Trauma and Tourniquets Nursing CE Course

• airway maintenance while protecting the cervical spine
• breathing and ventilation (maintain adequate oxygenation)
• circulation, including hemorrhage control (maintain adequate end-organ perfusion)
• disability (perform essential neurologic evaluation)
• exposure and environmental control (undress the patient and inspect for injuries while preventing hypothermia; ACS, 2018; James & Pennardt, 2022; Raja & Zane, 2022)

As trauma care continues to evolve, the steps of this initial rapid assessment have not changed and should be repeated throughout care. Interventions at each point can take time, and a deterioration in a previous step can occur. Therefore, any decline in a patient's status requires a repeat primary survey (ACS, 2018; James & Pennardt, 2022; Raja & Zane, 2022).

Airway

Airway obstruction or compromise is a preventable cause of death for trauma victims. Assessing a trauma patient's ability to speak clearly and answer questions appropriately, such as stating their name, provides a rapid assessment of airway patency. However, this assessment must be repeated frequently, as airway compromise can occur quickly. The Glasgow Coma Scale (GCS, see Table 1) is another tool that can help determine the level of consciousness (LOC). The GCS assesses an individual's best response in three categories: eye opening, verbal response, and motor response. The highest score of 15 indicates the client is responsive. The lower the score is, the more an individual is neurologically compromised. When the GCS score is below 8 (in the absence of reversible causes like sedation), intubation is usually necessary. Intubation should also be considered for any GCS score below 12 (ACS, 2018; James & Pennardt, 2022; Raja & Zane, 2022).

Table 1

Glasgow Coma Scale (GCS)

(CDC, n.d.)

An airway examination should include a visual inspection of the patient. Inspect their face and oral cavity (i.e., facial injuries, oral or dental injuries, obstruction, foreign bodies, tongue swelling, blood, emesis). Observe the patient for respiratory distress and listen for stridor, hoarseness, or gurgling. Inspect and palpate the neck for laceration, crepitus, swelling, hemorrhage, or other injuries. When managing a trauma patient's airway, it is imperative to minimize cervical spine movement. Nurses should assume a cervical spine injury when a patient presents with significant blunt trauma. The approved techniques for airway management that maintain cervical spine stability are the chin-lift and jaw-thrust maneuvers (ACS, 2018; James & Pennardt, 2022; Raja & Zane, 2022).

Utilize the following technique for the chin-lift maneuver:

• place the fingers of one hand under the mandible
• lift gently to move the patient's chin anteriorly
• depress the lower lip with the thumb on the same hand to open the mouth
• avoid hyperextension of the neck (ACS, 2018)

Utilize the following technique for the jaw-thrust maneuver:

• place a hand on each angle of the mandibles
• displace the mandible forward
• avoid hyperextension of the neck (ACS, 2018)

Additional airway support may be needed for trauma patients. Less invasive airway adjuncts include the nasopharyngeal (NPA, see Figure 1) and oropharyngeal (OPA, see Figure 2) airways. The NPA is an appropriate choice for an alert patient with airway compromise unless head or facial trauma is present or there is a suspected basilar skull fracture. The lubricated NPA is inserted through the nostril. An OPA is useful when tongue obstruction is present. However, there is a risk of gagging and vomiting, which can lead to aspiration (ACS, 2018). The technique for inserting an OPA is as follows:

• turn the airway upside down
• insert the airway until it touches the patient's soft palate
• rotate the airway 180 degrees
• slip the airway over the tongue (ACS, 2018)

If the patient does not gag during the insertion of an OPA, their airway may be unstable, and intubation should be considered. Nurses should not assess the gag reflex of an immobilized trauma patient as this can increase the risk of vomiting and aspiration. Patients with difficult airways may benefit from the placement of an advanced airway such as an endotracheal tube (ET, see Figure 5) or a supraglottic airway (SGA). Examples of SGAs are a laryngeal mask airway (LMA) or a multi-lumen esophageal tube (Combitube, see Figure 4). The provider does not have to visualize the glottis to place either of these airways; they do not require head and neck movement. An LMA (see Figure 3) is placed above the glottis. This device allows for oxygen delivery into the lungs while blocking the esophagus. Only trained individuals should place an LMA (ACS, 2018; James & Pennardt, 2022; Raja & Zane, 2022).

