Authors: Andrew D. Fisher and Will G.
With the increase in Active Violent Incidents (AVIs) over the last few years and the shared lessons learned (LL) from the U.S. and Canadian militaries’ experience in Afghanistan and Iraq, there has been an explosion of life-saving devices hitting the market. Nothing has become a larger issue than hemorrhage control. Hemorrhage is the leading cause of death in both the civilian and military setting. It also happens to be one of the easiest to treat. Manual pressure has been shown to be as quick and effective in a manikin model for junctional hemorrhage as several commercially available products that are currently being used by the U.S. Army.1 However, it is the resurgence of the extremity tourniquet (TQ) that has saved thousands of lives. The Committee on Tactical Combat Casualty Care (CoTCCC) has thoroughly studied and approved of two TQs for use in combat, 1) the Combat Application Tourniquet® (C-A-T) (North American Rescue, Greer, SC) (Figure 1) and 2) the SOF Tactical-Tourniquet Wide (SOF®TT-W) (Tactical Medical Solutions, Anderson, SC). Their civilian counterpart the Committee on Tactical Emergency Casualty Care (C-TECC) follows similar guidelines.
Figure 1 Combat Application Tourniquet® (CAT)
In response to AVIs, groups and initiatives like the Hartford Consensus, Stop The Bleed, and C-TECC have called for more bystanders training in hemorrhage control.2 Many of these are successful and are being taught using similar if not the same TQs recommended by the CoTCCC and C-TECC. However, there is still an overall lack of uniform guidelines for TQ application3, which may be cause for inadequate TQs being used throughout the United States.
Figure 2 SOF® Tactical Tourniquet Wide (SOFT-TW)
There are several commercially available TQs being sold that do not have scientific data to support its effectiveness or are being marketed in a manner that has the appearance of being recommended by such groups as the CoTCCC. Still others promote the use of improvised TQs. There is evidence to support the use of improvised TQs, when they are properly applied.4,5 Though, other data suggest that improvised TQs are not nearly effective as commercially available TQs.4,6 This may be for any number of reasons. A vital reason is the inverse relationship between the TQ width and the pressure needed to stop arterial bleeding. Many improvised TQs and other commercially available TQs simply do not have the ability to stop the arterial hemorrhage due to this width/pressure relationship. Pneumatic tubing or other elastic/rubber material was a popular TQ in World War II and can be effective. Nevertheless, data suggests that they may inadequately occlude arterial bleeding and only stop venous bleeding, both of which can worsen hemorrhage and outcomes.7 They can also be extremely painful and pressure difficulties can result in excessive pressure.8 In the event a novice applies a rubber TQ, will they be able to apply it in concentric wraps to ensure there is adequate pressure to stop arterial bleeding?
More recent anecdotal data from the Boston bombing found that that six of the rubber and improvised type TQs had to be replaced with C-A-Ts.9 Furthermore, the most common EMS tourniquet consisted of rubber tubing and a Kelly clamp.9
Figure 3 Rubber Tubing and Kelly Clamp
The idea of one-handed tourniquets are often marketed as a simple solution in the case you have one healthy extremity. Again, data suggests, it is difficult to employ with varying degrees of success in stopping arterial blood flow.10,11 Finally, the American College of Surgeons Committee on Trauma, recommended against “use of narrow, elastic, or bungee-type devices.”7
Figure 4 Stretch-Wrap-And-Tuck Tourniquet® (SWAT-T)
Medical endorsements of a product are not equivalent to scientific evidence of its effectiveness and can often be misleading for the bystander or novice. It must be understood that, first and foremost, tactical medicine is medicine. This means it is governed by conventional practice for implementing the employment of new equipment. The standard of care in modern medicine is built on a foundation of good evidence and scientific analysis. This is called Evidence Based Medicine (EBM). In the broad strokes, a new medicine, medical device or technique must be tested in a research or laboratory setting before being used on actual patients or casualties. If an acceptable level of efficacy can be established in these controlled settings then patient trials are attempted to gather data in real world applications. This data is analyzed, collated and studied to examine the success or failure of the drug, device, technology or technique. If all goes as planned a new standard of care is accepted by the medical community. If there is no improvement over the existing standard of care, then the idea is usually shelved until some innovation takes place. If there is a lack of positive outcomes than the existing treatments, then the findings are published as a warning to the industry. Medical professionals used EBM to compliment clinical judgment and common sense. Tactical medicine is no different. Tactical operations require a tiered medical response centered on matching an appropriate intervention to the level of threat and gear available. The CoTCCC and C-TECC guidelines are based in science to promote a high standard of care within this specific environment.
Figure 5 Rapid Application Tourniquet System (RATS)
Clinicians will not prescribe a new medication with a proper monogram to include understanding the possible side effects and adverse effects. The same goes for new technology and techniques. No medical professional would use an unproven medical device as part of his or her regular practice. The outcomes can be unpredictable. This could be considered malpractice and negligence. Again, there is no difference between tactical medicine and clinical medicine.
So, what does this mean to the bystander or non-medic that wants to carry first-aid gear including a tourniquet on their person? Simple, your choices of medical devices (aka tourniquet) must be based on science and evidence; not dogmatic brand loyalty or slavish following of tactical fashion icons. Even with CoTCCC approved TQs, there are many instances where TQs are not applied correctly.12 Why would one believe non-TCCC recommended TQs could be applied correctly to stop arterial hemorrhage?
