1. Tourniquet
Dr. IMRAN JAN

2.  The word tourniquet is derived from
French
 Provides bloodless field
 Blood removed & prevented from
re-entering
 External pressure applied at the
root of the limb occludes arteries &
veins

3.  Term coined by Petit in 1718
 Lister-first employed it to provide a
bloodless field
 1873 Johann von Esmarch-bandage
- Flat & woven from India rubber.
Associated with nerve palsies
 Harvey Cushing -1904-pneumatic
Tourniquet

4. 2 types
 non pneumatic
 Pneumatic
Pneumatic
 Non automatic
 Automatic
TYPES OF TOURNIQUET

5.  Pressure exerted unknown
 A linear increase in pressure with
each turn of esmarch bandage
 An esmarch bandage can be
autoclaved
NON PNEUMATIC

6. PNEUMATIC TOURNIQUET
 Principle same as blood pressure
cuffs
 Stronger more secure
 Stiff backing piece-maintains the
effective width.

7. NON AUTOMATIC
 A pneumatic cuff, hand operated pump & a
pressure gauge
 Pressure in cuff known
Disadvantages
 No automatic compensation for leaks
 Regular check on the pressure in the cuff
 Difficult to rapidly ↑ the pressure above the
patient’s systolic BP
 Could result in venous engorgement

8. AUTOMATIC
 A pumped reservoir-gas comes from
container of volatile liquid (dichloro
difluoro methane); from bottled air
or nitrogen or compressed air line
 Constant supply to compensate for
leaks

9. SITE FOR APPLICATION OF A
TOURNIQUET
 Site with enough muscle bulk to
disseminate the pressure in the cuff
evenly.
 Around upper arm or thigh

10. WIDTH OF A TOURNIQUET
 Pressure in the occluding cuff of a
Sphygmomanometer = underlying central
artery pressure
 For forearm-width 20%> the diameter of
the upper arm
 For lower limb- >40% of the circumference
of the thigh or 8 inches (20cm)
 Narrower the cuff; the higher the pressure
required

11.  Elevate the limb vertically for four
minutes
 Or by covering with an inflating
envelope or applying an esmarch
bandage
EXSANGUINATION

12. DANGERS FROM
EXSANGUINATION
 Risky when achieved by compression
 Frictional shearing force-damages the skin
weakened by senility; steroids or RA & Ehler Danlos
 Ends of fractured bone; foreign bodies damage the
skin
 Subcutaneous nerves should be padded
 Compressive exsanguination – not in the presence
of dvt, malignant tumour or infection
 In an elderly - exsanguination of both lower limbs
Causes overloading with possible cardiac arrest
 ↑in 50% of the blood being forced back

13. TOURNIQUET
PRESSURE
Cushing’s method
For ripper limb- systolic BP+50
For lower limb- 2 times the systolic BP

14. DANGERS FROM THE
PRESSURE IN THE
TOURNIQUET Underlying skin to be protected well
 No irritant or inflammable skin preparation solutions
do not soak under the cuff
 Atherosclerotic vessels have a possibility of
compression
 Local damage if skin fragile, bone irregular
 Muscles suffer permanent damage from pressure
 Function of nerves is impaired by both pressure &
ischaemia
 Patients with diabetes mellitus, alcoholics & RA are at
higher risk

15. TOURNIQUET PARALYSIS SYNDROME
 Described by Moldaver in 1954
 Caused by pressure rather than ischaemia
FEATURES
 Motor paralysis with hypotonia or atonia. Sensory
dissociation –touch; pressure, vibration & position sense
usually are absent
 Colour & temperature of skin are normal
 Peripheral pulses are normal
 The block to the nerve conduction is at the level of
tourniquet
 Motor nerve stimulation distal to the block may still produce
contraction
 Pressure distorts the myelin sheath-ratracts from the nodes
of Ranvier- segmental demyelination
 Recovery takes three months

16.  Tissues distal to the cuff become anoxic; acidotic
& loaded with metabolites
 Critical levels of acidosis-after 2 hrs - venous pH
falls to 6.9 pO2 to 4 mm Hg, pCO2 risen to 104 mm
Hg
 Three hours of ischemia – 40 minutes for acid
base levels to return to normal
DANGERS FROM ISCHAEMIA

17. POST TOURNIQUET SYNDROME
 Immediate swelling of tissues on release of
a tourniquet
 Due to reactive hyperemia and to ↑ capillary
permeability to fluids & protein
 Swelling more severe when tourniquet
time↑ beyond 2 hrs
 Longer the ischaemia and older the patient
more the untoward reaction