The technique for LMA insertion consists of the following:

• check the cuff of the LMA before insertion
• place the patient's head in a sniffing position (i.e., head extended and neck flexed) unless there is suspected spinal cord trauma (in which case, use the jaw thrust maneuver)
• lubricate the LMA and grasp like a pen behind the mask portion
• insert along the hard palate until full resistance is met
• inflate the cuff and begin ventilation
• ensure approximately 8 cm of the tube is visible from the mouth (ACLS Certification Institute, n.d.)

Figure 1

Nasopharyngeal airway (NPA)

(Pflegewiki, 2007)

Figure 2

Oropharyngeal Airway (OPA)

(ICUnurses, 2014b)

Figure 3

Laryngeal Mask Airway (LMA)

(ICUnurses, 2014a)

Figure 4

Combitube

(Ochiwar, 2013)

Figure 5

Endotracheal Tube Placement

(BruceBlaus, 2017)

A multi-lumen esophageal tube has a portion in the esophagus and another in the trachea. The tube is inserted, and the port in the trachea is identified. The esophageal port is occluded, and ventilation is provided through the bronchial port. End-tidal CO₂ (ETCO₂) can be used to confirm placement. Both devices should be replaced by a definitive airway, such as an ET tube, as soon as possible. ET tubes are placed in the trachea with a cuff below the vocal cords inflated to prevent aspiration. A surgical airway (cricothyroidotomy or a tracheostomy) is also considered a definitive airway (ACS, 2018; James & Pennardt, 2022; Raja & Zane, 2022). Criteria for the placement of a definitive airway include the following:

• inability to maintain airway or breathing
• GCS below 8
• sustained seizure activity (ACS, 2018)

Drug-assisted intubation describes rapid sequence intubation (RSI) with pharmacologic intervention. RSI has historically been defined as the administration of a sedative and a neuromuscular blocking agent to induce unconsciousness and paralysis to facilitate intubation. Etomidate (Amidate, 0.3 mg/kg) and ketamine (Ketalar, 1.5 mg/kg) are commonly used induction agents. Both medications, in the absence of acute shock, have cardiovascular stability. Succinylcholine (Anectine, 1-2 mg/kg) is the paralytic of choice. Hospital protocols for drug-assisted intubation should be followed (ACS, 2018; James & Pennardt, 2022; Raja & Zane, 2022).

Once an ET tube has been placed, a clinical assessment should be used to validate the proper placement, which includes:

• visual observation of the rise and fall of the chest
• auscultation of the lungs
• chest x-ray
• pulse oximetry
• end-tidal carbon dioxide (ETCO₂; ACS, 2018)

ETCO₂ through capnography is the most reliable parameter to validate that the ET is in the trachea and is the standard of care for patients who have been intubated. In addition, a chest x-ray is often performed to validate the proper positioning of the tube in the trachea (ACS, 2018).  

Breathing

In all cases, providing adequate oxygenation and ventilation is critical. Chest trauma accounts for 20% to 25% of trauma-related deaths due to inadequate oxygenation and ventilation. Trauma teams should inspect the chest wall for signs of injury (i.e., asymmetrical or paradoxical movement [flail chest]). Next, palpate the chest wall for crepitus or deformity and auscultate the lungs. A portable chest x-ray should be done for unstable patients to evaluate for tension pneumothorax, massive hemothorax, or cardiac tamponade. These are life-threatening findings and should be identified and treated in the primary survey stage. The focused abdominal sonography in trauma (FAST) exam is a bedside ultrasound that can detect each of these life-threatening injuries. For patients with ipsilateral decreased breath sounds and hypotension, presumptively treat a tension pneumothorax with needle decompression; a rapid FAST exam can be done to confirm the diagnosis. The trauma team can bypass needle decompression for chest tube placement if the equipment is readily available (ACS, 2018; James & Pennardt, 2022; Kostiuk & Burns, 2022; Raja & Zane, 2022).

The American Heart Association (AHA) guidelines state that once an advanced airway is placed, the patient should be ventilated at a rate of a breath every 6 seconds (i.e., 10 breaths per minute). Most trauma patients require supplemental oxygen. Continuous pulse oximetry is recommended for all trauma patients to assess oxygen saturation changes. Breathing and ventilation changes can occur quickly. If a patient requires ventilation but does not have a definitive airway, using a bag-mask device is the standard of care. If possible, 2 people should assist with the bag-mask ventilation to ensure an adequate seal (ACS, 2018; Craig-Brangan & Day, 2019; James & Pennardt, 2022; Kostiuk & Burns, 2022; Raja & Zane, 2022).

