Page 28 - JSOM Winter 2023

Key Finding 3 stop all arterial flow (all bleeding), and application security to
The frequency of strap/redirect-system problems impacting prevent accidental release. Other important general concepts
tourniquet security was high for hook-and-loop systems. The for most tourniquets are that strap/redirect systems use un-
triglide redirect buckle of the TMT makes its strap less likely threading/rethreading or unclipping/reclipping for placement
to accidentally be successfully released than that of the CAT7 around a trapped limb; the techniques, importance, and indi-
or OMT. Appropriate finishing of CAT7 applications makes cators of good strap pulling before use of the tightening sys-
its strap more secure than that of the OMT. We lack data re- tem; recognition of strap security; that most tightening systems
garding how frequently hook-and-loop straps are accidentally involve rotation of some part, which shortens the amount of
released in real tourniquet use, but we find releasing inade- strap around the limb via strap twisting or strap bunching;
quately secured CAT7 applications (no “Time” strap over limb and recognition of tightening-system security.
strap) and OMT applications very easy and fast in the labora-
tory via pulling open the strap hook-and-loop. Failure to do In contrast, when tourniquets may be used by appliers with
appropriate hook-and-loop overlapping makes strap opening limited training, designs that diminish opportunities for crit-
even easier. The five self-securing strap/redirect systems of the ical application problems will have fewer critical application
tourniquets in this study are very difficult or impossible to re- problems. Self-securing systems, especially self-securing tight-
lease while the tourniquet is tightened to occlusion, so they are ening systems, have serious process advantages for use by ap-
considerably more secure than hook-and-loop systems. pliers with limited training.

As with strap/redirect systems, self-securing tightening systems Acknowledgments
avoided opportunities for application errors to result in a lack The authors thank the following Drake University undergrad-
of tourniquet security. The frequency of securing problems uates of the Trauma Research Team for their help carrying out
with windlass rod tightening systems was high. We even noted the experiments: Jared Defriend, Mikayla Soelter, Amanda
a “training scar” when a research-experienced applier called Gregory, Bryan Williams, Mia Fidanze, Erin O’Keefe, Quynh
“Done” with the CAT7 without securing the time strap over Pham, Lindsey Skerrett, Kristen Skriver, Erin Steffenson, Dani
the bracket opening. Self-securing tightening systems did not Eernisse, Jack Libbesmeier, Kayla Markuson, Taylor Rent-
have physical securing struggles or errors regarding appropri- schler, and Stephanie Richardson.
ate securing.
Disclosures
Key Finding 4 None of the authors have any financial relationships relevant
Most studies examining tourniquet effectiveness consider oc- to this article to disclose, and there was no outside funding.
clusion. Most, but not all, require occlusion with appliers able As indicated in the methods, tourniquets were requested from
46
to take their hands off the tourniquet. Explicit discussion of the manufacturers or distributors, and seven of the eight models
security of occlusive applications is rare in the emergency-use of tourniquet were donated. PW, CB, and JD are paid by their
limb-tourniquet literature. Because most patients who receive respective institutions, and the other authors were volunteer
an emergency tourniquet application require some transport to researchers. None of the authors has stock in any tourniquet
definitive care, we believe tourniquet security is a critical design companies, and none do any paid consulting with any tour-
aspect. Decisions regarding tourniquet choices may become niquet companies. The authors talk to and share data with
very different when both occlusion and tourniquet security are any and all companies and individuals who are interested and
considered. This should be especially true in situations poten- won’t keep any secrets. The lab equipment belongs to Drake
tially involving appliers with little to no tourniquet training. University and UnityPoint Health Iowa Methodist Medical
Center.
Limitations
This study had the expected laboratory-setting limitations Author Contributions
of no actual injuries and substitution of an audible Doppler PW and CB contributed to concept development and project
signal for bleeding as a cue for appliers. Appliers received design. All authors contributed to the acquisition, analysis,
minimal training, but it occurred directly before tourniquet and interpretation of data and the drafting and revising of the
applications. Additionally, the convenience sample of appliers article. All authors gave final approval of the manuscript.
was recruited predominantly on a college campus by under-
graduate students pursuing degrees in biological sciences. We References
believe the frequency of bad process techniques would likely 1. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency
be higher with the stress of real injuries, no fresh training, and tourniquets to stop bleeding in major limb trauma. J Trauma.
fewer science-inclined appliers. 2008;64:S38–S50.
2. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle casualty survival
with emergency tourniquet use to stop limb bleeding. J Emerg
Conclusions Med. 2011;41:590–597.
3. Teixeira PGR, Brown CVR, Emigh B, et al. Civilian prehospital
Training for a specific tourniquet should include emphasis tourniquet use is associated with improved survival in patients with
on problem processes for that tourniquet; for example: cor- peripheral vascular injury. J Am Coll Surg. 2018;226:769–776.
rect CAT rod securing and strap securing, the presence of the 4. Scerbo MH, Holcomb JB, Taub E, et al. The trauma center is too
TMT clip, full hook-and-loop opening with the TMT, correct late: major limb trauma without a pre-hospital tourniquet has in-
TMT rod securing, where to pull the X8T, how to rethread the creased death from hemorrhagic shock. J Trauma Acute Care Surg.
Tac RMT, and how not to engage the RST release mechanism 2017;83:1165–1172.
while advancing the RST ratcheting buckle. All general tour- 5. Howard JT, Kotwal RS, Stern CA, et al. Use of combat casualty
care data to assess the US military trauma system during the Af-
niquet training should include the important general concepts ghanistan and Iraq conflicts, 2001–2017. JAMA Surg. 2019;154:
of proximal placement, sufficient circumferential tightness to 600–608.

26 | JSOM Volume 23, Edition 4 / Winter 2023