Page 37 - Journal of Special Operations Medicine - Winter 2015

the confusion and difficulties of care either in the street Defense or US Government. The authors are employees
or on the battlefield. A manikin cannot completely re- of the US Government. This work was prepared as part
place a living being in its response to either hemorrhage of their official duties and, as such, there is no copyright
or use of a tourniquet to control that hemorrhage. The to be transferred.
two users had considerable experience with tourniquet
use and may not accurately represent inexperienced us- Disclosure
ers. The proximal thigh is the limb segment with the
greatest girth, and is most in need of hemorrhage con- The authors declare no conflicts of interest.
trol in the military. However, smaller limb segments (leg,
arm, forearm) may allow easier use of improvised tour- References
niquets, as segment circumference is inversely associated
with tourniquet effectiveness. Hence, our results may 1. Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with emer-
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have underestimated the potential effectiveness of im- gency tourniquet use to stop bleeding in major limb trauma.
Ann Surg. 2009;249:1–7.
provised tourniquets on smaller limb segments. 2. Kragh JF Jr, O’Neill ML, Walters TJ, et al. Minor morbidity
with emergency tourniquet use to stop bleeding in severe limb
There are many directions for further testing. Processes trauma: research, history, and reconciling advocates and abo-
are needed to screen for and implement best improvised litionists. Mil Med. 2011;176:817–823.
tourniquet practices and components. The topic of im- 3. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of
trauma deaths: a reassessment. J Trauma. 1995;38:185–193.
provised tourniquets has recently become legitimized 4. Chesters A, Roberts I, Harris T. Minimising blood loss in
in the medical literature. For example, in 2015, Stew- early trauma resuscitation. Trauma. 2014;16:27–36.
art et al. reviewed the medical literature of improvised 5. Bellamy RF. The causes of death in conventional land war-
tourniquets and concluded, among other things, that, fare: implications for combat casualty care research. Mil Med.
“Objective evidence has shown certain improvised de- 1984;149:55–62.
signs, namely, the windlass type, to be as effective as, 6. Lindsey D. The case of the much-maligned tourniquet. Am J
Nurs. 1957;57:444–445.
if not better than, commercially available tourniquets 7. Doyle GS, Taillac PP. Tourniquets: a review of current use
at controlling arterial blood flow in a limb. Moreover, with proposals for expanded prehospital use. Prehosp Emerg
the risk of complications from their use does not dif- Care. 2008;12:241–256.
fer hugely from that seen in formal devices. However, it 8. Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital
would be naïve to suggest that improvised tourniquets tourniquet use in Operation Iraqi Freedom: effect on hemor-
rhage control and outcomes. J Trauma. 2008;64:S28–37.
can be regarded as equal in their efficacy to commercial 9. Tarpey MJ. Tactical combat casualty care in Operation Iraqi
tourniquets such as the CAT. By the very nature of its Freedom. Army Med Dept J. 2005:38–41.
being, the improvised tourniquet can vary hugely in its 10. Passos E, Dingley B, Smith A, et al. Tourniquet use for periph-
fabrication and hence its effectiveness. Tourniquets do eral vascular injuries in the civilian setting. Injury. 2014;45:
573–577.
harm, and it is those that are applied incorrectly that 11. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based
cause the most harm.” Efforts to make commercial prehospital guideline for external hemorrhage control: Amer-
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tourniquets more available may lessen the need to im- ican College of Surgeons Committee on Trauma. Prehosp
provise tourniquets. Emerg Care. 2014;18:163–173.
12. Jacobs LM, Burns KJ, McSwain N, et al. Initial management
In summary, in a laboratory setting, a common commer- of mass-casualty incidents due to firearms: improving sur-
vival. Bull Am Coll Surg. 2013;98:10–13.
cial tourniquet, the CAT, outperformed two different 13. Fox N, Rajani RR, Bokhari F, et al. Evaluation and man-
improvised tourniquet techniques in a model of tourni- agement of penetrating lower extremity arterial trauma:
quet use on the thigh. an Eastern Association for the Surgery of Trauma practice
management guideline. J Trauma Acute Care Surg. 2012;73:
S315–320.
Funding 14. Jacobs LM, McSwain NE Jr, Rotondo MF, et al. Improving
survival from active shooter events: the Hartford Consensus.
This project was funded by the US Army Medical re- J Trauma Acute Care Surg. 2013;74:1399–1400.
search and Materiel Command and the Defense Health 15. Guo JY, Liu Y, Ma YL, et al. Evaluation of emergency tourni-
Program (Proposal 201105: Operational system man- quets for prehospital use in China. Chin J Traumatol. 2011;
14:151–155.
agement and post-market surveillance of hemorrhage 16. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emer-
control devices used in medical care of US serviceper- gency tourniquets to stop bleeding in major limb trauma. J
sons in the current war). Trauma. 2008;64:S38–49.
17. King DR, van der Wilden G, Kragh JF Jr, et al. Forward as-
Disclaimer sessment of 79 prehospital battlefield tourniquets used in the
current war. J Spec Oper Med. 2012;12:33–38.
The opinions or assertions contained herein are the pri- 18. Kragh JF Jr, Walters TJ, Westmoreland T, et al. Tragedy into
vate views of the authors and are not to be construed drama: an American history of tourniquet use in the current
as official or reflecting the views of the Department of war. J Spec Oper Med. 2013;13:5–25.

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