The MOANS mnemonic helps nurses identify patients who may be difficult to ventilate:

• mask seal
• obesity/obstruction
• age (over the age of 55)
• no teeth
• stiff lungs (ACS, 2018)

Patients who are difficult to ventilate with a bag-mask device may require an airway that supports a bag valve (LMA or a multi-lumen esophageal airway) until a definitive airway can be placed (ACS, 2018).

Circulation and Hemorrhage Control

Circulation with hemorrhage control is the third step in the primary survey. In a mass casualty/combat scenario, life-threatening hemorrhage prioritizes airway and breathing in the primary survey. An estimated 30% to 40% of preventable trauma deaths are due to uncontrolled bleeding. This statistic increases to 90% within combat settings. Therefore, it is critical to control hemorrhaging in the immediate aftermath of trauma. Perform an initial evaluation of a patient's circulatory status by palpating central pulses and inspecting for major bleeding injuries. A major arterial bleed can cause death within 5 minutes. The four areas where major bleeding can occur are the thorax, peritoneal cavity, retroperitoneal cavity, and pelvic and long bone fractures. Apply direct manual pressure to the site. A tourniquet should be considered when this does not control the bleeding. Next, the provider should assess peripheral pulses, skin color, and warmth. (ACS, 2018; Kostiuk & Burns, 2022; Scerbo et al., 2017).

The US military has a long history of using tourniquets as a first-line intervention for extremity hemorrhage control. In contrast, data on civilian tourniquet use are lacking. While the prolonged use of a tourniquet can lead to permanent neurovascular damage requiring amputation, recent studies have found better overall outcomes when tourniquets were used in prehospital settings compared to no tourniquet. Results included increased systolic blood pressure upon arrival at the trauma center, decreased need for blood products, fewer limb complications, and reduced mortality related to hemorrhagic shock (Scerbo et al., 2017; Smith et al., 2019).

After the Sandy Hook school shooting in 2012, the Hartford Consensus Group published recommendations for managing injuries in a mass casualty setting. They identified that the priority is stopping bleeding after suppressing an actual threat. This led to an initiative signed by President Obama in 2015 called the Stop the Bleed campaign, under the motto "See something, do something." The campaign aims to teach bystanders how to stop bleeding by providing free education and advocating for bleeding control kits to be available in public places alongside defibrillators. Tourniquets are essential to stop severe bleeding if applying direct pressure does not work. In addition, the AHA updated their First Aid Guidelines to include consideration of a tourniquet when direct pressure does not control the bleeding. The guidelines also state that a tourniquet can be considered a first-line intervention when an individual cannot provide standard bleeding control. Situations in which standard bleeding interventions may be inadequate include mass casualties, multisystem traumas, and inaccessible wounds (AHA, n.d.; Quail, 2017).

The goal of using a tourniquet is to stop arterial bleeding. Commercial tourniquets should be used when available. One option is the windlass device, which is a manual tourniquet. Once applied, the windlass is tightened until the arterial blood flow stops and pulses distal to the injury disappear. Another option is the pneumatic tourniquet, inflated with air to a pressure that stops the bleeding and distal pulses become undetectable. When a commercial tourniquet is unavailable, belts, clothing, or cables could be used, ideally at least 2 inches wide. A wider tourniquet requires less pressure to stop the blood flow. Also, the item should be made of inelastic material to avoid the tourniquet slipping. Tourniquets should never be applied over a joint; once a tourniquet has been applied, it should not be removed until the patient has access to definitive care. Improper tourniquet application can lead to compartment syndrome. Because the risk of long-term complications from a tourniquet is rare, the decision to save a life over a limb must be made when intervening with a tourniquet. For significant bleeding from a pelvic injury, a pelvic binder should be placed to minimize bleeding (ACS, 2018; Bulger et al., 2014; Day, 2016).

Steps for controlling external hemorrhage are as follows (ACOS, 2018; Bulger et al., 2014; Day, 2016):

• Apply direct pressure to the site with clothing or a clean towel.
• If the wound is large, pack clothing or a towel into the wound and then apply pressure.
• Apply pressure with two hands and do not release until definitive care is available.
• If the hemorrhage is uncontrolled, a tourniquet should be considered.    
• Place the tourniquet above the injury site.
• Apply the tourniquet by tightening until the bleeding stops, and distal pulses are no longer palpable.
• If the bleeding does not stop, consider applying a second tourniquet.
• Mark the patient's forehead with a T and the time the tourniquet was placed.
• Do not cover the tourniquet with clothing or blankets.
• Frequently assess the site.
• Do not release the tourniquet until definitive care is available.
• Consider a topical hemostatic agent with direct pressure for any joint injury with uncontrolled bleeding.

