Page 34 - JSOM Winter 2019

was not identified as a critical requirement, it is desirable as TABLE 7 Combat and Civilian Usage Scoring
time of application is a need at next level treatment echelons. It 5 Usage reports >50 applications.
was not determined critical in this review but is recommended 4 Published case studies with efficacy reports.
for all future designs. 3 Known or recorded usage without efficacy reported.
2 Unknown combat or civilian usage (starting score).
Complications and Safety – This review accounted for known
reported or published complications, failures, or safety issues 1 <80% efficacy reported in usage.
of devices and scored as high, medium or low risk. All tour- 0 Reports of unsuccessful usage or efficacy.
niquets started with a score of 5 for having 0 failure or safety
issues. Subsequent scores were based on known reporting User Preferences – The various tourniquet studies used a myr-
through medical literature or official military message traffic. iad of definitions for user preferences making it difficult to as-
Word-of-mouth reports or rumors are unreliable as they can- sess. In nearly all studies, user preference is also skewed in that
not be cited from an official source. This is a critical short- most users had previous exposure to one or more of the tour-
coming in the casualty documentation, safety and reporting niquets through previous training. For this review, we scaled
system. user preferences as High, Upper, Middle, Lower, Low, or none
recorded. Scores were also weighted depending on the number
of users in the study.
TABLE 5 Complications Scoring
5 No Failure Reports.
4 Minor Failure Point in Studies. TABLE 8 User Preference Scoring
4 Mechanical Failure but tourniquet remains functional. 5 High User Preference >50% (n >20).
3 Training-based Failure. 4 Upper User Preference >50% (n <20).
2 >5 Mechanical Failure in Studies. 3 Middle User Preference 26–49%.
0 Life-threatening failure reported. 2 Lower User Preference <25% (n <20).
1 Low User Preference <25% (n >20).
Complications were scored as minor if there was a reported 0 None Recorded.
failure or mechanical problem, but the tourniquet was still ef-
fective in controlling bleeding. There were also instances of Logistics – The primary focus of logistics is the individual
training-based failures in many of the studies reviewed. The unit cost of a tourniquet device. Devices were scored ac-
most common training problem that caused device failure was cording to their commercial and government-services agency
not pulling strap slack tight enough before twisting windlass (GSA) established costs. Commercial prices were generally
rods or ratcheting devices. While this training error is not spe- based on the price on the primary vendors website as of 06
cifically a device failure, it can cause the device to fail. As some AUG 2019. Additional scores were included if the device has
studies recorded such failures against the efficacy of a device, an established national stock number (NSN) in the logistics
the working group attempted to identify these training fail- system.
ures as a complication for scoring. Mechanical failures that
resulted in low scoring were generally reports in one or more
studies. TABLE 9 Logistics Scoring
5 YES – NSN in DOD Logistics System.
TABLE 6 Safety Scoring 0 NO – NSN not in DOD Logistics System.
5 No safety issues identified. 5 Very Low Cost <$15.
4 Minor safety issue identified. 4 Low Cost $16–30.
3 Environmental safety issue identified. 3 Mid Cost $31–45.
3 Manufacturer recall safety issue. 2 High Cost $46–100.
1 Significant safety issue identified. 1 Very High Cost >$100.
0 Life-threatening safety issue identified.
Pain – Pain was not included in the assessment criteria. Several
Significant or life-threatening safety issues were defined by the studies considered tourniquet devices to fail in testing due to
working group as device problems that signaled a question recipient discomfort. It is established that virtually all success-
of efficacy or potential for harm to a patient or rescuer. En- ful tourniquet applications will most likely involve significant
vironmental safety issues were identified by some studies and pain in conscious casualties. As such, tourniquet pain is often
the scoring was based on whether the issue effected a device’s inevitable and is a different problem set than hemorrhage con-
efficacy and functionality. trol. Tourniquet pain should be addressed by the analgesia rec-
ommendations in the TCCC Guidelines. Additionally, other
Usage Reports – This review accounted for combat usage re- studies have indicated that tourniquet pain is an inadequate
ports and civilian usage reports in published literature to in- measure of effectiveness in training. 16
clude studies of deployed usage and/or case reports of usage
on casualties. Vendor-supplied reporting was not included in The omission of pain as criteria should not be confused with
this review. It can be assumed there are many applications of potential twisting or damage of tissue due to the shape, struc-
various tourniquets to trauma casualties worldwide, but with- ture or mechanism of a tourniquet if the device cannot even be
out reliable documentation or reporting, that data is virtually tolerated during a simple training application.
impossible to capture and is unreliable. As such, all tourni-
quets started with a score of 2 and were further scored based Scoring – There is a maximum possible score of 50.
on findings in the literature.

32 | JSOM Volume 19, Edition 4 / Winter 2019