Page 50 - Journal of Special Operations Medicine - Winter 2015

body are likely to be easier than SWATT applications to 3. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based
an isolated limb model. Application of the three non- prehospital guideline for external hemorrhage control: Amer-
elastic tourniquets does not impart much limb motion, ican College of Surgeons Committee on Trauma. Prehosp
Emerg Care. 2014;18:163–173.
so use of an isolated limb model versus a limb attached 4. Jacobs LM. Joint committee to create a national policy to en-
to a body would be less likely to affect the ease of ap- hance survivability from mass casualty shooting events: Hart-
plication with those designs. ford Consensus II. J Am Coll Surg. 2014;218:476–478.
5. King DR, Larentzakis A, Ramly EP, Boston Trauma Collab-
Recipient Discomfort orative. Tourniquet use at the Boston Marathon bombing: lost
in translation. J Trauma Acute Care Surg. 2015;78:594–599.
Our results in this and prior studies indicate that severe 6. Graham B, Breault MJ, McEwen JA, et al. Occlusion of arte-
discomfort is not indicative of, nor necessary for, tour- rial flow in the extremities at subsystolic pressures through the
niquet effectiveness. 7,8,15 We speculate that the degree of use of wide tourniquet cuffs. Clin Orthop. 1993;286:257–261.
discomfort associated with an arterially effective tourni- 7. Wall PL, Duevel DC, Hassan MB, et al. Tourniquets and oc-
clusion: the pressure of design. Mil Med. 2013;178:578–587.
quet relates to the following: (1) design choices such as 8. Wall PL, Coughlin O, Rometti M, et al. Tourniquet pressures:
sharp corners; (2) Completion Pressures, which relate strap width and tensioning system widths. J Spec Oper Med.
to tourniquet width and tightening system; and (3) the 2014;14:19–29.
character and extent of skin bunching, which relate to 9. Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in
tightening system design and Friction Pressure. 15 peripheral nerves compressed by a pneumatic tourniquet. J
Anat. 1972;113:433–455.
10. Mohler LR, Pedowitz RA, Lopez MA, et al. Effects of tour-
Conclusions niquet compression on neuromuscular function. Clin Orthop
Relat Res. 1999;359:213–220.
The 3.8cm-wide nonelastic strap CAT, SOFTT-W, and 11. Wall PL, Welander JD, Smith HL, et al. What do the people
RMT-P, and the 10.4cm-wide elastic strap SWATT who transport trauma patients know about tourniquets? J
Trauma Acute Care Surg. 2014;77:734–742.
can all stop distal limb arterial flow. As expected, the 12. Clumpner BR, Polston RW, Kragh JF Jr, et al. Single versus
pressures involved were lowest for the SWATT. Con- double routing of the band in the Combat Application Tour-
sidering the reported pneumatic tourniquet circumfer- niquet. J Spec Oper Med. 2013;13:34–41.
ence and pressure relationship, the 3.8cm-wide strap 13. Shackelford SA, Butler FK, Kragh JF Jr, et al. Optimizing the
6
tourniquets’ calf and forearm Occlusion Pressures were use of limb tourniquets in tactical combat casualty care: TCCC
guidelines change 14-02. J Spec Oper Med. 2015;15:17–31.
not as low as expected compared to prior thigh and arm 14. Bruning JL, Klintz BL. Computational Handbook of Statis-
applications. 7,8 tics. 2nd ed. Glenview, IL: Scott, Foresman and Company;
1977.
The under-tourniquet pressure change from Occlusion to 15. Slaven SE, Wall PL, Rinker JH, et al. Initial tourniquet pres-
Completion varies by tourniquet tightening system and sure does not affect tourniquet arterial occlusion pressure. J
Spec Oper Med. 2015;15:39–49.
can involve a pressure decrease with the windlass tight- 16. Kragh JF Jr, Burrows S, Wasner C, et al. Analysis of recovered
ening systems. Additionally, significant under-tourniquet tourniquets from casualties of Operation Enduring Freedom
pressure losses occur in as little as 120 seconds following and Operation New Dawn. Mil Med. 2013;178:806–810.
Completion, and so can loss of Occlusion. This is espe- 17. Kragh JF Jr, O’Neill ML, Walters TJ, et al. The military emer-
cially true for nonelastic strap tourniquet designs. gency tourniquet program’s lessons learned with devices and
designs. Mil Med. 2011;176:1144–1152.

Disclosure
None of the authors have any financial relationships rel- Dr Wall is a researcher in the Surgery Education Department
evant to this article to disclose, and there was no outside of UnityPoint Health Iowa Methodist Medical Center, Des
funding. The study was performed at Drake University, Moines, Iowa. E-mail: piperwall@q.com or piper.wall@unity
Des Moines, Iowa. point.org.

References Dr Sahr is a trauma surgeon at UnityPoint Health Iowa Meth-
odist Medical Center, Des Moines, Iowa.
1. Walters TJ, Mabry RL. Issues related to the use of tourniquets
on the battlefield. Mil Med. 2005;170:770–775. Dr Buising is the associate director of the Biochemistry, Cell
2. Kragh JF Jr, O’Neill ML, Walters TJ, et al. Minor morbidity and Molecular Biology Program at Drake University, Des
with emergency tourniquet use to stop bleeding in severe limb Moines, Iowa.
trauma: research, history, and reconciling advocates and aboli-
tionists. Mil Med. 2011;176: 817–823.

38 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015