Featured Tourniquet Buyer’s Guide Aaron Adams March 25, 2020 Photos By Kenda Lenseigne The How, Why, and What of Stopping the Bleed In 2017, the total number of violent crimes in the United States reached 1.28 million. Violent hazards may arise from an array of different situations, ranging from active shooters, attacks with edged weapons, motor vehicles, or explosives. Since the Route 91 Festival mass shooting in Vegas, more people are asking what they can do if they or someone around them is injured. Here are some statistics concerning mass shootings: 2012 Aurora Movie Theater: 12 killed, 70 injured 2016 Pulse Night Club: 49 killed, 53 injured 2017 Route 91 Festival: 58 killed, 700 injured Data collection from these events coupled with evidence coming out of the Iraq and Afghanistan Wars has highlighted the importance of hemorrhage control. So, what can you do if a traumatic event occurs to you or someone around you? Simple, stop the bleed, because blood is life. Our options for controlling bleeding break down to either direct pressure or by using a tourniquet. (See figures A & B) Figure A: Example of a non-compressible area where tourniquets are not usable and direct pressure is necessary. Figure B: Tourniquets can be used on compressible areas of the body. Note, this picture accurately depicts the neck is a compressible area. It should go without saying, however, that you should not put a tourniquet around the neck. This should be handled with direct pressure on the injury side with careful consideration not to occlude the airway. What’s a tourniquet? Simply put, it’s a device used to control severe bleeding from a large vein or artery in an extremity. Tourniquets are lightweight, compact, and have a long history in controlling bleeding — their use has been depicted in Neolithic-era cave paintings of limb amputations. Fast-forward to more modern times and tourniquets were widely used by both sides during the U.S. Civil War. Soldiers were taught to use a bandana and a stick to stop bleeding. During World War I, tourniquets would see continued use, yet lack of proper training coupled with prolonged evacuation times produced less-than-optimal outcomes. World War II saw similar results, as many reports stated tourniquets were improperly applied, causing death or amputations. The Korean War was the first point in recent history that saw positive results for tourniquets. General Carl Hughes recalled seeing lives saved and denied limbs being lost when tourniquets were employed (Welling, McKay, Rasmussen, & Rich, 2012). The biggest change from WWII and Korea was training in the use of tourniquets, which, coupled with faster evacuation times, saw many more casualties surviving what would previously be fatal wounds. The Iraq and Afghanistan wars brought further credibility and validation to the use of tourniquets. This was accomplished with the implementation of the Joint Theatre Trauma Systems (JTTS), allowing for extensive data collection in real time. So, why was there so much data available to collect on tourniquets? Simply put, better body armor. Today, soldiers are surviving rifle hits to their torso due to hard plates, where in previous wars, hits to the thoracic area would be more common and severe. Alongside more robust body armor, the Iraq and Afghanistan war has seen devastating injuries from IED blasts, increasing injuries to extremities. The use of tourniquets coupled with shortened medical evacuation (MEDEVAC) time have proved the validity of the device. The information gathered since the JTTS began in 2004 has translated to the widespread distribution of tourniquets and training in the U.S. military. So, how does the use of tourniquets by the military translate into civilian life? Remember, uncontrolled bleeding is the number-one preventable cause of death. A tragic event can occur anywhere at any time, such as an accident at the range, a vehicle crash, or IED blast as seen at the Boston Marathon. A tourniquet should be a common part of your everyday carry, just as much as your wallet, phone, handgun, and pocket knife. Let’s start by doing away with two fallacies surrounding this life-saving apparatus. 1. Application of a tourniquet means the loss of an extremity. False. The loss of an extremity is extremely rare, and on the contrary, death from uncontrolled bleeding far outweighs the extreme circumstance of losing a limb. 2. Tourniquets left in place for an extended period causes tissue ischemia or nerve damage. False. Long-term damage to an arm or leg is rare if the tourniquet is left on for less than two hours. There have even been recorded cases of tourniquets left on for more than eight hours without permanent damage. APPLICATIONS OF TOURNIQUETS The bare-bones basics for applying tourniquets are the same no matter what device you decide to purchase; wrap the device around a limb, secure it, determine that there’s no distal (downstream) pulse, and record the time of application. The common phrases you’ll hear when applying a tourniquet is “high and tight,” which means secure the device high on the limb, and reef on that