Page 34 - Journal of Special Operations Medicine - Spring 2014

Emergency Tourniquet Effectiveness
in Four Positions on the Proximal Thigh

John F. Kragh, Jr., MD; Timothy E. Wallum, BS;
James K. Aden III, PhD; Michael A. Dubick, PhD; David G. Baer, PhD

ABSTRACT
Objective: The purpose of the present study is to deter- tourniquet practices should be. For example, in 2012,
mine the performance of tourniquet use by the place- tourniquet users asked us two questions on how best to
ment of the tourniquet’s windlass on the extremity in position the tourniquet on an extremity that is in need of
four positions—medial, lateral, anterior, and posterior— hemorrhage control. The two questions were similar and
to inform tourniquet instructors and develop best tour- regarded the orientation of the tourniquet in its circum-
niquet practices. Methods: A HapMed Leg Tourniquet ferential envelopment of the extremity. The two questions
™
Trainer was used as a manikin to test the effectiveness of came forward at about the same time from unrelated
an emergency tourniquet, the Special Operations Forces persons on different continents, but the questions dealt
Tactical Tourniquet. Two users made 10 tests, each in with whether the tourniquet is best used on the anterior
four positions. Results: Effectiveness rates of tourniquet thigh as opposed to the lateral, medial, or posterior thigh.
use were 100% in all four positions. The two tourniquet One question, from an instructor contracted to train U.S.
users were both right-hand dominant and used their right military personnel, was whether medial or lateral place-
hand to turn the windlass. One user turned the windlass ment was better. Another question was whether the wind-
clockwise, and the other turned it counterclockwise. The lass should be medial, lateral, anterior, or posterior. The
association between time to stop bleeding and tourniquet user, an Australian expert in disaster medicine, wanted
position was statistically significant but associations be- this knowledge to be established in order to develop best
tween time to stop bleeding and the user, user-by-position, practices. We found no adequate evidence of superiority
and windlass turn number were not statistically signifi- of any position reported in clinical experience, both in
cant. The association between tourniquet position and studies of collapsible tube science and in published re-
pressure under the tourniquet was statistically significant, search of tourniquet use (either operative or emergency
and the association between user and pressure under the use). Both questioners oriented the tourniquet placement
tourniquet was statistically significant, but the user-by- by the windlass position on the thigh, the most common
position and windlass turn number were not statistically limb segment in need of tourniquet use.
significant. The associations between tourniquet position
and blood loss volume, user and blood loss volume, and The purpose of the present study was to determine
user-by-position and blood loss volume were statistically and compare the performance of tourniquet use by the
significant. Conclusions: The present study found that placement of the tourniquet on the extremity in four po-
tourniquet effectiveness rates were uniformly 100% ir- sitions (medial, lateral, anterior, and posterior) in order
respective of whether the windlass position was medial, to inform tourniquet instruction and develop best tour-
lateral, anterior, or posterior. These excellent clinical and niquet practices.
statistical results indicate that users may continue to place
the tourniquets as they prefer upon the proximal thigh.
Methods
Keywords: first aid, resuscitation, damage control, hemor- The approved laboratory protocol (U.S. Army Institute
rhage, trauma, shock of Surgical Research Regulatory Office, Practical Bio-
medical Engineering Research of Tourniquet Application
and Use, L-12-009) was executed from March to Au-
gust 2013. This study was conducted under a protocol
Introduction
reviewed and approved by the regulatory office and in
Since 2003, the U.S. Army Institute of Surgical Research accordance with good laboratory practices. Tourniquet
has run an Emergency Tourniquet Program that has users included a pair of investigators familiar with mili-
helped develop best tourniquet practices associated with tary tourniquet training and their clinical use. One inves-
improved casualty survival. However, many ques- tigator was an expert in tourniquet use and tourniquet
1-4
tions remain inadequately evidenced as to what the best research; the other investigator was trained in tourniquet

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