In Reply to Dr Jerome

To the Editor:

The author group for “Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations: A Case Report and Review” ¹ read the response titled “In Response to Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations.” ²

We thank Dr Jerome for his interest in our article, for his acknowledgement of the importance of the topic of tourniquets and tourniquet conversions, and for the credible discussion points that he raised. Our goal in this response is to acknowledge his contributions to the subject and appropriately clarify our intentions in the original manuscript.

The main points in Dr Jerome's response centers around the idea that our original article was limited in terms of practical application and did not appropriately introduce a novel, applicable guideline model that practitioners can effectively use to influence their clinical decision-making in tourniquet conversion situations. Dr Jerome proposes a set of guidelines that more simply influences clinical decision-making because his guideline model addresses the primary concern of when a tourniquet conversion should and should not occur, whereas the original article focused primarily on when and how to perform a tourniquet conversion, which we believe are both important points as programs consider adopting new guidelines. Dr Jerome's guidelines are mainly determined by the amount of time that the tourniquet has been in place and the risk/benefit assessment on tourniquet conversion vs. reperfusion syndrome, based on statistical evidence outlining the relative risk of reperfusion syndrome compared to the amount of time a tourniquet has been in place. While we are in agreement with Dr Jerome's proposed guidelines, Figure 1 addresses the time for tourniquet conversion as less than 6 hours while discussing the process of how conversion should be attempted. As always, knowledge and clarification are of the utmost importance, and the addition of the 2–6 hour caveat is important and should be considered in programs that do not have individuals equipped and trained to manage reperfusion syndrome.

The author group would like to clarify that our original article was a case report and review, based on an evidentiary case study. Our goal was to summarize and outline the current literature and various organizational guidelines surrounding tourniquet conversion into a cohesive article for reader education. In Figure 3 of the original article, our suggested conversion guideline was not inherently incorrect simply because it did not present a novel guideline. It is merely meant to supplement the tourniquet procedure guideline presented in Figure 1. The goals of our article were not to propose a novel guideline, nor did we claim to. We believe that our article was an appropriate, coherent summary of the historical evidence and current techniques/guidelines surrounding tourniquet conversion.

Dr Jerome brings up the additional point that there is little futility in reattempting a tourniquet conversion in 10–15 min, if the previous attempt was successful. We would like to point out that our model was based on the current evidence and current guidelines associated with tourniquet conversion, and reattempting tourniquet conversion after failed attempts is still evidence-supported practice. ³ Prior to the reattempting of tourniquet conversion in Figure 3, it is stated to:

“Pack the wound using hemostatic gauze and manual direct pressure applied for a minimum of 3 minutes.”

“A pressure dressing should then be properly applied to the wound.”

Since the wound dressing should already be monitored for bleeding, there should not be any additional risk for hypothermia. Hemostatic gauze has been shown to make a significant difference at the 5-minute mark of application, and 10–15 min has the potential to make the necessary difference between hemostasis without changing tools or adding additional providers.^4–6

In summary, we concur with Dr Jerome's assessments and proposed guidelines as a simplified way of viewing the timeline of tourniquet conversion with clarification on the level of training needed in the 2–6 h time period. We do believe the already widely used tourniquet conversion protocol listed in Figure 1 provides a thorough walkthrough of both the when and how of tourniquet conversion and is adequate to be distributed to providers who are trained in the management of reperfusion syndrome. While we believe that some of his analysis was outside of the intended scope of the original paper, we recognize that his contributions and proposed ideas make this project overall stronger and more compelling. We hope that the insight gained by readers of both of these manuscripts will result in improved patient outcomes and overall safer use of tourniquets and tourniquet conversions.