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had pressure losses within 5mmHg of their loss plateaus 3. Wall PL, Sahr SM, Buising CM. Different width and tightening
and close to 1mmHg of their loss plateaus within 10 system emergency tourniquets on distal limb segments. J Spec
minutes on the thigh. Oper Med. 2015;15:28–38.
4. King DR, van der Wilden G, Kragh JF Jr, Blackbourne LH.
Forward assessment of 79 prehospital battlefield tourniquets
This study has the limitation of one tourniquet recipi- used in the current war. J Spec Op Med. 2012;12:33–38.
ent. The advantages of one recipient are control of the 5. Kragh JF Jr, O’Neill ML, Walters TJ, et al. Minor morbidity
tourniquet-important variables blood pressure, circum- with emergency tourniquet use to stop bleeding in severe limb
ference, and tissue composition. Additionally, using one trauma: research, history, and reconciling advocates and aboli-
tionists. Mil Med. 2011;176:817–823.
recipient allowed gel-circumference matching to the 6. Shackelford SA, Butler FK, Kragh JF Jr, et al. Optimizing the
thigh, thigh-image matching across applications, and use of limb tourniquets in tactical combat casualty care: TCCC
subjecting only one author to 300 second tourniquet guidelines change 14-02. J Spec Oper Med. 2015;15:17–31.
durations and tourniquet pressures higher than needed 7. Biehl WC, Morgan JM, Wagner FW, Gabriel RA. The safety of
the Esmarch tourniquet. Foot Ankle. 1993;14:278–283.
for arterial occlusion. The gel cylinders’ limitations are 8. Schindelin J, Arganda-Carreras I, Frise E, et al. Fiji: an open-
as follows: the gels do not compositionally match a hu- source platform for biological-image analysis. Nat Methods.
man limb; the gel pressure decays are not identical to 2012;9:676–682.
those of a thigh; and gels suffer some surface tearing 9. Slaven SE, Wall PL, Rinker JH, et al. Initial tourniquet pressure
that does not occur with skin. The cylinders’ benefits does not affect tourniquet arterial occlusion pressure. J Spec
were a precise and static experimental set-up, the abil- Oper Med. 2015;15:39–49.
ity to rule out free fluid movement, use of size-matched
cylinders with different resistances to distortion in re-
sponse to mechanical load (Poisson’s ratios), extension Ms Rometti was an undergraduate research mentor in the
of tourniquet durations, and repair with heat (270°F Biochemistry, Cell and Molecular Biology Program at Drake
[132°C] melting temperature). University, Des Moines, Iowa, and is now a medical student
at the University of Kansas School of Medicine, Kansas City,
Conclusion Kansas.

Even without tourniquet movement or limb muscle Dr Wall is a researcher in the Surgery Education Department
tension changes, pressure losses occur within minutes of UnityPoint Health Iowa Methodist Medical Center, Des
under tourniquets. These pressure losses are substantial Moines, Iowa. E-mail: piperwall@q.com.
with nonelastic tourniquets. Therefore, proper initial
tourniquet application does not guarantee maintenance Dr Buising is a professor of biology and Director of the Bio-
of arterial occlusion. Given the opportunity, tourniquet chemistry, Cell and Molecular Biology Program at Drake Uni-
versity, Des Moines, Iowa.
applications should be reassessed for continued arterial
occlusion 5 or 10 minutes after application. Ms Gildemaster was an undergraduate research mentor
in the Biochemistry, Cell and Molecular Biology Program at
Disclosures Drake University, Des Moines, Iowa, and is now a research
associate at Kemin Food Technology.
None of the authors have any financial relationships rel-
evant to this article to disclose, and there was no outside Dr Hopkins is a retired pediatric surgeon and a researcher in
funding. the Surgery Education Department of UnityPoint Health Iowa
Methodist Medical Center, Des Moines, Iowa.
References Dr Sahr is a trauma surgeon at UnityPoint Health Iowa
1. Wall PL, Duevel DC, Hassan MB, et al. Tourniquets and oc- Methodist Medical Center, Des Moines, Iowa.
clusion: the pressure of design. Mil Med. 2013;178:578–587.
2. Wall PL, Coughlin O, Rometti M, et al. Tourniquet pressures:
strap width and tensioning system widths. J Spec Oper Med.
2014;14:19–29.

26 Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016