Page 31 - Journal of Special Operations Medicine - Summer 2016

Tourniquet Effectiveness When Placed Over the
Joint Service Lightweight Integrated Suit Technology

Lower Extremity Hemorrhage Control for
Chemical, Biological, Radiological, and Nuclear Environments

Thomas Peponis, MD; Elie Ramly, MD; Kym A. Roth, NP; David R. King, MD

ABSTRACT
Background: Chemical, biological, radiological, and Keywords: tourniquet; hemorrhage; Combat Application Tour-
nuclear threats (CBRNs) are uncommon; however, niquet; Joint Service Lightweight Integrated Suit Technology
Special Operations Forces (SOF) are likely at the high-
est risk for tactical exposure. In the event of exposure,
SOF will rely on the Joint Service Lightweight Inte- Introduction
grated Suit Technology (JSLIST) for survival. Doctrine
dictates that a tourniquet should be applied over the Although chemical, biological, radiological, and nuclear
JSLIST after a severe limb injury with hemorrhage. threats (CBRNs) are uncommon, Special Operations
There is no evidence in the literature that the Combat Forces (SOF) likely remain at the highest risk for expo-
Application Tourniquet (C-A-T), which is currently sure during nonproliferation, counter-proliferation, and
the most widely available tourniquet on the battle- consequence management missions. To operationalize
field, can effectively occlude arterial blood flow when the CBRN environment, the Joint Service Lightweight In-
applied over the JSLIST. We hypothesized that C-A-T tegrated Suit Technology (JSLIST; Lanx Fabric Systems,
application over the JSLIST would be ineffective at http://www.lanxfabrics.com) is required. In the nonper-
occluding arterial blood flow in the lower extremity. missive CBRN environment, the integrity of the protec-
Materials and Methods: Following institutional review tive suit is crucial to survival. Military doctrine stipulates
board approval, 20 healthy volunteers were recruited that lower extremity exsanguination be controlled by
to participate. All volunteers wore the G3 Combat Pant application of a tourniquet over the JSLIST suit to main-
and they donned the JSLIST. First, an operating room tain maximal integrity of the suit, without exposing the
pneumatic tourniquet (gold standard) was applied in wound, while awaiting proper decontamination.
the proximal thigh and inflated to 300mmHg. Distal
arterial interrogation was performed by examination of The effectiveness of tourniquets for wartime hemor-
distal pulses and noninvasive arterial plethysmography rhage control, and the resulting improvement in sur-
wave-form analysis. After a 1-hour recovery period, vival, has been well described. In 2007, the Navy
1–5
the C-A-T was applied and tightened. A double rout- Experimental Diving Unit tested the effectiveness of 13
ing technique was used, with three 180º turns of the different types of tourniquets that were self-applied over
windlass. The same distal interrogation followed. Half long-sleeved military uniforms in stressful and unfavor-
of the volunteers had the pneumatic tourniquet applied able conditions. Based on this and other studies, the
first, and the other half had the C-A-T applied first. Re- Combat Application Tourniquet Generation 6 (C-A-T;
sults: All volunteers had palpable pulses at baseline de- North American Rescue, http://combattourniquet.com)
spite a wide range in volunteer body mass index. Distal was eventually adopted and became the tourniquet to be
pulses were absent in all volunteers following inflation carried forward into combat. The C-A-T is a lightweight
of the pneumatic tourniquet as well as tightening of the tourniquet that uses a windlass mechanism.
C-A-T. The observed difference between the mean am-
plitude of plethysmographic waveforms was not differ- All published testing of C-A-T effectiveness has been over
ent. Conclusion: The C-A-T effectively occludes arterial a standard, single-layer military uniform. To our knowl-
flow in the lower extremity, even when applied over edge, there is no evidence supporting the effectiveness
the JSLIST. This finding supports existing military doc- (and current military doctrine) of the C-A-T applied over
trine for tourniquet application over the JSLIST in the the substantially bulkier JSLIST. We hypothesized that
nonpermissive CBRN environment to control extremity C-A-T application over the JSLIST would be ineffective
exsanguination. at occluding arterial blood flow in the lower extremity.

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