Because massive blood loss can lead to shock, obtaining vascular access in trauma patients is critical. Patients often require fluid replacement to maintain appropriate perfusion; warmed normal saline (NS) or lactated ringers (LR) solution is recommended. The trauma team should consider a blood transfusion in cases of persistent hypotension after 2 liters of NS or LR. For patients on anticoagulants, reversal of anticoagulation may be necessary in cases of life-threatening bleeding. The recommended access is a pair of 16- or 18-gauge or larger peripheral intravenous (IV) catheters. Nurses should draw blood for laboratory testing (arterial blood gas [ABG], lactic acid, complete blood count [CBC], and comprehensive metabolic profile [CMP]) and type and crossmatch during IV placement. When adequate peripheral access cannot be obtained quickly, intraosseous (IO) access should be considered for all age groups. If emergency medications are required, IV/IO access provides better absorption of medications than the ET tube route. IO medications are absorbed more rapidly into central circulation than a peripheral IV. The IO provides access to the medullary space of the long bones. This space is noncollapsible and highly vascular. The proximal humerus and proximal tibia are the most common sites. Fluids, blood products, medications, and contrast media can all be infused through IO access. IO access can be established in 10 seconds, allowing fluid resuscitation to begin immediately. Fluids administered via IO reach the central circulation at the same rate as fluids infused through a central line. Using IO access reduces the risk of infection compared to peripheral and central access, most likely due to the short dwell time (i.e., under 24 hours; ACS, 2018; Dornhofer & Kellar, 2022; Raja & Zane, 2022).

Specially trained providers should place IO devices. Nurses may place IO devices if allowed by their institution and the board of nursing for their state. A bone fracture and previous insertion in the same site within the last 24 hours are contraindications to IO administration. Also, an MRI cannot be performed on a patient with IO access (ACS, 2018; Dornhofer & Kellar, 2022).

Nurses should appropriately verify the placement of an IO by the following:

• a loss of resistance once the needle passes through the bone
• the absence of signs of infiltration
• the needle remaining in position when flushed
• successful aspiration of bone marrow or blood (but the absence of either of these does not necessarily indicate incorrect placement; ACS, 2018; Dornhofer & Kellar, 2022)

Nursing implications after insertion of IO access are as follows:

• stabilize the device per facility protocol
• immobilize the involved extremity to protect from accidental dislodgement
• maintain device patency with a continuous infusion of 0.9% normal saline
• manage infusion pain from pressure receptors in the bone (infusion pain is more intense than insertion pain; ACS, 2018; Dornhofer & Kellar, 2022)

Complications from the use of an IO may include:

• osteomyelitis (limit dwell time to 24 hours)
• infiltration (same manifestations as a peripheral IV)
• compartment syndrome (rare)
• occlusion of the needle with fibrin mesh or bone marrow (minimized by using stylet during insertion of the IO; ACS, 2018; Dornhofer & Kellar, 2022)

A qualified provider must perform the removal of an IO. As with any IV removal, inspect the device to ensure it is intact. If the needle detaches from the hub, use needle forceps to withdraw it. Nurses should also document the time of removal. The same site cannot be accessed for the next 24 hours. The use of an IO should be reserved for emergency resuscitation situations. Once alternative venous access is obtained, the IO should be discontinued (ACS, 2018; Dornhofer & Kellar, 2022).

Disability

The disability step of the primary survey includes a brief neurologic examination to assess the LOC and interventions to prevent long-term neurological damage. The GCS is an easy, objective assessment of LOC. A decrease in the GCS score may indicate a perfusion problem or a reduction in oxygen to the brain. The provider should immediately reassess the patient's airway, breathing, and circulation. Checking the blood glucose level is vital since hypoglycemia can cause a decreased LOC. The trauma team should also consider drug and alcohol screening because these substances can impair LOC. A computed tomography (CT) scan should be completed for patients with a suspected head injury when they are stable enough to tolerate it. Raising the head of the bed slightly and mild hyperventilation may help maintain or reduce intracranial pressure for patients with a head injury. Avoid moderate to severe hyperventilation, aiming for a PCO₂ above 25 (ideally 35). Pupils should also be assessed for size, shape, and reactivity. Systolic blood pressure should be greater than 100 mm Hg for individuals between the ages of 50 and 69 and greater than 110 mm Hg for individuals between the ages of 15 and 49 and those older than 70. Persistent hypotension and bradycardia could signal neurogenic shock. Nurses should advocate for a neurosurgical consult if the disability step indicates worsening neurological function (ACS, 2018; James & Pennardt, 2022; Kostiuk & Burns, 2022; Raja & Zane, 2022).

