Page 59 - JSOM Fall 2019

TABLE 1 Cont.
Problem
Numbers Reference Reference Type Additional Information
a
2, 4 Goolsby et al., Report concerning The instruction card contains the text “Pull free end of the Velcro strap, thread
2016 43 layperson tourniquet it through the buckle, & securely fasten it back onto itself.” The accompanying
training using a lower- drawing shows a direction of strap pull away from the limb rather than tangential
body mannequin to the limb at the redirect buckle. The text does not contain an emphasis on pulling
the strap very tight and the shown direction of pull is suboptimal.
With appropriate tightness at completed application defined as “a combination of
the tourniquet distorting the underlying mannequin flesh and an observer being
unable to force slide his or her index and middle fingers (held side-by-side and
laid flat on the mannequin) between the tourniquet and the mannequin leg,” 61
of 157 appliers provided with a four-step instruction card applied the tourniquet
too loosely. The root cause of the inadequate C-A-T tightness, either suboptimal
strap tightness before use of the windlass or failure to twist the windlass, was not
reported.
2 Committee on Training slide set Slide 68 shows strap pull upward rather than tangential to the redirect buckle.
Tactical Combat
Casualty Care 2017 45
2 Glick et al., 2018 20 Report concerning Figure 1A shows an applier pulling the strap of the C-A-T upward, away from the
tourniquet effectiveness in limb, rather than tangential to the limb at the location of the strap redirect buckle.
a laboratory setting with
application pictures
2 Other YouTube Informational and news- Suboptimal tourniquet application techniques are prevalent: Not all straps are
videos with “stop the clip videos of “Stop the pulled in an optimal direction; not all straps are pulled tight; the windlass often has
bleed” in the title 32–41 Bleed” course-associated no visible resistance to turning within the first 180°s (a clear indication of a strap
tourniquet applications not pulled adequately tight); a high degree of strap bunching is sometimes visible (a
from Oregon Health clear indication of a strap not pulled adequately tight); little effort is apparent; and
and Science University, no vocabulary is present regarding maintaining the windlass slot parallel to the sta-
UnityPoint-Cedar Rapids, bilization plate. One of the videos includes suboptimal application of a SWATT; the
Baylor, Cincinnati, Miami, applier fails to maintain adequate stretch throughout the wrapping process.
University of Texas Health
Center at Houston, Bryan
Health, Gwinnett Medical
Center, and Pitt County,
North Carolina
3 Kragh et al., 2011 7 Report concerning military C-A-Ts used by military personnel have damage and breakage from inadequate strap
tourniquet use tightness before engagement of the windlass. The report also shows a failure to
maintain the slot in the C-A-T windlass parallel to the stabilization plate because of
a failure to achieve adequate strap tightness before engagement of the windlass. The
authors call greater than three turns “too many twists of the windlass.”
3 Taylor et al., 2011 10 Report concerning Failure to understand the importance of and train to achieve appropriate C-A-T
tourniquet effectiveness strap tightness before engagement of the windlass is indicated in the discussion sec-
in laboratory setting, tion. The methods state, “A full explanation was given to each individual of how the
nonstaged picture windlass CAT tourniquet should be applied, as per the manufacturer’s instructions
and mandatory First Aid training for serving soldiers. Participants were then asked
to apply it at the mid-thigh level.” The results section indicates that with 24 par-
ticipants, C-A-T thigh occlusion was only achieved four times with self- application
and only twice when “applied by a researcher.” The discussion section has the fol-
lowing: “However, the experience of the researchers was that discomfort was not
the limiting factor in application. The windlass mechanism of the latest model of
CAT tourniquet currently in service has a clear limit to the distance of travel of ~30
mm. Even when correctly applied, this seemed insufficient to adequately constrict
the thigh. This limit was invariably reached before discomfort precluded further
tightening in our participants.” This text clearly indicates a failure to achieve ade-
quate strap tightness before engaging the windlass. In the researcher’s defense, the
manufacturer’s 2011 C-A-T instructions for “Two-handed Application,” which in-
volved double-routing of the strap, show inadequate strap tightness before windlass
engagement and state “When the band is pulled tight, no more than 3 fingers will fit
between the band and the limb.” 64
The clinical consequence of inadequate strap tightness before windlass engagement
is shown in Figure 1 of the publication. A C-A-T is applied high on the thigh with
more than two windlass turns based on the coils of fabric under the windlass and on
the extensive pleating of the hook-and-loop strap. The clinical importance of sub-
optimal strap application technique is shown with the persistent hemorrhage that
occurred because of difficulty achieving adequate C-A-T pressure—a difficulty that
occurs when the strap is not pulled adequately tight before windlass engagement.
(continues)

Getting Tourniquets Right | 57