Tourniquet Refresher Course: The Why & the How and the Pitfalls!

Some people who inject drugs don’t have much trouble finding veins, and don’t need to use a tourniquet, while others have always used them as part of their injecting practice. Other people decide to add tournies to their injecting routine as they get older and their veins get harder to find over time. We thought it was timely to do a bit of a review so people could develop or update skills and techniques in using tournies to get the most out of them. 

Why use a tourniquet?  

The reason why tourniquets are recommended is because they make it easier to inject and easier injecting usually means safer injecting. There are two ways tourniquets help. First of all, the safest way to inject, reducing the risk of infections and track marks, is to make your veins sit up and pop out. The easiest way to do that for just a few minutes, long enough to inject into, is to cut off blood flow. Tourniquets are used to dilate veins, making them bigger and more prominent so they are easier to find and inject into. Secondly, dilating the veins helps to “anchor” them so they don’t roll around as much when you’re trying to insert the needle.  

Two common misunderstandings people can sometimes have when using a tourniquet are around how tightly they put their tourniquet on and when and how to release it. A lot of people think “the tighter the better”. While too loose tourniquets are not much help at all, putting a tourni on too tightly cuts off the circulation of blood into the arm altogether - you need blood to still flow so that veins will get bigger.  

The other common mistake people make is that they do not realise they need to release the tourniquet before pushing on the plunger. If you don’t release the tourni first you risk bursting the vein, creating resistance and bruising.  

Some people don’t like using tourniquets because they have difficulties releasing them. However there are ways to use tourniquets that can be easily removed with a one-hand action. If you are using a latex “bluey” then tie in a bow that can be pulled out easily with one hand. Practice makes perfect! See the NUAA video here. 

How tight should a tourniquet be?  

You just need a light squeeze from your tourniquet! Make sure you can still feel your pulse at all times!  

When do I release the tourniquet?  

As soon as you are sure your needle is in a vein, that is, straight after you get blood gently entering the syringe when you jack back.  

What can I use as a tourniquet?  

Single use latex disposable "blueys" are available where you get your needles. These are recommended because hep B, hep C and HIV can be transmitted by blood on tourniquets. If you use a proper medical tourniquet, it's best not to let anyone else use it, not even your partner. Use belts or scarves only if you can guarantee that no-one else will use them as a tourniquet or wear them.  

If you have trouble using a tourniquet, you can twist your shirt sleeve above the elbow and hold the twist under your arm. Again, be aware of blood. Remember, you don't have to see blood for it to be there. Another trick is to hold a can or other hard object under your arm and press down on it to get the veins in your arms up. 

How to use a tourniquet, step by step  

1. Place the tourniquet above where you’re trying to inject, and tighten it gently. Tighter is NOT better; make sure you can still feel your pulse at all times!  

2. Squeeze your hand a couple of times. Sometimes tapping or rubbing the skin over the vein a few times also helps but there is no value in turning your arm around like a helicopter blade… remember, less can be more!  

3. Be patient; give your veins a few minutes to fill up with blood and dilate.  

4. Make sure the vein “bounces” when you press it. If it’s more like a solid cord it is probably a collapsed or clotted vein, which is no good for injection.  

5. Once you’ve found a usable vein, swab the skin above with an alcohol wipe. When the skin is dry, about 30 seconds, insert the needle into the vein at a 45-degree angle, bevel upwards.  

6. You know you’re in the vein when you get a small “jackback” of blood into the syringe. A large, bright red pulsating jackback of blood suggests you may have hit an artery.  

7. While drawing blood back into the syringe is a way of checking that the needle is still in the vein, don’t draw back too much blood before injecting as it can clot while still in the syringe, which may block it. If the needle accidentally comes out of the vein before you have injected, a syringe full of blood will also make it harder to know when you’re in the next vein.  

8. Once you know the needle is in the vein, release the tourniquet. Otherwise, when you push the plunger, your shot may burst the vein or cause backflow of the drug into the surrounding tissues, which is no fun at all. Be very still and release the tourniquet very gently, as the movement from the release can move the needle from the vein.  

9. Now the tourniquet is loose and fluid from the syringe is allowed a clear passage through the vein, you can press the plunger. If you are concerned the needle has shifted in your vein, you can double-check that it's all still in place by jacking back again first. However, try to avoid jacking back too often as it can cause bruising and increase risk of track marks. 

How tournies work... For those who love a scientific explanation!  

To understand how tourniquets work and why things can go wrong it’s important to know a bit about your blood circulation. 

Blood carrying oxygen from the lungs is pumped around the body by your heart in vessels called arteries, and because it is being pumped away from the heart, the pressure of the blood in your arteries is relatively high compared to the pressure in your veins. People who have accidentally injected into an artery will know this, because bright frothy red blood tends to spurt out and needs a long period of firm pressure to make it stop bleeding, whereas after injecting into veins blood oozes out much more slowly.  

The (arterial) pulse you can feel in your wrist is the pressure wave that coincides with the pumping action of the heart. When a doctor takes your blood pressure by pumping up the blood pressure cuff, he/she is measuring how much pressure is needed to cut off the blood flow in the arteries to the arm; that is the pressure needed to stop the pulse in your wrist. This pressure reading is the upper measure of your “blood pressure”, which is normally about 120 mmHg. 

Having trouble getting a vein?  

Most of us know what it is like to not be able to find a good vein, even using a tourni. You may have to try the other arm. It really does help to stay calm - especially hard if you’re sick - but try to take a few deep breaths and relax your muscles. Try to take short breaks in between unsuccessful attempts to keep yourself even-tempered.  

One reason we get panicky is when we have blood in the syringe from a partially successful attempt that might coagulate before we get our shot away. In reality, it can take up to twenty or thirty minutes for blood to clot in the syringe to the degree that a shot is not usable. The more hydrated you are from drinking water and the better your general health is, the longer you will have. So make sure you have drunk plenty of water before your shot to make your veins fatter and your blood thinner, then try to relax and focus, even if you are having trouble locating a good vein.  

Stopping the bleeding from each puncture wound before moving on to the next injecting site is important from a blood-borne infection perspective and a good way to pace yourself so that you don’t psych yourself out. 

How do you know your tourniquet is too tight?  

1. You will notice that your veins don’t dilate like they should.  

2. Because the blood’s oxygen supply to nerves and tissues in the arm has been cut off, you may feel some tingling, or pins and needles, in your hand. Your arm will become heavy and start to ache, then become painful and eventually numb. It will also look pale and then bluish.  

3. When you let the tourniquet off, you’ll feel a surge of warmth as the blood rushes back into the arm through the arteries. Not a good sign! 

 But if your tourniquet is too loose, it will not stop the blood flow...