Exposure and Environmental Control

Removing all clothing from a trauma patient allows for visualization of the entire body to assess for injuries. Next, log roll the patient while maintaining cervical spine precautions to examine their back. Identifying musculoskeletal trauma is critical to preserving circulation and maintaining neurovascular function. Following the assessment, hypothermia is prevented by applying warm blankets, placing an external warming device, or infusing warmed IV fluids. A high-flow fluid warmer is recommended to heat crystalloids; a microwave can be used if a fluid warmer is unavailable. However, blood products should never be heated in the microwave. Hypothermia can contribute to multiple organ dysfunction syndrome and coagulopathy (ACS, 2018; James & Pennardt, 2022; Kostiuk & Burns, 2022; Raja & Zane, 2022).

Secondary Survey

Once the primary survey is complete, the trauma team should perform a secondary assessment. A more thorough history is taken during the secondary survey, and a head-to-toe assessment is completed (James & Pennardt, 2022). The trauma team can use the acronym SAMPLE to collect the history:

• signs and symptoms, including any new developments that have occurred post-injury
• allergies, specifically to medications
• medication list, specifically anticoagulants and beta-blockers
• past medical history, including previous surgeries
• last meal (in preparation for surgery)
• events leading to the injury (James & Pennardt, 2022)

The goal of the secondary survey is to identify any additional injuries through the performance of a head-to-toe physical examination. See Table 2 for pertinent assessment findings by body system.

Table 2

Pertinent Physical Assessment Findings by Body System

(Raja & Zane, 2022; Zemaitis et al., 2021)

Stabilization of Musculoskeletal Injuries

When musculoskeletal trauma is identified, the trauma care team should immobilize the injured extremity to manage pain, decrease swelling, and prevent further neurovascular damage. Splinting may also help control bleeding. While there are no absolute contraindications to using a splint in trauma, caution should be exercised in the presence of open fractures, evidence of compartment syndrome, and neurovascular compromise. The goal of splinting is temporary immobilization until definitive treatment is available. When considering how to splint a fracture, nurses should consider how the fracture presents. For simple fractures, the patient should have a distal pulse. In this case, the splint should be applied to maintain the current position of the extremity. If the extremity is in an abnormal position and no distal pulse is assessed, the limb may require manipulation before the splint can be applied. Research is lacking on whether an angulated bone should be straightened before splinting. This procedure can be painful, so sedation and analgesia are recommended if available. Realignment should not be attempted on an open fracture (ACS, 2018; McKelvin, 2018).

Splints should not take priority over resuscitation efforts, but they can control bleeding and should be considered essential treatment to prevent circulatory collapse if internal bleeding is suspected. Splinting must be done before transporting the patient (ACS, 2018). Any of the following injuries should be considered for splinting:

• fractures
• dislocations
• severe strains and sprains
• torn tendons or ligaments (McKelvin, 2018)

Multiple types of splints can immobilize injuries. Long-leg splints are used for tibia fractures. These may be metal or cardboard and should also be padded. Pillow splints or padded cardboard splints are suitable for ankle fractures. Injuries to the upper extremities and hands should be splinted in a normal anatomic position using a flat or pillow splint. For a knee injury, flex the knee 10 degrees to relieve pressure (ACS, 2018).

Traction splints, such as Hare and Sager splints, are used to realign a femoral fracture and promote adequate blood flow. General considerations for the application of a traction splint are as follows (ACS, 2018):

• Two personnel are required.
• Evaluate distal pulses before splint placement.
• Place the upper splint at the crease of the buttock.
• The distal end of the splint should extend 6 inches past the ankle.
• Place straps above and below the knee.
• Align the femur by manual traction at the ankle and maintain traction while the splint is applied.
• Once the splint is in place, apply traction in increments until the extremity is stabilized.
• Re-evaluate distal pulses after splint placement.

