Page 46 - JSOM Fall 2020

Conversion

Simulated Method of Exchanging Tourniquet Use for Pressure Dressing Use

John F. Kragh Jr, MD *; James K. Aden 3rd, PhD ; Michael A. Dubick, PhD 3
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ABSTRACT
Background: Given little data to assess guidelines, we sought For example, SSG Matt Decker gave a combat medic presen-
a way to exchange one type of intervention, field tourniquet tation at a meeting of the Committee on Tactical Combat Ca-
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use, for another, use of a pressure dressing. The study purpose sualty Care in 2016. The minutes note that he “is a [military]
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was to test performance of controlling simulated bleeding with reserve component flight medic and an emergency department
a stepwise procedure of tourniquet conversion. Methods: An nurse in his civilian job. He presented a case from Helmand
experiment was designed to assess 15 tests of a caregiver mak- Province in Afghanistan from early 2016 that involved Pro-
ing tourniquet-dressing conversions. Tests were divided into longed Field Care. His helicopter answered a 9-line [radioed]
trials: tourniquet use and its conversion. In laboratory con- request for evacuation of a casualty with a gunshot wound to
ditions, the tourniquet trial was care under gunfire; then, the his right thigh. He treated the casualty in place for 17 hours
conversion trial was emergency healthcare. A HapMed Leg because several problems prevented evacuation. Treatment[s]
Tourniquet Trainer simulated a limb amputation. An investi- included red blood cells, whole blood via Vampire [transfu-
gator provided healthcare. Results: Mean (± standard devia- sion] protocol, fentanyl, ketamine drip, multiple attempts
tion [SD]) test time and blood loss were 9 ± 3.6 minutes and (finally successful) to convert the limb tourniquet to other
334 ± 353.9mL, respectively. The first test took 17 minutes. By means of hemorrhage control, and more. SSG Decker’s lessons
test number, times decreased; the last six took ≤7 minutes. All learned included [among others]: Limb tourniquet conversion
tourniquet trials controlled bleeding. Mean (±SD) tourniquet can be difficult—be persistent.”
pressure and blood loss were 222 ± 18.0mmHg and 146 ±
40.9mL, respectively. Bleeding remained uncontrolled in one Given little data 8–11 and limited guidance reported 3–7,12–19 on
conversion. Initial attempts to wrap a dressing were effec- which to assess clinical guidelines, we preliminarily developed
tive in 73% of tries (n = 11 of 15). Four of 15 wrap attempts a way to simulate converting a tourniquet intervention to a
(27%) were repeated to troubleshoot bleeding recurrence, and wrap dressing intervention. For healthcare providers at work,
the first three tests required a repetition. Mean (±SD) dress- acquiring and using this conversion skill have practical im-
ing pressures and blood losses were 141 ± 17.6mmHg and portance for readiness. The purpose of this study was to test
188 ± 327.4mL, respectively. Unsatisfactory conversion trials performance of controlling simulated wound bleeding with a
had a dressing pressure <137mmHg. Dressings and wraps hid stepwise procedure of tourniquet conversion.
the wound to impair assessment of bleeding. Conclusions: In
testing a method of converting a limb tourniquet to a pres- Methods
sure dressing, the caregiver performed faster with experience
accrual. The tourniquet results were uniformly good, but con- This study was conducted in 2016 within the limits of proto-
version results were worse and more varied. Simulating con- col guidelines at the US Army Institute of Surgical Research.
version was disappointing on a manikin and indicated that its The design was a stepwise experiment of simulated caregiving
redesign might be needed to suit this method. The procedural in a laboratory. The study was to model a change or conver-
method constituted a start for further development. sion of one intervention, tourniquet use, into another, pressure
dressing. The steps of the conversion task were timed. One
Keywords: bleeding control and prevention; bandage; dress- tourniquet device was used, one model of hemostatic dressing
ing, emergency; skill; tourniquets was used, and one pressure dressing design was used but in
two widths. The pressure dressing, an elastic bandage in the
form of a roll, also had a pneumatic bladder, and its func-
tion was assessed as either inflated or uninflated. We random-
Introduction ized order of width and inflation status. Originally, we were
Since 2001, tourniquet use to stop bleeding from wounds has to conduct 30 tests but other priorities from the operational
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become more common. Irrespective of why someone applied health community superseded completion, so here we report
a tourniquet, it is often managed later by other caregivers who the results of 15 tests. The community recently reprioritized
may need to exchange the tourniquet for another intervention, development of conversion guidelines, so we decided to report
like a pressure dressing. 3–5 results now.
*Correspondence to: 3698 Chambers Pass, Joint Base San Antonio Fort Sam Houston, TX or john.f.kragh.civ@mail.mil
1 Dr Kragh is a researcher of bleeding control at the Institute of Surgical Research (ISR), Fort Sam Houston, Texas, and an associate professor in
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the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Dr Aden is a statistician at the Brooke
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Army Medical Center, Fort Sam Houston, Texas. Dr Dubick is a researcher and chairperson of Hemorrhage Control and Resuscitation Research
Department at the ISR.
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