Page 60 - JSOM Fall 2019

TABLE 1 Cont.
Problem
Numbers Reference Reference Type Additional Information
a
3 Childers et al., Report with a secondary An investigator secured the C-A-T “over the Battle Dress Uniform, parallel to and
2011 46 goal “to determine the approximately 2 cm inferior to the inguinal ligament,” with “the tightest possible
average number of turns fit by confirming that no more than three fingers could fit under the tourniquet.”
of the tourniquet windlass Then the Marine tourniquet recipient turned the windlass. Of 332 tourniquet appli-
necessary to stop the distal cations, 196 (59%) required all three allowed turns to stop the distal pulse. From
pulse.” the secondary goal onward, the paper fails to acknowledge or even consider the
existence of the suboptimal application problem of inadequate strap tightness before
windlass engagement (a technique problem enhanced by the tourniquet design and
the manufacturer’s instructions of the time). The conclusions statement, “Service-
members should be taught that CATs may routinely require three turns to be effec-
tive” not only fails to address the problem of suboptimal application technique but
goes so far as to accept it.
3, 4 Kleinman et al., Article concerning law The photograph shows a C-A-T applied to a thigh too loosely to indent the pant
2012 44 enforcement first-aid leg fabric, which indicates an inadequate strap pull before windlass use and inade-
training with either staged quate pressure for arterial occlusion (may have been using Care Under Fire scenario,
picture or picture from which makes over clothing appropriate).
training
3, 4 King et al., 2012 21 Report concerning the The nonstaged picture shown as Figure 4 shows three tourniquets on one thigh. This
effectiveness of battlefield indicates appliers using less-than-optimal application technique for at least two tour-
tourniquets on arrival at niquets. The windlass of the middle C-A-T has too many turns for a strap that was
a forward surgical team, pulled adequately tight before windlass use. The distal C-A-T shows double-routing,
nonstaged picture which is in accordance with the instructions of the time but which makes achieving
adequate strap tightness considerably more difficult than does single-routing. The
view of the proximal C-A-T is obscured, precluding assessment of windlass turn
number or strap routing.
Of 65 limbs with tourniquets, 54 had distal pulses on arrival at a forward surgical
team. This does not necessarily mean that appliers did not adequately tighten the
tourniquets initially, but at the very least it indicates problems with reassessment of
tourniquet applications.
3 Wall et al., 2013 64 Report concerning self Sixteen appliers trained with the Generation 6 C-A-T manufacturer’s printed instruc-
and buddy tourniquet tions, PowerPoint slides, and training videos; were specifically told to pay special
applications in a attention to Kragh et al.’s work regarding the military’s lessons learned concerning
7
laboratory setting C-A-T application; and were directed to pull the strap very tight with complete
removal of slack. Secured strap pressures >100mmHg before windlass engagement
were only achieved in four of 32 double-routed C-A-T thigh applications, seven of
16 double-routed C-A-T arm applications, and 11 of 16 single-routed C-A-T arm
applications. Pressures >150mmHg were achieved in zero double-routed thigh appli-
cations, one double-routed arm application, and four single-routed arm applications.
3 Kragh et al., 2013 8 Report concerning military Evidence of inadequate strap pressures before windlass use is shown in Figure 5 of
tourniquet use the paper: 50% of C-A-T applications involved three or four windlass turns and
95% of C-A-T applications involved two or more windlass turns. Even with a dou-
ble-routed Generation 6 C-A-T, very good pulling technique allows appliers to reach
strap pressures that result in occlusion with one or possibly two windlass turns.
3 Weppner et al., Report concerning After varied Generation 6 C-A-T environmental exposure in Afghanistan, an in-
2013 47 tourniquet effectiveness in vestigator secured C-A-Ts on the thighs of Marines over the Desert Marine Corps
a laboratory setting after Camouflage Utility Uniform. “After ensuring a tight fit of the tourniquet” by the
Afghanistan exposure investigator, the windlass was turned by the Marine until pulse elimination, break-
age, unbearable pain, or four windlass turns. Of 1,320 C-A-T applications without
breakage, pulse elimination required one turn in 9%, two turns in 26%, three turns
in 60%, and four turns in 5%. The authors stated, “our results support previous
reports that most CATs require 3 turns to be efficacious,” which overlooks the
problem of the investigator failing to achieve adequate strap tightness. The authors
recommended, “Servicemembers should be trained that most CATs may routinely
require three turns to be effective,” which fails to recognize or address the problem
of suboptimal application technique.
3 Wall et al., 2014 61 Report concerning RMT Appliers were given unlimited training access, manufacturer’s printed instructions,
pressures in a laboratory instructional videos, and practice sessions with verbal feedback. All tourniquets
setting were buddy applied. Without a specific pressure goal, two of 32 thigh applications
and 12 of 32 arm applications had secured strap pressures >100mmHg before ratch-
et engagement. Only one thigh and four arm applications had pressures >150mmHg
before ratchet engagement.
3 Wall et al., 2015 66 Report concerning Buddy applied C-A-T (Generation 6, single-routed), SOFTTW (Generation 2), and
distal limb tourniquet RMT applications to forearms and calves generally had undesirably low pressures
effectiveness in a before engagement of the tightening systems despite the directive to pull the strap
laboratory setting “as tightly as the applier could manage” before using the mechanical advantage
tightening system. Of 32 applications (16 appliers) for each tourniquet, secured
strap pressures >100mmHg were only achieved in 23 C-A-T, nine SOFTTW, and 24
RMT applications, and pressures >150mmHg were only achieved in seven C-A-T,
one SOFTTW, and 12 RMT applications.
(continues)

58 | JSOM Volume 19, Edition 3 / Fall 2019