlimb.
2. Sciatic nerve in the lower limb are m/c involved.
3. Large diameter nerve fibers are more commonly affected.
13. Muscle Injury:-
• Tends to be greatest beneath the tourniquet because of the
combination of ischaemia and mechanical deformation.
• May persist after tourniquet deflation as a result of micro-vascular
congestion.
• Post tourniquet syndrome
• Usually normalize by 3 weeks
14. Excess bleeds intra op
• Under- pressurized cuff, insufficient exsanguination,
improper cuff selection, loosely applied cuff, calcified vessels
or too slow inflation or deflation.
• Bleeding may occur despite a properly applied and inflated
tourniquet, in a patient with non calcified vessels. (the
phenomenon of tourniquet ooze)
15. •Vessels bypass the tourniquet through the medulla of the
humerus or femur.
•It typically starts about 30 minutes after tourniquet inflation.
•Increasing the tourniquet pressure does not help.
16. Vascular Injury:-
• Direct vascular injury is an uncommon complication of tourniquet use.
• It occurs most commonly in children, obese, elderly, and patients with
peripheral vascular disease.
17. Skin injury:-
• Skin injuries are uncommon.
• But excessive tourniquet time or poorly placed tourniquets
may result in
• cutaneous abrasions, blisters and even pressure necrosis.
18. Pre- application precautions:-
• The pressure source, cuff, regulator, tubing, and connectors to be
checked before use.
• Wider cuff should be used
• Layer of cotton padding to be done.
• Cuff should overlap at least 3 inches, but not more than 6 inches as it
may cause generation of high pressures.
• The extremity should be exsanguinated before inflating tourniquet.
19. Tourniquet paralysis syndrome:-
• Caused by pressure rather than ischaemia.
• Moldaver described in 1954 with features:-
1. Motor paralysis with hypotonia or atonia without atrophy.
2. Sensory dissociation.
3. Color and temperature of the skin is normal as sympathetic functions are
normal.
4. Peripheral pulses are normal.
• Recovery may take till 3 months.
