Posted on 22 Comments

How Long Can You Leave A Tourniquet Before Amputation?

Tourniquets are a frequent topic of discussion on the Mountain Man Medical YouTube channel and I’ve been seeing a lot of rumors. Most of these rumors come from the old ways of doing things.

All medicine is constantly changing, year to year and sometimes month to month as scientists and doctors search for the best way to keep a person alive, and trauma is no exception.

If you haven’t had any medical training for a few years you might not be up to date on the latest techniques for managing trauma. One of the most common myths I see pop up is this:

“Tourniquets are a last resort. If you apply a TQ, the victims injured limb will be amputated.”

Not only is this wrong, but it’s very dangerous.

Now hold on, I don’t fault anyone for thinking this because it used to be taught as standard practice. But, since the War on Terror began, there have been plenty of cases to be studied and now we know this isn’t true.

Lets first start with what’s going on in the body when a TQ is applied.

Tourniquets are effective for controlling a life-threatening bleed because it clamps down all the vessels supplying blood to the extremity.

I’m sure you already knew that but let’s pretend that you didn’t for a moment.

Blood is carrying oxygen and keeps the tissues alive. Without this essential oxygen, the tissues will die. The blood is also responsible for carrying away toxins that would build up if not removed. When a TQ is applied, blood stops moving and neither of these essential things takes place.

So, the Question Becomes:

How long can a tourniquet be applied before the tissues die from a lack of oxygen and a buildup of toxins, and the limb must be amputated?

According to the National Center for Biotechnology Information (NCBI):

“Muscle damage is nearly complete by 6 hours, with likely required amputation. Numerous studies have been performed to determine the maximum duration of tourniquet use before complications. The general conclusion is that a tourniquet can be left in place for 2 h(ours) with little risk of permanent ischaemic injury.”

Now it’s important to note that the study detailed by the NCBI is looking more at Pneumatic Tourniquets instead of the windless style like a CAT.

Riester 5255 Pneumatic Tourniquet, Blood Stasis 5255
Riester 5255 Pneumatic Tourniquet

So, let’s look at more evidence.

According to Peter T. Pons, MD, FACEP:

“The experience gained over the past 15 years of combat has clearly demonstrated that recommended, commercially available tourniquets can, in fact, be used safely. Data from the U.S. military have shown that survival for trauma victims who have a tourniquet applied before they bleed into shock is 9 times greater than for victims who receive a tourniquet after they go into shock.

 In addition, the data show that tourniquets can be safely applied to an extremity for a period of up to 2 hours with no concern about amputation. In fact, there have been no amputations in the U.S. military as a direct result of tourniquet application in patients with an application time of 2 hours or less.”

This means that if you are injured in an area with an average EMS response time of 15 minutes and 19 seconds, applying a TQ has very little risk of requiring amputation.

It’s possible to bleed out from a femoral artery in 2:30-3:00 minutes, so the risk of death before EMS can get on scene is substantial, while the risk of amputation is low to none.

The Takeaway:

Don’t be afraid to use your TQ for life threatening bleeds. Though the risk of amputation is low, it’s still preferable to death.

22 thoughts on “How Long Can You Leave A Tourniquet Before Amputation?

  1. Great to know. Thank you for the vital information to help others!

  2. I thought I had read that it generally is safe for 6 hours and maybe up to 12 based on battlefield experience.

    1. According to the National Center for Biotechnology Information (NCBI):

      “Muscle damage is nearly complete by 6 hours, with likely required amputation. Numerous studies have been performed to determine the maximum duration of tourniquet use before complications. The general conclusion is that a tourniquet can be left in place for 2 h(ours) with little risk of permanent ischaemic injury.”

  3. Is there any procedure you can do to prevent an amputation if you need to leave the tourniquet on longer than 2 hr .

    1. The quick answer is, yes there’s a method for converting the TQ to a pressure dressing in the event you are held in place longer than the 2 hour mark.

      But, it’s more complex then I can go into in this short space.

      It can be very dangerous since the casualty can bleed out of course, so there are a set of guidelines that should be followed to do it successfully.

      If you come back next week, I’ll have a more detailed answer for you.

  4. Ok so you can leave the TQ in place for 2 hours with no permanent damage. With blood flow stopped does clotting occur in the injury? With the injury protected to prevent reopening the wound, and blood loss slowed some due to clotting, can the TQ be loosened to extend the amputation max? The TQ could be used to stop initial bleeding, then the wound carterized to seal the area, then the TQ loosened to restore blood flow to all the rest of the unijured extremity. I don’t know but for me this article created more questions then the answer it provided.

    1. So this is a question I’ve gotten a lot about this topic. I’m working on an article about this, but it’s more complex then I can go into in this short space.

      The quick answer is, yes there is a method for converting the TQ to a pressure dressing in the event you are held in place longer than the 2 hour mark.

      This can be very dangerous since the casualty can bleed out of course, so there are a set of guidelines that should be followed to do it successfully.

      If you come back next week, I’ll have a more detailed answer for you.

  5. Is there a procedure you can use if for some reason you would have to keep a tourniquet on longer than 2hr.

    1. So this is a question I’ve gotten a lot about this topic. I’m working on an article about this, but it’s more complex then I can go into in this short space.

