How best to remove the tourniquet
Methods of tourniquet removal include unwrapping, cutting, or dissolving the hair with commercial hair removal agents such as Nair (Church & Dwight Co, Inc, Princeton, NJ).2,10-12
Unwrapping. In cases where the tourniquet is easily visualized and minimal edema is present, simply unwrapping the constricting hair may be successful. This can be accomplished by identifying a loose end of the hair, grasping the free end with a pinching instrument such as a hemostat or forceps, and carefully unwrapping the hair from the appendage1,11 (strength of recommendation [SOR]: B).
Cutting. If cutting the hair is necessary due to the presence of mild to moderate edema or failure of the unwrapping technique, a blunt probe may be inserted between the hair and the appendage to protect soft tissues from the cutting implement. Once the probe has been inserted, the tourniquet may be cut using scissors or a #11 scalpel blade applied to the surface of the blunt instrument1,11 (SOR: C). Alternative instrumentation, including a #12 Bard Parker curved scalpel blade and a Littauer suture-removal scissor, may be useful when the tourniquet is too tightly wound to allow for insertion of a blunt probe instrument (SOR: C).
Dissolving. A commercially available depilatory agent, such as Nair, may be useful for mild cases, but would not be appropriate when a tourniquet has cut into the skin. Calcium thioglycolate, a common depilatory active ingredient, breaks down disulfide bonds in keratin, thereby weakening hair strands. Chemical agents containing calcium thioglycolate should be used with caution, as keratin is also present in the epidermis and use of these agents may cause irritation to the skin.
When an incisional approach is needed
At times, epithelialization over the tourniquet or severe swelling of a digit may necessitate an incisional approach. If there is any doubt about whether you can completely remove all of the strands of the tourniquet, an incision into the digit itself must be made to disrupt constriction. Historically, a digital nerve block has been the preferred mode of analgesia; however, recent evidence suggests that less invasive pain management strategies, such as a sucrose pacifier, EMLA cream, or ZAP topical analgesia gel may be effective13 (SOR: A).
If you must use this approach, you’ll need to consider the placement of the digital neurovascular bundles of the fingers and toes, located at approximately the 2, 4, 8, and 10 o’clock positions. Following sterile preparation and draping, a longitudinal incision should be made at either the 3 or 9 o’clock position, thus locating it between neurovascular bundles1,11 (SOR: B).
Alternatively, a longitudinal incision can be made directly over the extensor tendon, located dorsally at 12 o’clock. Any resulting tendon laceration would be parallel to the tendon fibers, and could be expected to heal with splinting and wound care1,11,14 (SOR: B).
Prior to initiating treatment, parents or caregivers should be warned about the potential for bleeding and pain during the procedure.