Page 73 - JSOM Fall 2018

Does Pain Have a Role When It Comes to Tourniquet Training?

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Jonathan Alterie, DO ; Andrew J. Dennis, DO ; Adil Baig, MD ;
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Ann Impens, PhD ; Katarina Ivkovic, MA ; Kimberly T. Joseph, MD ; Thomas A. Messer, MD ;
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Stathis Poulakidas, MD ; Frederic L. Starr, MD ; Dorion E. Wiley, MD ;
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Faran Bokhari, MD, MBA ; Kimberly K. Nagy, MD 12
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ABSTRACT
Background: One of the greatest conundrums with tourniquet Introduction
(TQ) education is the use of an appropriate surrogate of hem­
orrhage in the training setting to determine whether a TQ has The tourniquet (TQ) has played a prominent role in the US
been successfully used. At our facility, we currently use loss of military for well over a century. For example, there is the in­
audible Doppler signal or loss of palpable pulse to represent famous story of American Civil War General Albert Sidney
adequate occlusion of vasculature and thus successful TQ ap­ Johnston, who perished due to blood loss from a gunshot
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plication. We set out to determine whether pain can be used wound to the leg despite having a TQ in his own pocket. Or,
to indicate successful TQ application in the training setting. from the medical literature, A Manual of Military Surgery,
Methods: Three tourniquet systems (a pneumatic tourniquet, 1861, insisted Soldiers be trained and issued TQs to combat
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Combat Application Tourniquet [C­A­T], and Stretch Wrap death resulting from hemorrhagic wounds in battle.
and Tuck Tourniquet [SWAT­T]) were used to occlude the ar­
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terial vasculature of the left upper arm (LUA), right upper arm Surprisingly, it was only recently that the TQ made its way
(RUA), left forearm (LFA), right forearm (RFA), right thigh into the kits of most US troops. Until 2005, the TQ was issued
(RTH), and right calf (RCA) of 41 volunteers. A 4MHz, hand­ mainly to Special Operation Units for Tactical Combat Casualty
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held Doppler ultrasound was used to confirm loss of Doppler Care purposes. This delay in broadly issuing the TQ for troops
signal (LOS) at the radial or posterior tibial artery to denote was due to literature that described risks and morbidity with
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successful TQ application. Once successful placement of the improper TQ use. However, recent literature and anecdotal
TQ was noted, subjects rated their pain from 0 to 10 on the vi­ evidence demonstrates the TQ, when used properly, can be safe
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sual analog scale. In addition, the circumference of each limb, and life­saving, and thus issued to the majority of troops.
the pressure with the pneumatic TQ, number of twists with the The interest in TQs life­saving benefits does not stop on the bat­
C­A­T, and length of TQ used for the SWAT­T to obtain LOS tlefield. Many police officers, medics and civilian responders are
was recorded. Results: All 41 subjects had measurements at all adopting Tactical Combat Casualty Care–like guidelines to use
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anatomic sites with the pneumatic TQ, except one participant TQs for major limb trauma in the civilian setting. As the TQ
who was unable to complete the LUA. In total, pain was rated continues to be used both on and off the battlefield, the need for
as 1 or less by 61% of subjects for LUA, 50% for LFA, 57.5% review of TQ education must not go unnoticed.
for RUA, 52.5% RFA, 15% for RTH, and 25% for RCA. Pain
was rated 3 or 4 by 45% of subjects for RTH. For the C­A­T, One of the greatest conundrums with TQ education is the use
data were collected from 40 participants. In total, pain was of an appropriate surrogate of hemorrhage in the training set­
rated as 1 or less by 57.5% for the LUA, 70% for the LFA, ting to determine whether a TQ has been successfully used.
62.5% for the RUA, 75% for the RFA, 15% for the RTH, At our facility, we currently use loss of audible Doppler sig­
and 40% for the RCA. Pain was rated 3 or 4 by 42.5%. The nal (LOS) or loss of palpable pulse to represent occlusion of
SWAT­T group consisted of 37 participants for all anatomic vasculature and thus successful TQ application. We set out to
locations. In total, pain was rated as 1 or less by 27% for determine whether pain can be used to indicate successful TQ
LUA, 40.5% for the LFA, 27.0% for the RUA, 43.2 for the application in the training setting.
RFA, 18.9% for the RTH, and 16.2% for the RCA. Pain was
rated 5 by 21.6% for RTH application, and 3 or 4 by 35%. Methods
Conclusion: The unexpected low pain values recorded when
loss of signal was reached make the use of pain too sensitive as Approval of the study was granted by Cook County Health
an indicator to confirm adequate occlusion of vasculature and, and Hospital System Institutional Review Board. Study partic­
thus, successful TQ application. ipants were randomly selected male and female resident physi­
cians, medical students, police officers, paramedics, and health
care professionals who were randomly present at our study
Keywords: tourniquet; pain; vasculature occlusion
sites. Informed consent was obtained from each volunteer.

*Correspondence to Jonathan Alterie, DO, 1900 W Polk Street, Flr 13, Chicago, IL 60612 or jalterie66@midwestern.edu

1 Dr Alterie is with the Trauma and Burn Unit, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL; Midwestern University Chicago
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College of Osteopathic Medicine, Downers Grove, IL; and Institute for Healthcare Innovation, Downers Grove, IL. Dr Dennis, Dr Baig,
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6 Dr Joseph, Dr Messer, Dr Poulakidas, Dr Starr, Dr Wiley, Dr Bohari and Dr Nagy are with the Department of Trauma and Burn,
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John H. Stroger, Jr. Hospital, Cook County Hospital, Chicago, IL; Dr Impens and Ms Ivkovic are with the Institute for Healthcare Innovation,
Midwestern University, Downers Grove, IL.
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