Forty years ago, Peter Rosen, MD, then the chair of the Emergency Department at Denver General Hospital (now Denver Health), defined a concept he called “The Technical Imperative.” Quite simply, the Technical Imperative is the principle that “If a procedure is taught, it will be used with a frequency greater than its indications.”
Recently, a group of researchers at Massachusetts General Hospital and Amsterdam UMC conducted a 5-year retrospective review of adults who presented at their trauma centers with a prehospital tourniquet.  They found that out of 147 patients:
- Tourniquet application was indicated in only 51% of patients
- Tourniquets were inappropriately placed in 27% of patients
- 5 patients sustained complications (nerve palsy and compartment syndrome)
Of the tourniquets that were placed inappropriately, 13 patients had venous tourniquets with the potential for increased external hemorrhage as well as compartment pressures and 4 patients had the tourniquet applied distal to the injury. Of particular concern, 32 of 72 tourniquets applied by EMS personnel were considered to be not-indicated. Several other studies have also documented incorrect or non-indicated tourniquet use. [3,4]
Thus it appears that the Technical Imperative remains operative 40 years after its identification. This represents a significant challenge for the Stop the Bleed initiative.
The stated goal of Stop the Bleed  and the Hartford Consensus Group [6-8] is to empower public safety responders and citizen immediate responders to stop life-threatening external hemorrhage. Paradoxically, however, the more responders we train to use tourniquets, the more we will struggle with the implications of the Technical Imperative.
How can we improve the use of this life-saving intervention by EMS personnel, other public safety professionals and citizen responders? I propose three strategies to help prevent overuse and misuse of tourniquets and mitigate the risk of tourniquet complications.
1. Emphasize that tourniquets are just one option in the bleeding control toolbox
Efforts to improve the utilization of tourniquets must begin with the educational programs teaching the various hemorrhage control interventions.
First, it is not unusual for Stop the Bleed programs to be referred to as “tourniquet courses.” This may be attention grabbing, but it risks fueling tourniquet overuse. Instructors must instead strongly promote the concept that Stop the Bleed education is about hemorrhage control and that tourniquets are merely one method of doing so. Emphasize that the initial action is application of direct pressure to the bleeding site using two hands and body weight while assessing the need for other interventions such as the tourniquet.
Second, training programs should stress that not all bleeding is life-threatening. One key concept is that not every penetrating wound results in major external hemorrhage. In fact, most bleeding probably does not constitute a life-threat. Educational programs should clearly define and describe the types of injury and bleeding that require the interventions being taught.
Specifically, instructors should reinforce the following signs of life-threatening bleeding:
- Pulsatile or steady bleeding that is coming from a wound
- Blood that is pooling on the ground
- Clothing or bandages are steadily becoming soaked with blood
- Amputation of an arm or a leg
- The patient was bleeding and now is unconscious or confused (indicating that the patient is in shock)
Instructors should also give examples of injuries and wounds that result in minor bleeding and do not require a tourniquet. These include injuries such as simple lacerations, abrasions, etc. Even many if not most limb gunshot wounds and stab wounds do not require tourniquet application if they do not result in major hemorrhage as outlined above.
The key teaching point is that while all skin disruptions bleed, tourniquet application should be reserved for life-threatening limb hemorrhage. All other bleeding can usually be controlled with direct pressure.
In addition, during the tourniquet portion of training, instructors should emphasize two points that can help avoid incorrect application:
- The tourniquet must be placed above the bleeding wound on the limb
- The tourniquet must be tightened until all bleeding stops from the wound site
Finally, it should be stressed that if the responder is in doubt about the magnitude of the bleeding and the need for aggressive intervention, it is preferable to act to control what bleeding is seen rather than allow the hemorrhage to continue unabated.
2. Improve communication about tourniquet application
Given the fact that proper tourniquet application to a limb compresses tissue and obstructs arterial blood flow leading to limb ischemia, the duration of tourniquet application is a critical determinant of subsequent complications such as nerve palsy and compartment syndrome as well as limb survival.
Strong communication protocols will help avoid inadvertent prolonged application and make sure caregivers have the opportunity to correct an inappropriately placed device.
- Any time a tourniquet has been placed — whether a commercial or an improvised device — the person who placed the tourniquet must notify subsequent caregivers of its presence.
- EMS responders should ask citizen responders what specific actions they took to control bleeding and, in particular, whether they applied a tourniquet of any type.
