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tourniquets or under parts of tourniquets that do not conform 4. Wall P. Tactical Ratcheting Medical Tourniquet over uncon-
around the bladder, the inflated bladder should be constrained strained #1 neonatal bp cuff with bladder 21mmHg over atmo-
within a flexible but nonelastic material such as 1-inch tubu- spheric pressure [video]. https://vimeo.com/375042828. Accessed
lar polyester webbing. Unfortunately, adding the constraining 26 November 2019.
webbing increases the size of the bleb under the tourniquet, 5. Wall P. Tactical Ratcheting Medical Tourniquet over constrained
#1 neonatal bp cuff with bladder 18mmHg over atmospheric
which probably has some effect on the pressure isobars in the pressure [video]. https://vimeo.com/376021908. Accessed 27 No-
tissue under the tourniquet. vember 2019.
6. Grebing BR, Coughlin MJ. Evaluation of the Esmark bandage
Pressure is a critical variable in the emergency use limb tour- as a tourniquet for forefoot surgery. Foot Ankle Int. 2004;25(6):
niquet certification process being developed by an ASTM E54 397–405.
Committee on Homeland Security Applications task group. 7. Biehl WC, Morgan JM, Wagner FW, Gabriel RA. The safety of
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the Esmarch Tourniquet. Foot Ankle. 1993;14(5):278–283.
The benchmark pressures currently being used in the devel- 8. Guirguis EM, Bell MS. The wrist tourniquet: an alternative tech-
opment of that process were collected with the inflated blad- nique in hand surgery. J Hand Surg Am. 1990;15(3):516–519.
der-based system. Therefore, it is important that tourniquet 9. Wall PL, Duevel DC, Hassan MB, et al. Tourniquets and occlu-
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certification-task-group members, designers, recommending sion: the pressure of design. Mil Med. 2013;178(5):578–587.
organizations, purchasing decision makers, and potential 10. Wall PL, Coughlin O, Rometti M, et al. Tourniquet pressures:
users can access response and limitations information con- strap width and tensioning system widths. J Spec Oper Med.
2014;14(4):19–29.
cerning the inflated bladder system as a tourniquet pressure 11. Slaven SE, Wall PL, Rinker JH, et al. Initial tourniquet pressure
measuring system. does not affect tourniquet arterial occlusion pressure. J Spec Oper
Med. 2015;15(1):39–49.
As indicated, the major study limitation is that this was a 12. Wall PL, Sahr SM, Buising CM. Different width and tightening
laboratory study characterizing the responses of the inflated system emergency tourniquets on distal limb segments. J Spec
bladder pressure-measuring system in a pressurized chamber. Oper Med. 2015;15(4):28–38.
Nonetheless, the data clearly indicates inflated bladder pres- 13. Wall PL, Weasel J, Rometti M, et al. Pressures under 3.8cm,
5.1cm, and side-by-side 3.8cm-wide tourniquets. J Spec Oper
sure-measuring system limitations that should be kept in mind Med. 2016;16(2):28–35.
when discussing reported emergency use limb tourniquets 14. Wall P, Buising C, Nelms D, et al. Effects of distance between
pressures. paired tourniquets. J Spec Oper Med. 2017;17(4):37–44.
15. Crenshaw AG, Hargens AR, Gershuni DH, et al. Wide tourniquet
cuffs more effective at lower inflation pressures. Acta Orthop.
Conclusions 1988;59(4):447–451.
16. Graham B, Breault MJ, McEwen JA, et al. Occlusion of arterial
Within its linear response range, the inflated bladder pressure- flow in the extremities at subsystolic pressures through the use of
measuring system accurately indicates average surface-applied wide tourniquet cuffs. Clin Orthop Relat Res. 1993;286:257–261.
pressure. For average applied pressures less than 100mmHg, 17. Moore MR, Garfin SR, Hargens AR. Wide tourniquets eliminate
which, depending on strap pulling technique and tourniquet blood flow at low inflation pressures. J Hand Surg Am. 1987;12
design choices, often exist prior to mechanical advantage tight- (6):1006–1011.
ening system use, 10-13,25,26 the inflated bladder pressure-mea- 18. McKeague AL, Cox D. Joint operational evaluation of field tour-
niquets Final Report Phase 1. Naval Medical Research Unit San
suring system will indicate higher pressures than actual Antonio NAMRU TR 2012-13. 2012.
applied pressures. For average applied pressures greater than 19. Dory RE, Cox DD, Endler BM. Test and evaluation of New York
550mmHg, which include occlusion and completion pressures City Industries for the Blind (NYCIB) tourniquets – Phase I. Na-
with some 3.8cm-wide tourniquets including Generation 6 val Medical Research Unit San Antonio NAMRU-SA Technical
Combat Application Tourniquets, 9-12 the inflated bladder pres- Report #2014-23. February 3, 2014.
sure-measuring system will indicate lower pressures than ac- 20. Tekscan, Inc. Whitepaper. Comparison of interface pressure mea-
tual applied pressures. surement options. Download from Tekscan website. https://www
.tekscan.com/resources/whitepaper/comparison-interface
-pressure-measurement-options. Accessed November 19, 2019.
Disclosures 21. Pressure Profile Systems, Inc. Website. https://pressureprofile.
None of the authors have any financial relationships relevant com/about/tactile-sensing. Accessed November 20, 2019.
to this article to disclose, and there was no outside funding. 22. Kue RC, Temin ES, Weiner SG, et al. Tourniquet use in a civil-
ian emergency medical services setting: a descriptive analysis of
the Boston EMS experience. Prehosp Emerg Care. 2015;19(3):
Author Contributions 399–404.
All authors contributed to all aspects of the project and had 23. Wolff LH, Adkins TF. Tourniquet problems in war injuries. Bull
final approval of the manuscript. U.S. Army Medical Dept. 1945;87:77-84.
24. Hester A, Robinson C, Kinser R, et al. Increasing Confidence in
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