Page 34 - Journal of Special Operations Medicine - Spring 2015

Operating Area­Afghanistan: “This application tech­ routed once through the buckle (single­slit routing) in
nique (‘high and tight’) combined with prolonged tour­ 35% of lower extremity placements and 53% of upper
niquet time has been associated with complications in extremity placements. Similar findings were confirmed
4
at least two non­US casualties . . . If a ‘high and tight’ by Kragh et al. in a 2013 analysis of recovered tourni­
tourniquet is placed during care under fire, emphasize quets, showing that 37% of C­A­Ts were routed once
reassessment and repositioning at the earliest opportu­ through the buckle; the samples of these two studies
nity during Tactical Field Care.” 64 overlapped substantially but not completely. 65

Discussion at the August 2014 meeting of the CoTCCC C­A­T effectiveness for single­ or double­slit routing has
recommended placement of tourniquets as proximal on not been assessed in a clinical series; however, the ques­
the limb as possible during the CUF phase, recogniz­ tion has been addressed in a laboratory study. In a mani­
ing that a strong emphasis should be placed on reassess­ kin model, the effectiveness for hemorrhage control was
ing the tourniquet during both the TFC and TACEVAC equal for both routings, while time to stop bleeding and
phases of care. It was also conceded that if the bleeding total blood loss volumes were significantly less with sin­
site is readily apparent, particularly for nonblast inju­ gle­slit routing.
6
ries, then placement just proximal to the bleeding site
was acceptable. It was noted that any mechanism that Discussion at the August 2014 meeting of the CoTCCC
creates multiple open wounds, such as blast, makes as­ led to the recommendation for single­slit routing of the
sessment of the injured limb more challenging and in­ CAT during CUF. It was noted that the sixth­generation
creases the risk of missing a wound exsanguination if C­A­T has an increased length of 37.5 inches, compared
the tourniquet is not placed as proximally as possible on to 31 inches for earlier versions, which further increases
the limb during the CUF phase of TCCC. the contact area of Omni­Tape Velcro (Velcro Indus­
®
®
tries B.V.; http://www.velcro.com/) for larger thighs.
Any high­and­tight tourniquet should be moved at the This increased contact area helped alleviate concerns
first opportunity to a position directly on the skin 2–3 regarding anecdotal experience with earlier versions
inches above the wound or converted to a hemostatic slipping in some cases. Buckle breakage, another hypo­
or pressure dressing at the first opportunity. The rec­ thetical concern with single­slit routing, has never been
ommended method for repositioning the tourniquet is reported for the C­A­T. It was also noted that the critical
to remove the clothing and place a second tourniquet first step in effective tourniquet placement is to ensure
just above the wound, then loosen the high­and­tight that the band is as tight as possible on the limb prior
original tourniquet. If bleeding is not controlled during to turning the windlass; single­slit routing of the band
the assessment of wound hemorrhage, then the loosened facilitates such tightening, while double­slit routing may
proximal tourniquet should be moved distal to become impair the initial tightening of the band since the Velcro
side by side with the second tourniquet; the tourniquets may adhere to itself during application and tension is
are tightened until bleeding is stopped and the distal partially lost while routing through the second slit, par­
pulse is not palpable. ticularly with inexperienced users.

Single-Slit Routing Training Issues in Tourniquet Use
The C­A­T is currently the most commonly fielded tour­ Tourniquet use for minimal injuries or bleeding that is
niquet in the US military and is one of two tourniquets not life threatening has no benefit. If placed during the
(along with the SOFTT) recommended by the CoTCCC CUF phase, such a tourniquet should be converted to a
for use on the battlefield. A 2013 survey of recovered hemostatic or pressure dressing at the first opportunity.
tourniquets showed that 75% of tourniquets were
C­A­Ts and 20% were SOFTTs. 65 Store the C­A­T single routed, the ready­to­go config­
uration, to save time whenever use is needed; double­
The manufacturer’s instructions for use (IFU) of the routed stowage wastes time during initial application.
C­A­T recommend single­slit routing of the band through
the buckle only for one­handed application to the up­ The recommended technique for converting a tourni­
per extremity; double­slit routing is recommended for all quet to a hemostatic or pressure dressing is to first place
lower extremity applications. One­handed application to the dressing, then loosen the tourniquet while observing
the lower extremity is not addressed in the IFU, however, closely for bleeding through the dressing. The loosened
and may be an additional indication for single­slit routing. 6 tourniquet should be left in place 2–3 inches above the
wound in case rebleeding occurs.
Analysis of recovered tourniquets by the Armed Forces
Medical Examiner in 2012 demonstrated that the stan­ Conversion of a tourniquet to a hemostatic or pressure
dard­issue C­A­T was commonly placed with the band dressing should be attempted at the first opportunity,

24 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015