Page 125 - JSOM Fall 2019

An Ongoing Series

Proficiency in Improvised Tourniquets for Extremities

A Review

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Chris Röhrich, BSc, 18D ; Timothy P. Plackett, DO, MPH *;
Britta M. Scholz, PhD ; Michael Hetzler, NRP 4
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ABSTRACT
Tourniquets have become ubiquitous tools for controlling In recent years, Special Operation Forces (SOF) have found
hemorrhage in the modern prehospital environment, and themselves in more austere and underresourced environments.
while commercial products are preferable, improvised tourni- Additionally, domestic terrorism, natural disasters, and crim-
quets play an important role when commercial options are not inal activities with mass casualty scenarios may not offer the
available. A properly constructed improvised tourniquet can availability or accessibility of commercial tourniquets. These
be highly effective provided the user adheres to certain princi- challenges, combined with geopolitical change and consider-
ples. This review article identifies key skills in the construction ations of nonpermissive scenarios, demand a change of per-
and application of improvised tourniquets on an extremity. An spective and the consideration of improvised medicine.
improvised tourniquet design for an extremity should include
three components: a strap, a rod, and a securing mechanism. Newer generations of SOF medical and nonmedical first
The strap can be made from a variety of materials, but cra- responders have been supplied and overindulged with an
vat-like fabric has been shown to work well. Optimal strap abundance of effective, commercially produced tourniquets.
dimensions should be at least 2cm in width and a continuous However, in emergency situations, medics and first responders
segment long enough to extend around the extremity while must also know what to do if a commercially designed tour-
still offering ends to accommodate and secure the rod. The niquet is not available and there is life-threatening extremity
rod should be constructed from a material that is hard, strong, hemorrhage. A prolonged operation or mass casualty scenario
and capable of withstanding the torque placed on it without where all commercial tourniquets have been used and medical
bending or breaking. After torque is applied, the rod must be responders need to improvise other hemorrhage control is eas-
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secured into position to maintain the constricting force and ily imagined. Furthermore, the need for such knowledge and
survive patient transport. Finally, the need for an improvised training is not limited to the military population. During the
tourniquet is a contingency that all first responders should an- Boston Marathon bombing of 2013, there were 27 improvised
ticipate. Hands-on training should be conducted routinely in tourniquets applied by civilian first responders, but all were
conjunction with other first responder tasks. found to be ineffective on arrival at the hospital. This event
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demonstrates not only the need (from a patient perspective)
Keywords: tourniquets; improvised tourniquet; hemorrhage; for improvised tourniquets but also the need for proper edu-
military medicine; emergency medical services; unconven- cation and training. The frequency of preventable death from
tional medicine exsanguinating extremity trauma in both military and civilian
health care shows that there is still progress to be made in
managing this problem. 6,7
Introduction
It is critical to note that while commercial and improvised
The first Tactical Combat Casualty Care (TCCC) guidelines tourniquets have many similarities, there are some significant
were published in 1996, initiating the modern mindset and differences. Commercial tourniquets are the product of rig-
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prehospital treatment of extremity hemorrhage with tourni- orous scientific study and subject to government regulatory
quets. As a result, limb tourniquet use increased in both prior- oversight. In the United States, the Food and Drug Admin-
ity and popularity. 2 istration (FDA), Department of Health and Human Services,
*Address correspondence to michael.hetzler@JSOMonline.org
1 Mr Röhrich is currently the head of medical training and education for a German consulting company. LTC Plackett is a trauma surgeon
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currently assigned to Fort Bragg, NC. Dr Scholz is a journalist and book author in Berlin, Germany. Mr Hetzler is presently an independent
contractor and a lecturer for the University College Cork of Ireland.
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