Page 118 - JSOM Summer 2020

Tourniquets USA

A Review of the Current Literature for Commercially Available
Alternative Tourniquets for Use in the Prehospital Civilian Environment

James Martinson, BS *; Habeeba Park, MD ; Frank Butler, MD ;
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Richard Hammesfahr, MD ; Joseph DuBose, MD ; Thomas Scalea, MD 6

ABSTRACT
The American College of Surgeons’ “Stop the Bleed” (STB) by the US Special Operations Command following the 2005
campaign emphasizes how to apply the Combat Application study conducted by the US Army Institute of Surgical Research
Tourniquet (CAT), a device adopted by the military to control (USAISR) due to its durability, portability, efficacy, and rela-
extremity hemorrhage. However, multiple commercially avail- tive simplicity, and since this endorsement has been considered
able alternatives to the CAT exist, and it would be helpful for the standard of care. 5,6
instructors to be knowledgeable about how these other models
compare. A PubMed search from January 2012 to January However, while the use of the CAT has been emphasized, there
2020 cross-referenced with a Google search for “tourniquet” exists a multitude of alternative tourniquets available to the
was performed for commercially available tourniquets that had public. Despite some models functioning similarly to the CAT,
been trialed against the CAT. Windlass-type models included the instruction provided by STB has been shown to not di-
the Special Operations Forces Tactical Tourniquet (SOFT-T), rectly apply to these. The work published by McCarty et al.
the SOFT-T Wide (SOFFT-W), the SAM-XT tourniquet, the found that although people trained by the initiative could use
Military Emergency Tourniquet (MET), and the Tactical Med- a CAT, they were not able to use wrap-type tourniquets or
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ical Tourniquet (TMT). Elastic-type tourniquets included were other windlass-type models. This was also noted in the review
the Stretch, Wrap, And Tuck Tourniquet (SWAT-T), the Israeli conducted by Wall et al. that emphasized how proper applica-
Silicone Tourniquet (IST), and the Rapid Activation Tourni- tion technique was critical for tourniquet success. Given that
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quet System (RATS). Ratchet-type tourniquets included were there are multiple tourniquets approved by the Committee on
the Ratcheting Medical Tourniquet (RMT) and TX2/TX3 Tactical Combat Casualty Care (CoTCCC), as well as more
tourniquets, and pneumatic-type tourniquets were the Emer- available on the market, instructors and providers alike should
gency and Military Tourniquet (EMT) and Tactical Pneumatic be knowledgeable on these alternatives to help best teach lay-
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Tourniquet (TPT). This review aims to describe the literature persons should they have questions. This is especially con-
surrounding these models so that instructors can help lay- cerning as not all tourniquets are equally effective, despite the
people make more informed purchases, stop the bleed, and manufacturer’s claims and advertising that may mislead the
save a life. general public. 10

Keywords: tourniquets; alternate; “Stop the Bleed;” review A recent review of the existing tourniquet literature was
published by Montgomery et al. to provide a comprehensive
analysis of these available models. Based on their search, they
created a 50-point grading system that evaluated each model
Introduction
on the basis of such variables as arterial occlusion, pressure,
Ever since the American College of Surgeons’ Stop the Bleed application speed, ease of use, complication rate, commercial
(STB) initiative began following the Hartford consensus, price, device specifications, and incidence of use in both com-
thousands of laypersons have been instructed in hemorrhage bat and civilian practice. For instance, the sixth and seventh
control. Through teaching how to recognize and treat generations of the CAT (CAT6 and CAT7) were graded at
1,2
life-threatening hemorrhage, these people have become po- 41.74 and 44.00, respectively. This review then recommended
tential immediate responders trained to pack and compress the CoTCCC approve nonpneumatic tourniquets with scores
wounds as well as tourniquet application, a tool proved to greater than 40, which prompted them to update their official
reduce mortality. The initiative teaches application of the list in April 2019. However, while extensive, it serves as a gen-
3,4
CAT, a windlass-model tourniquet commonly used in both eral assessment of each and does not directly discuss how each
the military and civilian setting for prehospital hemorrhage alternative model performed when compared against the CAT
control. It was selected as the military’s tourniquet of choice within select studies. Therefore, while direct comparison or
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*Correspondence to james.martinson@som.umaryland.edu
1 Mr Martinson is a fourth-year medical student at University of Maryland School of Medicine, Baltimore, MD. Dr Park is an assistant pro-
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fessor of surgery, University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center at the University of Maryland Medical
Center, Baltimore. Dr Butler is a member of the Committee on Tactical Combat Casualty Care, US Army Institute of Surgical Research, Joint
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Base San Antonio, TX. Dr Hammesfahr is medical director of the City of Marietta SWAT Tactical Emergency Medical Support, Marietta, GA.
5 Dr DuBose is an assistant professor of surgery at University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center at the
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University of Maryland Medical Center, Baltimore, MD. Dr Scalea is physician in chief, R Adams Cowley Shock Trauma Center, Francis X Kelly
Distinguished Professor of Trauma, University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center at the University of
Maryland Medical Center, Baltimore, MD.
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