- In addition to tourniquet presence, the time of application must also be documented and relayed to responders and caregivers both in the field and in the hospital.
One method for preventing communication failures is to place a piece of tape in a visually conspicuous location on the patient, such as the forehead, with the letters “TQ” written on the tape along with the time of application. One benefit of this method is that it is easily and immediately visualized. In addition, many commercial tourniquets have a place where the time of application can be written. Visual communication provides an important backup to verbal and written EMS reports.
3. Build continuous reassessment into tourniquet protocols
The U.S. Military experience of the last decade has demonstrated the life-saving effectiveness and relative safety of commercial tourniquets.  Complications are extremely rare and loss of limb non-existent if tourniquet time is less than 2 hours.
For this reason, both the Committee on Tactical Combat Casualty Care and the Committee on Tactical Emergency Casualty Care recommend that all tourniquets be reassessed and, if possible, converted to other means of hemorrhage control as soon as possible after application and no later than 2 hours post placement. [10,11]
The key is continuous reassessment. Whenever a tourniquet has been placed, caregivers must regularly assess the continued need for the device and whether or not the bleeding can be managed by another method. If a tourniquet is still required, caregivers should also assess whether or not it has been properly applied. Assessments should take place multiple times as follows:
- By prehospital caregivers if prehospital time is anticipated to be prolonged
- By the caregivers next in line to receive and manage the patient
- Each time the patient is handed off to other caregivers
For example, if a tourniquet was placed by a citizen, EMS personnel should reassess the wound, the nature of the hemorrhage, the choice of bleeding control, and the presence or absence of a distal pulse. Once the patient arrives to the receiving emergency department, the reassessment process should again be repeated by the emergency physician and then again by the receiving trauma surgeon.
More articles on bleeding control:
- 8 pitfalls to avoid in hemorrhage control
- Bleeding control for law enforcement officers
- Civilian tourniquet use associated with six-fold reduction in mortality
Here again we see the value of the “tape on the forehead” method. This visual cue helps avoid the rare (but not unheard of) situation in which a trauma team focuses on a patient’s multiple injuries and loses sight of the limb with a tourniquet. It also helps ensure continued awareness when a limb is covered with clothing or a sheet while other diagnostic workup is undertaken. In both of these situations, it becomes all too easy to exceed the 2-hour tourniquet reassessment time.
Benefits outweigh potential harms
Can we completely avoid the Technical Imperative in cases of external hemorrhage control? Given the goal of teaching the various methods of bleeding control, particularly tourniquet application, to as many people as possible, many of whom are relatively unsophisticated in terms of hemorrhage assessment and medical decision-making, the answer is probably not.
Given that likely reality, it is essential that medical caregivers of all levels be skilled in assessing tourniquet application, determining the necessity of that intervention and applying another one when indicated.
As Norman McSwain, MD, wrote many years ago, the logic of the Technical Imperative is that “any medical procedure should be judged by the balance of the positives against the negatives, that is, the chance of the patient being harmed versus the chance of the patient being benefited. … As new techniques become available for prehospital use … they must be evaluated to assure that the benefit to the patient will outweigh errors and complications.”
Using this philosophy as a guide, the imperative now is to develop strategies for preventing the overuse and misuse of tourniquets and mitigate their risk. With proper education, the overall benefits of tourniquet application outweigh the risk of errors and complications.
Peter T. Pons, MD, FACEP is professor emeritus in the Department of Emergency Medicine at the University of Colorado School of Medicine.
1. Rosen P, Dinerman N, Pons PT, Marlin R, Hansen H, Kanowitz A. The Technical Imperative: Its Definition and an Application to Prehospital Care. Topics in Emergency Medicine, 1981;3:78-86.
2. Mikdad S, Mokhtari AK, Luckhurst CM, et al. Implications of the National Stop the Bleed Campaign: The Swinging Pendulum of Prehospital Tourniquet Application in Civilian Limb Trauma. J Trauma Acute Care Surg 2021; epub ahead of print. DOI: 10.1097/TA.0000000000003247
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10. Joint Trauma System. Tactical Combat Casualty Care Guidelines 2020. https://www.deployedmedicine.com/content/40 Accessed June 19, 2021
11. Committee on Tactical Emergency Casualty Care. Tactical Emergency Casualty Care (TECC) Guidelines. https://www.c-tecc.org/guidelines Accessed June 19, 2021
12. McSwain NE. Another Look at the Technical Imperative. Topics in Emergency Medicine, 1981;3:87-90.