Nursing Implications

Nurses may encounter trauma patients in prehospital or ED settings. In addition, nurses as educators can provide teaching to bystanders who may be the first on the scene of a traumatic incident. The primary survey provides a rapid assessment of a patient's immediate needs, informing the appropriate interventions to manage the airway, ventilate, control hemorrhaging, stabilize musculoskeletal trauma, and prevent hypothermia. Knowing how to maintain an airway, provide ventilation, apply a tourniquet, and splint an extremity may make the difference between life and death for a trauma patient (ACS, 2018).

References

American College of Surgeons. (2018). Advanced trauma life support (ATLS) student course manual (10th ed.). American College of Surgeons.

American Heart Association. (n.d.). ECC guidelines: Part 15: First aid. Retrieved July 8, 2022, from https://eccguidelines.heart.org/circulation/aha-red-cross-first-aid-guidelines/part-15-first-aid

BruceBlaus. (2017). Endotracheal tube placement [Image]. https://commons.wikimedia.org/wiki/File:Endotracheal_Tube.png

Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., Sanddal, N. D., Butler, F. K., Fallat, M., Taillac, P., White, L., Salomone, J. P., Seifarth, W., Betzner, M. J., Johannigman, J., & McSwaing, N., Jr. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons committee on trauma. Prehospital Emergency Care, 18(2), 163-173. https://doi.org/10.3109/10903127.2014.896962

Centers for Disease Control and Prevention. (n.d.). Glasgow coma scale. Retrieved July 9, 2022, from https://www.cdc.gov/masstrauma/resources/gcs.pdf

Centers for Disease Control and Prevention. (2022). Accidents or unintentional injuries. National Center for Health Statistics. https://www.cdc.gov/nchs/fastats/accidental-injury.htm

Craig-Brangan, K. J., & Day, M. P. (2019). 2017/2018 AHA BLS, ACLS, and PALS guidelines. Nursing, 46(2), 40-45. https://doi.org/10.1097/01.NURSE.0000552705.65749.a0

Day, M. (2016). Control of traumatic extremity hemorrhage. Critical Care Nurse, 36(1), 40-51. https://doi.org/10.4037/ccn2016871

Dornhofer, P., & Kellar, J. Z. (2022). Intraosseous vascular access. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK554373

Dumovich, J., & Singh, P. (2022). Physiology, trauma. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK538478

Hinkle, J. L., & Cheever, K. H. (2018). Textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.

ICUnurses. (2014a). Laryngeal mask airway [Image]. https://upload.wikimedia.org/wikipedia/commons/7/79/LMA_Adult_size_4.JPG

ICUnurses. (2014b). Oropharyngeal airways [Image]. https://commons.wikimedia.org/wiki/File:Oral_Airways_%282%29.JPG

James, D., & Pennardt, A. M. (2022). Trauma care principles. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK547757

Kostiuk, M., & Burns, B. (2022). Trauma assessment. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK555913

McKelvin, R. (2018). Splinting of injuries: Best practice guidance. Journal of Paramedic Medicine, 10(12), 534-536. https://doi.org/10.12968/jpar.248.10.12.534

Ochiwar. (2013). Combitube [Image]. https://commons.wikimedia.org/wiki/File:Combitube.JPG

Pflegewiki. (2007). Wendltubus [Image]. https://commons.wikimedia.org/wiki/File:Wendltubus.jpg

Quail, M. (2017). What’s the stop the bleed campaign. Nursing, 47(12), 15-16. https://doi.org/10.1097/01.NURSE.0000526884.10306.68

Raja, A., & Zane, R. D. (2022). Initial management of trauma in adults. UpToDate. Retrieved July 5, 2022, from https://www.uptodate.com/contents/initial-management-of-trauma-in-adults

Scerbo, M. H., Holcomb, J. B., Taub, E., Gates, K., Love, J. D., Wade, C. E., & Cotton, B. A. (2017). The trauma is too late: Major limb trauma without a prehospital tourniquet has increased death from hemorrhagic shock. Journal of Trauma and Acute Care Surgery, 83(6), 1165-1172. https://doi.org/10.1097/TA.0000000000001666

Smith, A. A., Ochoa, J. E., Wong, S., Beatty, S., Elder, J., Guidry, C., McGrew, P., McGinness, C., Duchesne, J., & Schroll, R. (2019). Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications. Journal of Trauma and Acute Care Surgery, 86(1), 43-51. https://doi.org/10.1097/TA.0000000000002095

Zemaitis, M. R., Planas, J. H., & Waseem, M. (2021). Trauma secondary survey. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK441902