A low-cost, DIY tourniquet simulator with built-in self-assessment for prehospital providers in Guatemala city.

BACKGROUND: Hemorrhage is the leading cause of preventable death after trauma. In high-income countries first responders are trained in hemorrhage control techniques but this is not the case for developing countries like Guatemala. We present a low-cost training model for tourniquet application using a combination of virtual and physical components. METHODS: The training program includes a mobile application with didactic materials, videos and a gamified virtual reality environment for learning. Additionally, a physical training model of a bleeding lower extremity is developed allowing learners to practice tourniquet application using inexpensive and accessible materials. Validation of the simulator occurred through content and construct validation. Content validation involved subjective assessments by novices and experts, construct validation compared pre-training novices with experts. Training validation compared pre and post training novices for improvement. RESULTS: Our findings indicate that users found the simulator useful, realistic, and satisfactory. We found significant differences in tourniquet application skills between pre-training novices and experts. When comparing pre- and post-training novices, we found a significantly lower bleeding control time between the groups. CONCLUSION: This study suggests that this training approach can enhance access to life-saving skills for prehospital personnel. The inclusion of self-assessment components enables self-regulated learning and reduces the need for continuous instructor presence. Future improvements involve refining the tourniquet model, validating it with first-responder end users, and expanding the training program to include other skills.

Tourniquet self-application assessment in cold weather conditions.

BACKGROUND: Our study aimed to assess the ability of nonmedical civilians to self-apply extremity tourniquets in cold weather conditions while wearing insulating technical clothing after receiving basic training. METHODS: A field study was conducted among 37 voluntary participants of an expedition party to the Spanish Antarctic base. The researchers assessed the participant's ability to self-apply five commercial extremity tourniquets (CAT, OMNA, RMT, SWAT-T, and RATS) over cold-weather clothing and their achieved effectiveness for vascular occlusion. Upper extremity self-application was performed with a single-handed technique (OHT), and lower extremity applying a two-handed technique (THT). Perceptions of self-application ease mean values ± standard deviation (SD) were compared by applying a 5% statistical significance threshold. Frequency count determined tourniquet preference. RESULTS: All the tested ETs, except the SWAT-T, were properly self-applied with an OHT, resulting in effective vascular occlusion in the upper extremity. The five devices tested were self-applied correctly in the lower extremities using THT. The ratcheting marine-designed OMNA ranked the highest for application easiness on both the upper and lower extremities, and the windlass CAT model was the preferred device by most participants. CONCLUSIONS: Civilian extremity tourniquet self-application on both upper and lower extremities can be accomplished in cold weather conditions despite using cold-weather gloves and technical clothing after receiving brief training. The ratcheting marine-designed OMNA ranked the highest for application ease, and the windlass CAT model was the preferred device.

A randomized controlled trial: Comparison of one-per-mil tumescent technique and tourniquet in surgery for burn hand contracture in creating clear operative field and assessment of functional outcome.

BACKGROUND: This study aims to compare the use of one-per-mil tumescent solution (a mixture of epinephrine and 0.2% lidocaine in a ratio of 1:1,000,000 in normal saline solution) and tourniquet to create clear operative fields and to evaluate the functional outcomes after post burn hand contracture surgery. METHODS: The subjects of this randomized controlled trial were divided into one-permil tumescent technique and tourniquet group for a similar surgical procedure. Three independent assessors evaluated the clarity of the operative fields through recorded videos for the first 15 min and the first 10-minute of each hour of the surgery. Functional outcome was evaluated at least three months postoperatively using total active and passive motion (TAM and TPM) of each digit. Malondialdehyde (MDA) and tumor necrosis factor alpha (TNF-α) were tested during baseline (5 min before the procedures), ischemia phase, and reperfusion phase (a phase when the blood flow returned to the tissue). RESULTS: 35 subjects were included in this study: 17 in the tumescent group and 18 in the tourniquet group. We found a significant difference in the clarity of operative field between tumescent and tourniquet groups, 5 vs 35 bloodless operative fields, respectively (p < 0.05). TAM and TPM of each digit before surgery and 3 months postoperatively showed no significant difference between both groups (p > 0.05). Furthermore, we found no difference in MDA and TNF-α levels between both groups at their respective phases. CONCLUSIONS: The use of one-per-mil tumescent technique does not replace tourniquet use to create bloodless operative fields in burned hand contracture surgery. However, the postoperative functional results were similar in both groups showing that tumescent technique can be used as an alternative to tourniquet without compromising outcomes. The MDA and TNF-α examinations do not provide conclusive outcomes regarding ischemia and reperfusion injury.

A reproducible method for biochemical, histological and functional assessment of the effects of ischaemia-reperfusion syndrome in the lower limbs.

Current methodology described to mimic lower limb ischaemia-reperfusion injury (LL-IRI) does not accurately define the procedures and pressures exerted to induce and maintain ischaemia. In this piece of work, we propose a well-defined and detailed rat model that simulates the conditions established in clinical practice guidelines for tourniquet application and allows us to test treatments that aim to prevent/reduce LL-IRI. Eighty-six male WAG/RijHsd rats were subjected to hind limb IRI (LL-IRI), using a mechanical system applying a 1 kg tension to induce and maintain ischemia for 2 or 3 h, and assessed the damage caused by reperfusion at biochemical and muscular levels at different time points. At the biochemical level, both 2 and 3 h of ischemia induced changes (except for electrolyte levels); 3 h of ischemia induced greater changes in specific markers of muscular damage: creatine kinase (CK) and lactate dehydrogenase (LDH). At the histopathological level, 3 h of ischemia and 24 h of reperfusion was associated with an increase in hind limb girth, cross-sectional area, and weight and presence of neutrophils, as well as histological damage in more than 60% of muscle fibres. Our model allows to reliably reproduce the damage associated with the use of a pneumatic tourniquet. CK and LDH, as well as measures of tissue damage, allow to define and characterize the response to LL-IRI-related damage. A period of 3 h of ischemia followed by 3 h of reperfusion caused only local damage but showed greater sensitivity to detect differences in future studies on prophylactic treatments against LL-IRI.

