Page 61 - JSOM Fall 2019

TABLE 1 Cont.
Problem
Numbers Reference Reference Type Additional Information
a
3 Ünlü et al., 2015 22 Report concerning turns Turkish military Servicemembers applied C-A-Ts mid-thigh over a uniform (Care
of the C-A-T windlass Under Fire protocol). Of 145 appliers, 14 occluded with one turn, 37 occluded with
two turns, and the remaining 94 needed up to 6.5 turns for occlusion. From the
title onward, the authors failed to understand the importance of appropriate strap
tightness before windlass use and even promote multiple windlass turns: “Due to
differences in number of windlass turns necessary to achieve hemorrhage control in
different people, individual soldiers should be taught and trained on their respective
number of windlass turns.”
3, 4 Stewart et al., 2015 23 Review article concerning The report has three figures composed of staged photographs. One figure is meant
civilian tourniquets use to be instructional. No thigh indentation is visible in any photographs, indicating
with staged pictures suboptimal tightness. Showing pictures of ineffective applications that are not la-
beled as such is suboptimal for providing useful instruction in how to effectively
apply tourniquets.
3 Wall et al., 2016 62 Report concerning Tactical Appliers had real-time strap pressures, a secured strap pressure goal of >100mmHg,
and Wide RMT pressures and an application assistant. Nonetheless, some appliers settled for suboptimal strap
in a laboratory setting pressure: only 102 of 128 applications had secured pressures >100mmHg (58 had
pressures >150mmHg).
4 Wall et al., 2012 5 Report concerning Without feedback during training, 75 of 150 applications did not maintain correct
SWATT effectiveness in a stretch throughout the wrapping process. Appliers who had not maintained correct
laboratory setting stretch throughout the wrapping process received 10 minutes additional training
that included feedback and were then retested. During retesting, the appliers main-
tained correct stretch throughout the wrapping process.
4 Goolsby et al., Report concerning “Adequate tightness [at completed application] was determined by a combination
2015 67 layperson C-A-T training of the tourniquet indenting the mannequin’s skin, and an observer being unable to
using a lower-body slide his or her index finger between the tourniquet and the mannequin.” With this
mannequin definition, 58 of 145 appliers provided with an instruction card and 28 appliers
without an instruction card applied the C-A-T too loosely. An example instruction
card was not included in the report, and the root cause of the inadequate tightness,
either failure to turn the windlass or suboptimal strap tightness before use of the
windlass, was not reported.
4 Ross et al., 2017 4 Report concerning Without prior application instruction, 120 of 162 tourniquet applications were
layperson C-A-T, RMT, deemed “too loose” by the definition “adequate tightness [at the end of application]
and SWATT application was present if the researcher was unable to slide a finger under the tourniquet.”
using a mannequin
4 Sanak et al., 2018 68 Report concerning Appliers could choose to use a C-A-T, a SOFTTW, or an improvised tourniquet for a
tourniquet applications simulated injury at the elbow. Only 15 of the 24 arm applications were tight enough
by military operators to stop arterial flow. Most applications involved the C-A-T (19 as the single tour-
in a tactical medicine niquet, one with a SOFTTW). One application involved an improvised tourniquet.
competition
4 Goralnick et al., Report concerning Tested within 1 hour of completing a B-Con course, 11.3% of 465 appliers had
2018 69 layperson tourniquet incorrect C-A-T applications. “Tightness was assessed by the observer attempting to
training using a forcefully slide an instrument between the tourniquet and the mannequin,” and “too
mannequin loose to be effective” was recorded as the incorrect aspect of C-A-T application in
89% of incorrect applications. Strap tightness before windlass use was not reported
nor was the number of windlass turns for any of the applications.
C-A-T, Combat Application Tourniquet; CAT, Combat Application Tourniquet; EMS, Emergency Medical Services; NAEMT-PHTLS, National Associ-
ation of Emergency Medical Technician – Prehospital Trauma Life Support; RMT, Ratcheting Medical Tourniquet; SOFTTW, Special Operations Forces
Tactical Tourniquet – Wide; SWATT, Stretch Wrap and Tuck Tourniquet.
a Problem Number Key: 1. Tourniquet applied over clothing when not under fire. 2. Poor tourniquet strap-pulling techniques in staged pictures or videos.
3. Tourniquet strap not pulled tight enough before use of the mechanical advantage tightening system. 4. Completed tourniquet application not tight
enough to stop arterial flow.

a stated objective strap-pressure goal of >100mmHg, and an For elastic tourniquets such as the SWATT, the presence of
application assistant, appliers still sometimes settled for pres- visual information on the tourniquet concerning real-time
sures below the specified goal: 26 of 128 applications (26% stretch adequacy is still insufficient for some appliers to actu-
of applications) had preratchet engagement strap pressures ally apply the SWATT with adequate stretch without feedback
<100mmHg (pressures >100mmHg were obtainable because during training. Strength is not the issue, because those appli-
5
58 applications [45% of applications] had preratchet engage- ers achieved and maintained proper application stretch when
ment strap pressures >150mmHg). With 11 appliers, re- retested after approximately 10 minutes of remedial training
62
al-time strap-pressure monitoring during 600 Tactical RMT that included feedback. 5
applications, a high-priority strap-pressure target of 120 ±
5mmHg, and an application assistant, applications had pre- Concerns With Manikin-Based Training
ratchet engagement strap pressures of 102 to 135mmHg with and Research for Providing Objective Measures
a median of 122mmHg for tourniquets in a pair and a median of Tourniquet Application
of 120mmHg for single tourniquets (87% of all applications Many papers involve tourniquet use on manikins or isolated-limb
had strap pressures >114mmHg, 64% of all applications had simulations. Some obvious benefits are no tourniquet-recipient
strap pressures >114mmHg and <126mmHg). 24 risk, no need for recipient informed consent, greater consistency

Getting Tourniquets Right | 59