Page 54 - JSOM Fall 2019

Review

Getting Tourniquets Right = Getting Tourniquets Tight

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Piper Wall, DVM, PhD *; Charisse Buising, PhD ; Sheryl Sahr, MD 3
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ABSTRACT
Tourniquet application to stop limb bleeding is conceptually venous congestion, venous distension, rebleeding, expanding
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simple, but optimal application technique matters, gener- hematomas, compartment syndrome, and death. With current
ally requires training, and is more likely with objective mea- tourniquets, achieving arterial occlusion involves mechanical
sures of correct application technique. Evidence of problems advantage tightening systems. Among current nonelastic limb
with application techniques, knowledge, and training can tourniquets, failure to achieve adequate strap tightness before
be ascertained from January 2007 to August 2018 PubMed using the mechanical advantage system is associated with Com-
peer-reviewed papers and in Stop The Bleed–related videos. bat Application Tourniquet (C-A-T; CAT Resources, www
®
Available data indicates optimal technique when not under .combattourniquet.com) breakage, inability to reach arte-
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fire involves application directly on skin. For nonelastic tour- rial occlusion before reaching the limitations of tightening
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niquets, optimal application technique includes pulling the systems, difficulty properly engaging tightening systems,
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strap tangential to the limb at the redirect buckle (parallel to longer times to achieve occlusive pressures, difficulty secur-
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the limb- encircling strap entering the redirect buckle). Before ing windlasses, and unnecessary recipient discomfort. Five of
engaging the mechanical advantage tightening system, the se- these items will hinder achieving arterial occlusion, and two
cured strap should exert at least 150mmHg inward, and skin will hinder tourniquet training.
indentation should be visible. For Combat Application Tour-
niquets, optimal technique includes the slot in the windlass Visual aids such as videos can be useful for physical skills
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rod parallel to the stabilization plate during the single 180° training 11–14 and evaluating. To be beneficial training aids,
turn that should be sufficient for achieving arterial occlu- they should either show the correct process and outcome, or
sion, which involves visible skin indentation and pressures they should specifically and explicitly indicate what type of
of 250mmHg to 428mmHg on normotensive adult thighs. error is being shown and should explicitly indicate that the
Appropriate pressures on manikins and isolated-limb simula- shown error should be avoided. 11,12
tions depend on how the under-tourniquet pressure response
of each compares to the under-tourniquet pressure response Tourniquet pictures exist in the peer-reviewed medical litera-
of human limbs for matching tourniquet-force applications. ture, 6,7,10,15–30 and tourniquet training–related videos associated
Lack of such data is one of several concerns with manikin and with the Stop the Bleed campaign exist on the Internet. 31–41
isolated-limb simulation use. Regardless of model or human Most of the tourniquet-use pictures and Stop the Bleed– related
limb use, pictures and videos purporting to show proper tour- videos consist of clinical photographs, 6,10,21,27,28,30 staged pho-
niquet application techniques should show optimal tourniquet tographs, 7,15–18,29 study or training pictures, 19,20,22–26,42–45 and
application techniques and properly applied, arterially occlu- training or news videos. 31–41 Evidence of problems with appli-
sive limb tourniquets. Ideally, objective measures of correct cation techniques and application knowledge can be found in
tourniquet application technique would be included. all sets and in some of the writing. 10,15–23,29,31–47

Keywords: tourniquet; tourniquet application; hemorrhage; The purposes of this review are threefold: (1) to indicate the
first aid; emergency treatment scope of the dual problems of lack of optimal tourniquet ap-
plication knowledge and prevalence of suboptimal tourniquet
application technique, (2) to provide current optimal tourni-
quet application technique information, and (3) to encourage
Introduction
development and use of objective measures of optimal tourni-
Limb tourniquets are part of military and civilian prehospital quet-application technique.
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care and the Stop the Bleed campaign. Application of tourni-
quets to stop limb bleeding is conceptually simple, but optimal Methods
application technique is more likely to result from training
correct technique than from simply handing out tourniquets. 4,5 We searched PubMed for January 2007 to August 2018 papers
concerning emergency limb tourniquets. Within those publica-
Optimal application techniques matter because limb tourni- tions, we looked for pictures showing tourniquet applications,
quets that are not arterially occlusive lead to persistent bleeding, descriptions of tourniquet applications, and discussion of
*Correspondence to piperwall@q.com
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1 Dr Wall is a researcher in the Surgery Education Department of UnityPoint Health Iowa Methodist Medical Center, Des Moines, Iowa. Dr
Buising is a professor of biology and the director of the Biochemistry, Cell and Molecular Biology Program at Drake University, Des Moines,
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Iowa. Dr. Sahr is a trauma surgeon at Sanford Medical Center – Fargo, Fargo, North Dakota.
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