Recently, two non-TCCC TQs were evaluated against the C-A-T. The Rapid Application Tourniquet System (RATS) (Figure 5) and the Tactical Mechanical Tourniquet (TMT™) (Figure 6) did not show any improvement over the CAT, and further, the RATS resulted in greater blood loss and slower application time when compared to the C-A-T.13 Both the RATS and TMT were able to stop arterial hemorrhage in the manikin model, but were not shown to be more effective or superior to the C-A-T. It should be noted that these evaluations were completed under controlled laboratory conditions and not in an austere or tactical setting.
Figure 6 Tactical Mechanical Tourniquet (TMT™)
Additionally, a wider, but still elastic type TQ called the Stretch-Wrap-And-Tuck Tourniquet® (SWAT-T) (Figure 4) has been evaluated over the last few years. There appears to be some advantage to using this TQ on distal limbs when compared to the C-A-T as it applies to occlusion pressure.14 However, this and similar studies have been completed by the same group of researchers and in the same lab.15,16 While SWAT-T website discusses case reports and life-saving uses, there is little discussion on its use in tactical or austere environments or if the SWAT-T can be applied one-handed.
That is not to say, there cannot a change of evidence. If any of the non-TCCC type TQs improve the design and are able to demonstrate their effectiveness and/or superiority, with an endorsement from CoTCCC/C-TECC, then there is no reason to not support their use.
Would you want your paramedics or doctors working on your family to use a device that has questionable effect? Of course not.
Would you go into battle with an unproven weapon? Not a chance. So, why would you carry an inferior tourniquet to use on yourself or your family?
Why leave your decision in the life-saving equipment you carry to the judgment of a misleading brand ambassador or snazzy social media campaign? There is only one logical answer. Follow the evidence. Carry a proven tourniquet with proven results in combat and at home.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, the Department of Defense, Texas A&M College of Medicine, or the Canadian Armed Forces.
Andrew D. Fisher is a PA in the USAR and a second-year medical student. He has extensive experience with point-of-injury care and tactical medicine.
Will G is a CCPA with a long military background as an infantryman, infantry NCO, combat medic, and Physician Assistant. He has multiple deployments including the Balkans, Afghanistan, Caribbean and domestic operations.
- Kragh JF, Mann-Salinas EA, Kotwal RS, et al. Laboratory assessment of out-of-hospital interventions to control junctional bleeding from the groin in a manikin model. Am J Emerg Med. 2013;31(8):1276-1278.
- Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole Community Approach to Reducing Mortality From Active Violent Incidents. J Spec Ops Med. 2015;15(3):46-53.
- Ramly E, Runyan G, King DR. The state of the union: Nationwide absence of uniform guidelines for the prehospital use of tourniquets to control extremity exsanguination. J Trauma Acute Care Surg. 2016;80(5):787-791.
- Stewart SK, Duchesne JC, Khan MA. Improvised tourniquets: Obsolete or obligatory? J Trauma Acute Care Surg. 2015;78(1):178-183.
- Swan KG, Jr., Wright DS, Barbagiovanni SS, Swan BC, Swan KG. Tourniquets revisited. J Trauma. 2009;66(3):672-675.
- Altamirano MP, Kragh Jr JF, Aden 3rd JK, Dubick MA. Role of the windlass in improvised tourniquet use on a manikin hemorrhage model. J Spec Ops Med. 2015;15(2):42-46.
- Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163-173.
- Walters TJ, Mabry RL. Issues Related to the Use of Tourniquets on the Battlefield. Mil Med. 2005;170(9):770-775.
- King DR, Larentzakis A, Ramly EP, Boston Trauma C. Tourniquet use at the Boston Marathon bombing: Lost in translation. J Trauma Acute Care Surg. 2015;78(3):594-599.
- Wenke JC, Walters TJ, Greydanus DJ, Pusateri AE, Convertino VA. Physiological Evaluation of the U.S. Army One-Handed Tourniquet. Mil Med. 2005;170(9):776-781.
- Calkins D, Snow C, Costello M, Bentley TB. Evaluation of possible battlefield tourniquet systems for the far-forward setting. Mil Med. 2000;165:379-384.
- King DR, van der Wilden G, Kragh Jr JF, Blackborne LH. Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War. J Spec Ops Med. 2012;12(4):33-38.
- Gibson R, Housler GJ, Rush S, Aden 3rd JK, Kragh Jr JF, Dubick MA. Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model. J Spec Ops Med. 2016;16(1):29-35.
- Wall PL, Sahr SM, Buising CM. Different Width and Tightening System Emergency Tourniquets on Distal Limb Segments. J Spec Ops Med. 2015;15(4):28-38.
- Wall PL, Duevel DC, Hassan MB, Welander JD, Sahr SM, Buising CM. Tourniquets and occlusion: the pressure of design. Mil Med. 2013;178(5):578-587.
- Wall PL, Welander JD, Singh A, Sidwell RA, Buising CM. Stretch and Wrap Style Tourniquet Effectiveness With Minimal Training. Military Medicine. 2012;177(11):1366-1373.