Page 14 - JSOM Fall 2025

planned to compare Ukrainian-manufactured tourniquet pres- Pressure Measurements
sures and tightening-system use obtained with the same ap- Pressures were measured using a No. 1 neonatal-blood-
pliers and most of the same recipients to those obtained with pressure-cuff bladder inflated to 18mmHg above atmospheric
the X8T. pressure (baseline), secured beneath the limb-encircling strap
on the medial aspect of the limb, and connected to a Vernier
Pressure Sensor 400, Vernier LabPro interface, and Logger Pro
Methods
3.16.2 Software (Vernier Science Education, Beaverton, OR).
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The Drake University Institutional Review Board approved Pressures were recorded every second. The system was not
this prospective study (#2023-24012), which took place Au- used in X8T applications on arm circumferences <31.3cm (too
gust 2024 through April 2024. small to accomodate the bladder under only strap). 4
Tourniquets Applications
We had four of each tourniquet model: one for visual compar- Application side was block randomized in sets of 10 per tour-
isons (never applied), one for practicing, one for right limbs, niquet (SICH, DNIPRO, PULS, Y&B, X8T). Tourniquets were
one for left limbs. We placed a little white mark on one end of applied over thin scrubs material (Ukrainian- manufactured
each windlass rod as a possible aid in turn counting. tourniquets because the edge of the SICH-limb-encricling
strap caused a “paper cut” on the first recipient during strap
Four Ukrainian manufacturers provided tourniquets (Figure 1) securing through the modified triangle) or skin (X8T) on the
to Col. (Ret.) Warren Dorlac, MD, who sent the tourniquets to mid-arm then same-side mid-thigh of seated recipients with
us. The tourniquets are abbreviated as: the arm resting palm up on a table and knee flexed approx-
imately 90° with feet on the floor or elevated surface. Distal
• SICH (Strengthened Individual Combat Hybrid Tourni- arterial flow (radial artery, dorsal pedal artery, or posterior
quet; SICH Ukraine, LLC, Kyiv; Lot GS-III2023, manufac- tibial artery) was monitored with audible Doppler (Ultrasonic
tured 9/2023); Doppler Flow Detector Model 811 with 9.5MHz adult flat
• DNIPRO (TQ DNIPRO GEN 2; TQ DNIPRO, Dnipro, probe; Parks Medical Electronics, Aloha, OR). Arterial occlu-
Ukraine; Lot DNT2/23-17R 2023-09); sion was defined as loss of audible Doppler pulse. Arterial flow
• PULS (PULS Tourniquet; PULS Tourniquet, Ternopil; return was defined as return of audible Doppler pulse.
G1D1023B, manufactured 10/20/2023); and
• Y&B (Yellow & Blue tourniquet; Yellow & Blue, Dnipro, After tourniquet placement around the limb with the redirect
Ukraine; Gen 5 manufactured 2/1/2023). buckle positioned laterally for downward strap pulling, the
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applier pulled and secured the strap as tight as possible and
See reference 5 for tourniquet parts and references 6–9 for removed both hands from the tourniquet for pre-tightening-
video tourniquet descriptions. The strap of the SICH was system-use pressure (Figure 2). Tightening-system use began.
simple-threaded through the outer slot of the redirect. All use For the Ukrainian-manufactured tourniquets, rod rotation
windlass-rod tightening systems. Windlass-rod rotations im- was paused at first arterial occlusion (Figure 2), and the rod
mediately affect SICH and Y&B strap pressure. Built-in slack was secured as soon thereafter as allowed hands-off first com-
in the DNIPRO and PULS internal strap cause a lack of pres- pletion with no audible pulse (Figure 2).
sure increase during the first 90° of rod rotation.
Rod securing and application completion involved rod place-
The X8Ts (Figure 1) were requested from and donated by ment in the rod-holding part of the tourniquet and comple-
the manufacturer (manufactured 04/25/2022). X8Ts have a tion of additional application securing maneuvers: SICH–rod
self-securing-double-redirect strap/redirect system that can- end in top of modified triangle and any available portion of
not be unthreaded, a clip for securing around a trapped limb, limb-encircling strap threaded through a slot in the modified
and a self-securing tightening system with unidirectional dial triangle; DNIPRO and PULS–rod end in one side of open-
6
rotation parallel to the limb surface (see Reference 10 for top bracket with any available portion of limb-encircling
X8T video description). Dial rotation results in immediate, strap placed over rod in bracket and time strap secured across
full-width circumferential strap shortening via shortening of bracket opening; Y&B–rod end in triangle. 9
7,8
a strap that is sewn around the secondary strap redirect and
the clip of the primary strap redirect. Ten teeth advances (10 Returns of arterial flow before 100 seconds from first com-
clicks) create 180° of dial rotation (equivalent to one 180° pletion resulted in an additional 180° rod rotation and an
windlass-rod turn). additional completion. Pressure thresholds for early applica-
tion release were set at rod-secured pressures of 800mmHg
Appliers for arms and 1500mmHg for thighs. Pre-release pressure was
Following practice, eight researchers were chosen as tourniquet taken 100 seconds from first completion or sooner if early
appliers based on ability to frequently achieve pre-tightening- release; then the rod was unsecured and slowly unrotated to
system-use pressures >100mmHg with the X8T. Availability capture return-of-arterial-flow pressure prior to tourniquet
determined which applier did each application. removal.

Recipients X8T application differences were as follows: a hands-off first
Volunteers were ≥18 years and had no known bleeding or arterial occlusion pressure, first completion pressure one-click-
clotting abnormalities, circulation problems, pain syndromes, and-hands-off past first occlusion, returns of arterial flow
peripheral neuropathies, connective tissue disorders, or condi- before 100 seconds from first completion resulted in one addi-
tions that would contraindicate tourniquet application (e.g., tional tightening click, and no collection of return-of- arterial-
current forearm or thigh injuries). flow pressure during removal process.

12 | JSOM Volume 25, Edition 3 / Fall 2025