Page 127 - JSOM Fall 2019

In industrial or urban area, this may be readily accessible but FIGURE 3 Improvised tourniquet constructed out of a cravat for
is less commonly seen in more austere environments. However, the strap and a women’s hair brush for the rod (a piece of gauze was
there are anecdotal reports of pistol and rifle magazines being used, to help to secure the windlass in place).
successfully used as a rod in combat environments. Materials
from a first aid kit can be used to create a rod, such as bandage
scissors or a sharps container (Figures 1–3).

FIGURE 1 Improvised tourniquet constructed out of a cravat for the
strap and scissors for the rod.

criteria are met). The authors have successfully stopped ar-
terial flow using everything from sticks and pencils (the most
commonly described improvised windlasses) to pipe wrenches
(Figure 2) a women’s hair brush (Figure 3).

FIGURE 2 Improvised tourniquet constructed out of a cravat for the
strap and a wrench for the rod. Building and Securing an Improvised Tourniquets
A very successful technique for constructing an improvised
limb tourniquet is to use a cravat as the strap and attach the
rod to the strap before putting it on the extremity (Appendix
1). In this approach, the rod is first tied onto the cravat strap
itself approximately one-third of the distance from the end
of the strap. The strap is then placed around the extremity
with the rod positioned on the lateral aspect of the limb. The
strap is tightened down with two square knots, the rod is then
twisted until hemostasis is achieved and it cannot be twisted
any further. The rod is secured with leftover strap material on
top of the existing knots. Alternatively, the rod can be secured
with an additional cravat or tape. In practical experience, this
technique is more successful than the classically taught ap-
proach of tightening the strap onto the limb and then attach-
ing the rod to the strap. 12

Training
More frequently, wood is used given its availability in an out- Successful improvised tourniquets, as with any procedure,
door environment. Unfortunately, wood, particularly in an arid improve with training and repetition. In a recent randomized
climate, is also more prone to breakage and therefore may fail clinical trial, a formal hands-on course focusing on commercial
to be effective. This can potentially be overcome by adding tourniquet placement and hemorrhage control resulted in 88%
15
multiple like pieces together. In an experiment by Kragh and col- of participants being able to correctly apply a tourniquet, while
23
leagues, chopsticks, pencils, and craft sticks were tested for their only 16% of untrained individuals were able to appropriately
potential use as a rod. They found failure rates of greater than place an effective tourniquet. Other methods such as flashcards
15
50% when any item was used alone, but that success improved and audio kits (intended for just-in-time) education have been
when two or more of an item were bundled together to create used with varied success. However, in general, these just-in-time
a sturdier construct. Therefore, if a nonmetal rod is used, it is methods are less successful than more formal training. 24,25
worthwhile to consider fastening multiple rigid objects together
to create the windlass rod with a combined diameter of at least 2 Improvised tourniquet training should be an iterative process
cm. Attention should also be given to the length of the rod. If the that includes initial training as well as regularly scheduled sus-
windlass rod is too short, it will prove more difficult to secure. tainment training. In the previously mentioned clinical trial,
23
Optimally, the windlass should be 20cm to 30cm in length. participants were retested 3 to 9 months after their initial edu-
cation and nearly half of them were no longer able to correctly
The user is limited only by his or her imagination with regard place a tourniquet. In contrast, a recent study of a rural police
to materials that can be used for a rod (provided the stated department found minimal skill degradation for tourniquet

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