What is the optimal location for tourniquet (hemostatic device) placement in an emergency situation?

From the Guidelines

In an emergency situation, the optimal location for tourniquet placement is 2-3 inches above the bleeding site on the limb, but not over a joint, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. This placement allows for better compression of arteries against bone structure, increasing the effectiveness of the tourniquet.

• The tourniquet should be applied to the upper part of the limb (upper arm or upper thigh) where there is a single bone.
• It is essential to place the tourniquet directly on bare skin when possible, avoiding placement over pockets, buttons, or other objects.
• The tourniquet must be pulled very tight—until the bleeding stops completely—and the time of application should be noted.
• A properly applied tourniquet will be painful for the patient.
• Once applied, do not remove the tourniquet until medical professionals take over care, as removal can lead to sudden blood loss and shock.
• Tourniquets should only be used for life-threatening bleeding that cannot be controlled with direct pressure, as they temporarily cut off blood supply to the entire limb.
• Commercial tourniquets are preferred when available, but in their absence, a makeshift tourniquet can be created using a wide (2+ inches) strip of cloth and a rigid object for twisting, as suggested by the 2020 international consensus on first aid science with treatment recommendations 1. The most recent guidelines from 2024 1 prioritize the use of commercial tourniquets, which are probably superior to improvised tourniquets, and provide recommendations for their application in emergency situations.

From the Research

Optimal Location for Tourniquet Placement

• The optimal location for tourniquet placement is not explicitly stated in the provided studies, but it can be inferred that the proximal thigh is a suitable location 2.
• A study on emergency tourniquet effectiveness in four positions on the proximal thigh found that tourniquet effectiveness rates were 100% in all four positions (medial, lateral, anterior, and posterior) 2.
• Another study evaluated the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model, but it did not specifically address the optimal location for tourniquet placement 3.
• The use of tourniquets in limb trauma surgery is discussed in a study, but it does not provide information on the optimal location for tourniquet placement 4.
• A study on hemostatic dressings found that they can reduce tourniquet time while maintaining hemorrhage control, but it does not address the optimal location for tourniquet placement 5.
• A survey of indications for use of emergency tourniquets found that the current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having possibly lethal hemorrhage, but it does not provide information on the optimal location for tourniquet placement 6.

Tourniquet Placement Considerations

• The placement of the tourniquet's windlass on the extremity can affect its effectiveness, but a study found that the association between time to stop bleeding and tourniquet position was statistically significant, while the associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant 2.
• The pressure under the tourniquet can also be affected by the tourniquet position and the user, but the user-by-position and windlass turn number were not statistically significant 2.
• The blood loss volume can be affected by the tourniquet position, user, and user-by-position, but the associations between these factors were statistically significant 2.