      The quick answer is, yes there is a method for converting the TQ to a pressure dressing in the event you are held in place longer than the 2 hour mark.

      This can be very dangerous since the casualty can bleed out of course, so there are a set of guidelines that should be followed to do it successfully.

      If you come back next week, I’ll have a more detailed answer for you.

  6. In my EMT training we are also taught to write the time of application in a very visible place ON the patient. The forehead is recommended as ER personnel will see it immediately.

    1. Yes, agreed. I like to always have a permanent marker in my kit for that and taking notes.

  7. Great ;information and useful. My one comment is if you have put the tourniquet on correctly (ie have occluded the arteries which is neccessary to stop bleeding) it will be very painful because ischemic tissue (tissue with no blood supply) is very painful and in fact is considered one of the most painful conditions. Just be aware of that and warn the person to expect that and do not loosen the tourniquet to relieve the pain. A partially applied tourniquet will dramatically increase any arterial bleeding.

    1. Agreed! The medical term is “Tourniquet Pain” because it’s so common. The casualty might complain about the TQ over the gunshot wound and try to get you to loosen it.

      But don’t do that.

      And you are correct about a loose TQ actually increasing bleeding as well.

      Thanks for the great comments Chuck! Hope you stick around.

  8. An unanswered question is whether reapplication of a TQ is advisable if advanced help is several hours away and if so, how long can you leave TQ off before putting it on again?

    1. So this is a question I’ve gotten a lot about this topic. I’m working on an article about this, but it’s more complex then I can go into in this short space.

      The quick answer is, yes there is a method for converting the TQ to a pressure dressing in the event you are held in place longer than the 2 hour mark.

      This can be very dangerous since the casualty can bleed out of course, so there are a set of guidelines that should be followed to do it successfully.

      If you come back next week, I’ll have a more detailed answer for you.

  9. I had another question: does use of a “whatever is available” TQ change the time factor? I know use of a narrow belt is not advisable, but what else could be a viable substitute compared to the C-A-T or Pneumatic?

    1. A SWAT-T is a great choice and we sell them on our website if you’re interested.

      If you’re talking about improvised tourniquets then that will require a lot more space then I have room for here. I have an article and a YouTube video planned for this topic.

      https://www.youtube.com/channel/UCIcjqMjRxWYwTjq06Nq9_ug

      Come back to the site for the article and subscribe to the Mountain Man Medical Channel so you’ll know when the video drops.

  10. As an old Boy Scout and a son to a Vietnam, Army Medic – plus just common sense – I always knew that the info I was hearing just a couple years back about Tourniquets were bad – Were Plain Wrong!! Like you stated – you can bleed out in under 3 minutes…unless there’s a better solution, why not use one, if its possible? However, I never knew what the time limit was. I did learn if a Tourniquet was applied, to mark the time where it can be seen like on the forehead of the patient… But I never heard how long it can be applied before it needs to be loosened. Thanks very much for this information! I’m sure there are a lot of people out there that were taught tourniquets were bad.

    1. Thanks for the comment Art! Welcome aboard!

  11. In the spring of ’67, our health teacher taught us all a quick “First Aid” class. I didn’t know why but I loved that class. I aced it all the way through. On August 2nd of that same year, I had a life changing accident on the farm. I got my left arm caught in the auger of the feed grinder up to my elbow. I was bleeding like a stuck hog and I knew I had to act quick. I was stuck bad. Where it came from I do not freaking know (well, yes I do) but with near super strength, I tore my arm out of the trough, bending 1/8th inch steel, that held that auger and ran about 300 to 400 yards to the farmhouse. I was snatched up, put in the pick-up truck and began the journey to the hospital. I looked at my arm and assessed it. I tried direct pressure, no help at all. I tried indirect pressure, no help. The last resort was a tourniquet. I had nothing wide enough and I remembered it needed to be at least an inch wide. For some reason my focus went to my shoe. I leaned down, pulled my shoelace out of my shoe and somehow managed to tie it tightly around my arm. I was still bleeding but nowhere near what I was. We went about 5 miles down the road but it was way to bumpy. There was a huge hunk of meat bouncing that was killing me each time it bounced. The farmer turned around and took me to Akron Children’s Hospital where I stayed for 34 days. I found out that one artery was severed and the other was damaged with a hell of a lot more to “be fixed”. You said if a tourniquet is applied that appendage would be amputated. That is not entirely true, brother. I still have my arm, it just isn’t as pretty as it once was. If you make a blanket statement like that, somebody might remember what you said and not apply a tourniquet and, indeed, loose more than that appendage. There is definitely a time period and I was only 30 miles away from the hospital. When I saw my arm bleeding, it looked like a water hose slightly submerged in a bucket just churning the water upward some. Not only did I tie the tourniquet, I started singing my own rendition of “Get me out to the Hospital on time”!! When sh** gets real, it appears to me that God takes over and directs you and/or gives you what you need. I wasn’t being a smarta**, either. I just wanted others to know that there is a time for a short term tourniquet. Sorry it was so long but I had to get the story told so you understood my plight, if you will.

  12. My apologies for the book I wrote. When I saw the “apply a tourniquet and that appendage would be amputated”, I thought, Hell no!” lol Then I started writing. My bad.

    1. Ha! No worries Yank. What a crazy story! I’d love to know what you learned from that experience and how you see life now because of it.

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