18.  Buner described it is upper limb
 Puffness of hand & fingers
 Stiffness of joints in the hand
 Changes – hand pale when elevated &
congested when dependent
 Subjective sensation of numbness
 Objective evidence of weakness of the
muscles in the hand & forearm

19. METHODS OF PREVENTION
 Select of the correct operation for each pt
 Avoid wasting time
 Do not extend the tourniquet time
unnecessarily
 Ensure good haemostasis
 Elevate the limb after the operation
 Encourage the pt to perform active movement
of the pertinent part

20. DANGERS OF A TOURNIQUET
 Major complication are rare
 Gangrene from excessive period of ischemia
nerve palsies form excessive pressure
The dangers from the use of a tourniquet result
 From the process of exsanguination
 From pressure on tissue under the tourniquet
 From ischemia
 From bleeding after the closure of the wound
 From failure to remove the tourniquet

21.  Occur mostly in fingers when bands are
used without large clips
 Can be released when it is discovered
 Six hours –suggested as the dividing
line b/w removing the cuff & trying to
save the limb
DAGERS FROM FAILING TO
REMOVE THE TOURNIQUET

22.  Elevate the limb
 Wrap the bandage starting at the hand or
foot & working proximally by fully
stretching each turn
 Extremities left free
 Overlap of ½ inch
HOW TO APPLY AN ESMARCH
BANDAGE FOR
EXSANGUINATIONS

23. Apply it as for exsanguination
At the upper arm or thigh wrap it over
padding last 4 to 5 times one on top of the
other.
Unwind the distal end from distal upto the
area acting as a tourniquet
Tie the ends to the table
Caution:- tourniquet time kept to absolute
maximum. Pressure exerted is unknown
HOW TO APLY ESMARCH
BANDAGE AS A TOURNIQUET

24.  Apply a few layers of orthopediac wool at
the tourniquet site
 Wrap the pneumatic cuff on top of padding
after expressing all air from the cuff
 The connecting tube lies on the outer aspect
of the limb & points proximally
 Reinforce the valves of the pneumatic cuff
 Exsanguinate the limb by elevating for 4
minutes
 Raise the pressure to the predetermined
level
 Note the time & write it
HOW TO APPLY PNEUMATIC
TOURNIQUET

25.  Use a colourless skin preparation for toes & fingers
 Do not allows it to collect under the edge of
tourniquet
 If tourniquet fails in b/w remove it & reapply it
 Keep the tissues moist
 Avoid the use of hot spot light
 Remove tourniquet at the end of surgery
 Check that the circulation is satisfactory
THINGS TO BE BORNE IN MIND
WHEN A TOURNIQUET IS USED

26. HOW TO APPLY A DIGITAL
TOURNIQUET
 Fingers & toes
 Clean & anaesthetize the digit
 Wrap a layer of gauze around the base of digit
 Elevate the hand or foot for 4 minutes
 Wrap a single turn of rubber tubing over the
gauze & pull it tight
 Secure the tubing with a large artery clip
 Note the time & enter it on a record sheet

27.  Before every operating list check level of fluid in the
reservoir or pressure of gas
 Ensure that the machine will attain & hold pre set
pressure
 Inspect the cuff; its fasteners & tubing
 The esmarch bandage is inspected monthly for tears
or perished areas
 Check the cuff system for leaks
 Check the cuff system pressure gauge
 Records on the use of tourniquet must be kept- to
retrieve all information needed for research of
medico legal issues
ROUTINE CHECKS ON TOURNIQUET
EQUIPMENT

28. Double pneumatic cuffs have been used
for reducing the pain form tourniquet cuff
in regional IV analgesia
Each cuff is only half the width of the
normally used one . If operating time is
less than 40 minutes pain due to pressure
of cuff is an occasional problem

29.  0.5 ml plain Bupivacaine hydrochlocie-20 ml diluted
to 50ml of 0.2% solution with NaCl (maximum dosage
1.5mg/kg body wt)
 Measure patient’s BP
 Apply a tourniquet cuff
 23 G IV cannula on the dorsum of hand
 Exsanguinate the limb & inflate the cuff
 Inject the required dose
 Analgesia in 4-6 minutes
 On completion of surgery deflate it
 Sensation returns in 8 minutes
APPLICATION OF BIER’S BLOCK FOR
THE UPPER LIMB

30. Thank you