Esmarch's Exsanguination

ESMARCH'S EXSANGUINATION was proposed by Esmarch in 1873. The Esmarch apparatus consists of a bandage made of rubberized fabric, 8-9 meters in length and 5-6 cm in width, and a thick rubber elastic tube 1-1.7 meters in length, equipped with a chain at one end and a hook or buckle at the other for fastening. Instead of this, an ordinary drainage tube and rubber bandage are often used. In cases of emergency, bleeding can be stopped with a towel, handkerchief, belt, suspenders, rope, etc., the ends of which are tied over a stick and twisted by it to the required degree. Esmarch's exsanguination with a tourniquet is applicable primarily to the extremities, but on the latter, the tourniquet is not applied to the forearm and lower leg, where it is impossible to compress the arteries between two bones. According to Esmarch, before bandaging, the limb is raised upward for 3-5 minutes and stroked toward the center. This achieves some exsanguination of the limb. Then an elastic bandage is applied evenly from the fingertips toward the center. Bandaging is done with sufficient force so that the pulsation of the arteries in the periphery ceases. Having thus brought the exsanguination of the limb to the required place, the last turn of the bandage is secured with 3-4 turns of a rubber tourniquet and fastened with the chain. The rubber tourniquet should be strongly stretched before application, but one must ensure that no skin fold is pinched and subsequent necrosis occurs. Then the elastic bandage is removed from bottom to top, after which the color of the skin (white or bluish) is observed. With a properly applied tourniquet, the skin of the limb appears deathly white, exsanguinated. If the tourniquet is applied too loosely, venous stagnation and increased bleeding will result. In this case, the tourniquet is removed and reapplied with greater force than before. With too tight compression of the limb with a tourniquet, nerve trunks may be damaged. It is possible to apply an Esmarch tourniquet without preliminary bandaging by raising the limb vertically for a certain time (against the arterial flow). Esmarch's exsanguination offers great convenience during operations on the extremities, mainly in amputations. However, when applying a tourniquet, a number of complications occur: sequential bleeding, necrosis of the skin and stump, formation of thrombi with emboli, etc. The applied tourniquet should not remain in place for more than 2½-3 hours. Contraindications for applying the tourniquet are: purulent processes, infiltrates, lymphangitis, thrombosis, vascular diseases (sclerosis, spontaneous gangrene, phlebitis), etc. A more elastic compression of blood vessels can be achieved with Perthes' compressor (Perthes), constructed in the form of a hollow cuff of the type used in the Riva-Rocci apparatus. Perthes' compressor is connected to a manometer, by which the degree of compression of the blood vessels is determined and regulated (250 mm Hg is sufficient).