sucker. A more deliberate approach in applying the tourniquet would be to secure the device 2 to 3 inches above the wound. It’s critically important that a distal pulse check be performed on any limb where a tourniquet is applied. If a distal pulse is still present, consider additional tightening of the device, or applying a second tourniquet. Clearly mark the time of application or make a mental note so that you can relay that information to first responders or nursing staff when the patient is transferred to definitive care. It’s vitally important to remember in your training with tourniquets to recheck the device after each movement of the patient. If you drag someone to cover, recheck. Once you transfer the patient to a vehicle for transport, recheck. Moving the patient onto a gurney or hospital bed, recheck. The device will do its job, but it’s your job to make sure that you’re vigilant in making sure the bleeding has stopped, no matter the environment. TOURNIQUET TYPES Below are a few examples from various manufacturers. www.narescue.com/combat-application-tourniquet-c-a-t.html CAT: The Combat Application Tourniquet (CAT) comprises a composite black plastic windlass, (blue in the training version) a nylon strap, and writable timestamp to record time of use, which also doubles to secure the windlass. The CAT tourniquet is endorsed by Tactical Combat Casualty Care (TCCC) and is the U.S. Army’s tourniquet of choice. The only drawback to the CAT is that its use is limited to adults — it doesn’t work well for small kids or dogs. The only issues we have personally seen with the CAT is the longevity of the plastic windlass. Stress cracks have been seen in the windlass after extended periods of training and being exposed to multiple Arizona summers. The CAT also comes in a rescue version, the main difference being the color — high-visibility rescue orange for civilian and hospital settings. www.tacmedsolutions.com/SOF-Tourniquet-Gen-4 SOF-T: Special Operation Forces Tactical Tourniquet, currently in its fourth iteration, the Gen 4 has a 1½-inch strap that provides a wider compression surface area, adding more arterial compression. Some additional features include a retention clip, making one-handed application a breeze, and a 5.5-inch windlass made of aluminum bar stock, meaning it will hold up to harsh environments like sitting in your car during the hot summer months. Arizona firefighters have trained using this device for years without incident. It has been shown to secure to patients extremely well due to the triangular latch that locks onto the groove in the windlass without loosening. Even after dragging patients over 100 yards, no loosening was seen. It’s also TCCC approved. ratsmedical.com/collections/rats-tourniquets/products/rats-gen-2-black RATS: Rapid Application Tourniquet System (RATS). Marketed as the fastest tourniquet available, it’s made of a solid elastic core and a metal cleat that secures the device. It’s a simple yet effective device that works on adults, dogs, and small children. It’s suggested by the manufacturer that the tourniquet be kept in the plastic packaging until use, which hinders the concept of training unless you purchase more than one. In a study conducted in 2016, the RATS resulted in greater blood loss and slower application time when compared to the CAT tourniquet (Gibson, et al., 2016) — the test didn’t specify what type of training the participants were given prior to the test. We’ve seen that the RATS does take more training to become proficient, yet is much more compact and can be used on K9s. www.rescue-essentials.com/swat-t-tourniquet-black-or-orange SWAT-T: Stretch, Wrap, and Tuck (SWAT-T). This particular one is marketed as being one-third the cost and weighing less than other tourniquets. The SWAT-T is made of a hypo-allergenic poly-isopropylene material. It’s more versatile than most, as the device can be used as a tourniquet, pressure dressing, or elastic bandage. There have been some first responders who’ve had issues getting a “bite” on the tourniquet with one-handed application, especially when the tourniquet is wet. But how could this ever happen when there’s a few pints of blood or sweat flying around? Also, it’s important to preplan the tucking process by putting a twist in the last wrap to ensure you can secure the device. It’s extremely important to recheck the integrity of these tourniquets when moving patients, especially if it has been applied to the leg and you’re dragging the unfortunate party. We’ve personally experienced cases where after moving patients in training, the device loosened. Conclusion Remember, a big part of being able to save a life and stop bleeding in yourself or another is proper training, which will give you the confidence to act in a chaotic event. Whichever tourniquet you decide must be applied in the right context, in the proper location, and with the proper amount of pressure in order to occlude blood flow. About the Author Aaron Adams is a Captain in one of the busiest fire departments in the Southwest. 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