Page 25 - JSOM Fall 2025

We suggest all tourniquet designs using hook-and-loop-limb- Acknowledgments
encircling straps should consider having a sufficiently long We thank the Drake University undergraduates of the Trauma
limb-encircling strap that any base-area-strap-securing fea- Research Team for their help carrying out the experiments:
tures of the tightening system should be usable in all appli- Nia Eberhard-Mattes, Adrianna Clark, Adaire MacSwain,
cations, even applications on average to large circumference Ella Kocina, Maya Jean Elting, Cing Mang, Hallie Peak, Paige
thighs. The United States military thigh circumference used Ransdell, Sarah Foley, Hannah Moseley, and Soren Olesen.
for setting length requirements was 71.46cm as the 99th per-
centile for males in 1988. The 99th percentile increased to Author Contributions
29
77.40cm in 2012. The Committee on Tactical Combat Casu- PW and CB contributed to concept development. All authors
30
alty Care length statement requires only sufficient length for contributed to project design. All authors contributed to ac-
31
application on a 71.46cm-circumference thigh or 95.25cm of quisition, analysis, and interpretation of data and drafting or
tourniquet total length, which is insufficient to allow the free revising of the article. All authors had final approval of the
end to reach the base area on thighs larger than approximately manuscript.
56cm circumference (50% of the thighs in this study). With
hook-and-loop-limb-encircling straps, tourniquet lengths of Disclosures
139cm (44cm additional) would be required to engage base- None of the authors have any financial relationships relevant
area security on thighs of 71.46cm. Negatives to such strap- to this article to disclose, and there was no outside funding.
length increases would include increased tourniquet weight As indicated in the methods, the Ukrainian-manufactured
and volume, and additional strap to unthread and rethread tourniquets were provided by the manufacturers to Col.
through the redirect buckle. (Ret.) Warren Dorlac, MD, who sent the tourniquets to us,
and the X8T tourniquets were requested from and donated
As an additional general design consideration, we believe tour- by the manufacturer. PW and CB are paid by their respec-
niquet tightening should begin as soon as the tightening sys- tive institutions, and MJ was a volunteer researcher. None of
tem is engaged and not be delayed until 90° of rod rotation the authors owns stock in any tourniquet companies nor do
have occurred. Therefore, we believe slack in the DNIPRO any paid consulting with them. The authors talk to and share
and PULS inner strap, just like that of the CAT, is suboptimal data with any and all companies and individuals who are in-
because delays in increasing tourniquet pressure are delays in terested and do not keep any tourniquet-related secrets. PW
stopping bleeding. and CB are volunteer members of an ASTM International
Committee E54 on Homeland Security Applications task
Limitations group working on a performance standard for non-pneu-
Laboratory-setting limitations included: ideal application posi- matic emergency-use limb tourniquets. The lab equipment
tions; calm, uninjured recipients; audible Doppler substitution belongs to Drake University and UnityPoint Health Iowa
for bleeding; good lighting; limited distractions; and a small Methodist Medical Center.
group of calm, trained appliers. Recipients were a convenience
sample recruited from friends, college students including male Funding
and female collegiate athletes, and college faculty. A ma- No funding was received for this work. Please see the Disclo-
jor limitation regarding tourniquet wear is that applications sures section for information regarding equipment and mate-
were only as tight as needed for completion with no audible rial support.
pulse and had upper pressure limits. Use under fire would
likely involve worse application positions and therefore lower References
pre-tightening system pressures, requiring more windlass-rod 1. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency
turns just to reach “as tight as needed,” and potentially tight- tourniquets to stop bleeding in major limb trauma. J Trauma.
2008;64(2 Suppl):S38–S50. doi:10.1097/TA.0b013e31816086b1
ening-system use to “as tight as possible,” which means even 2. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle casualty survival
more windlass-rod turns. with emergency tourniquet use to stop limb bleeding. J Emerg
Med. 2011;41(6):590–597. doi:10.1016/j.jemermed.2009.07.022
3. Howard JT, Kotwal RS, Stern CA, et al. Use of combat casualty
Conclusion care data to assess the US military trauma system during the Af-
The SICH, DNIPRO, and PULS always reached completable ghanistan and Iraq conflicts, 2001-2017. JAMA Surg. 2019;154
(7):600–608. doi:10.1001/jamasurg.2019.0151
arterial occlusion; the Y&B did not. No tourniquet became 4. Wall P, Buising C, Jonas M. Lab evaluation of X8T-T2G tourni-
nonfunctional; however, Y&B stitching failures were concern- quet. J Spec Oper Med. Forthcoming.
ing, particularly if multiple uses might occur. The Y&B also 5. Wall P, Buising C, Jensen J, White A, Davis J, Renner CH. Effects
has significant design concerns: ease of clip bending, potential of tourniquet features on application processes. J Spec Oper Med.
for losing slider-redirect-buckle pieces, many incorrect slider- 2023;23(4):11–30. doi:10.55460/8FFG-1Q48
redirect-buckle rethreading options, potential for windlass-rod 6. Wall P. SICH tourniquet description. Vimeo. 2024. Accessed Au-
gust 14, 2024. https://vimeo.com/998377848
removal, and inability to always secure the rod in the triangle. 7. Wall P. DNIPRO tourniquet description. Vimeo. 2024. Accessed
August 14, 2024. https://vimeo.com/998385115
Regarding tourniquets in general, 180°-turn, windlass-rod- 8. Wall P. PULS tourniquet description. Vimeo. 2024. Accessed Sep-
tightening-system resolution routinely creates much higher tember 25, 2024. https://vimeo.com/1003301741
than needed and much higher than desirable pressures at 9. Wall P. Yellow & Blue tourniquet description. Vimeo. 2024. Ac-
application completion, which probably matters with long cessed September 25, 2024. https://vimeo.com/1003305742
tourniquet times. Additionally, hook-and-loop-limb-encircling 10. Wall P. X8T-T2G tourniquet description. Vimeo. 2024. Accessed
September 25, 2024. https://vimeo.com/1005938346
straps of current tourniquets, including the CAT, are too short 11. Hingtgen E, Wall P, Buising C. Characterizing a system for measur-
to engage base-area-strap-securing mechanisms on many adult ing limb tourniquet pressures. J Spec Oper Med. 2020;20(1):47–
thighs. 54. doi:10.55460/KRT6-FUKJ

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