Mechanical Assessment of Tissue Properties During Tourniquet Application.

INTRODUCTION: Successful tourniquet application increases survival rate of exsanguinating extremity hemorrhage victims. Tactile feedback during tourniquet application training should reflect human tissue properties in order to increase success in the field. This study aims to understand the mechanical properties of a human limb during tourniquet application. METHOD: Six cadaveric extremities-three uppers and three lowers-were tested from three body mass index groups: low (<19) healthy (19-24), and overweight (>24). Each specimen donned with a tourniquet and mounted to a servo-hydraulic testing machine, which enabled controlled tightening of the tourniquet while recording the tourniquet tension force and strap displacement. A thin-film pressure sensor placed between the specimen and the tourniquet recorded contact pressure. Each limb was tested with the tourniquet applied at two different sites resulting in testing at the upper arm, forearm, thigh, and shank. RESULTS: The load displacement curves during radial compression were found to be nonlinear overall, with identifiable linear regions. Average contact pressure under the tourniquet strap at 200N and 300N of tension force was 126.3 (σ = 41.2) mm Hg and 205.3 (σ = 75.3) mm Hg, respectively. There were no significant differences in tissue stiffness or contact pressure at 300N of tension force between limb (upper vs. lower) or body mass index. At 200N of tension, the upper limb had significantly higher contact pressure than the lower limb (P = 0.040). Relative radial compression was significantly different between upper (16.74, σ = 4.16%) and lower (10.15, σ = 2.25%) extremities at 200N tension (P = 0.005). CONCLUSIONS: Simulation of tissue compression during tourniquet application may be achieved with a material exhibiting elastic properties to mimic the force-displacement behavior seen in cadaveric tissue or with different layers of material. Different trainers for underweight, healthy, and overweight limbs may not be needed. Separate tourniquet training fixtures should be created for the upper and lower extremities.

Economic impact of anaesthesia methods used in hand surgery: Global costs and operating room's throughput.

PURPOSE: Recently, local anaesthesia has become popular among hand surgeons. We hypothesized that using the "wide awake local anaesthesia no tourniquet" (WALANT) approach would result in lower global costs and in an increase in the operating room (OR)'s efficiency. METHODS: All cases of carpal tunnel (CTR) and trigger finger releases (TFR) performed over 2016 and 2017 were divided into four groups, following which the anaesthesia method was used. Total OR occupation time, surgical time and the "all but surgery" time were analysed. A common minimum bill per anaesthesia was generated. RESULTS: WALANT or local anaesthesia and tourniquet increase the OR's throughput by having shorter operation room occupation times than other methods (17.5-33%). Costs of the two procedures are reduced by 21-31% when using local anaesthesia methods. CONCLUSION: Preferring those techniques for CTR and TFR has a notable beneficial impact on the costs and on the OR's efficiency. This effect is more evident on short surgical procedures. LOE: Level of evidence III, economic analysis.

Stop the Bleed: An Interprofessional Community Service Learning Project Assessing the Efficacy of Pharmacist-Led Hemorrhage Control Education for Laypersons.

OBJECTIVES: Stop the Bleed (STB) is a national initiative that provides lifesaving hemorrhagic control education. In 2019, pharmacists were added as health-care personnel eligible to become STB instructors. This study was conducted to evaluate the efficacy of pharmacist-led STB trainings for school employees in South Texas. METHODS: Pharmacist-led STB trainings were provided to teachers and staff in Laredo, Texas. The 60-min trainings included a presentation followed by hands-on practice of tourniquet application, wound-packing, and direct pressure application. Training efficacy was assessed through anonymous pre- and postevent surveys, which evaluated changes in knowledge, comfort level, and willingness to assist in hemorrhage control interventions. Student volunteers (predominantly pharmacy and medical students) assisted in leading the hands-on portion, providing a unique interprofessional learning opportunity. RESULTS: Participants with previous training (N = 98) were excluded, resulting in a final cohort of 437 (response rate 87.4%). Compared with baseline, comfort level using tourniquets (mean, 3.17/5 vs 4.20/5; P < 0.0001), opinion regarding tourniquet safety (2.59/3 vs 2.94/3; P < 0.0001), and knowledge regarding tourniquets (70.86/100 vs 75.84/100; P < 0.0001) and proper tourniquet placement (2.40/4 vs 3.15/4; P < 0.0001) significantly improved. CONCLUSIONS: Pharmacist-led STB trainings are efficacious in increasing school worker knowledge and willingness to respond in an emergency hemorrhagic situation.

Relationship Between Interface Pressures and Pneumatic Cuff Inflation Pressure at Different Assessment Sites of the Lower Limb to Aid Soft Exoskeleton Design.

OBJECTIVE: The aim was to develop a means of predicting interface pressure from cuff inflation pressure during circumferential compression at the lower limb, in order to inform the design of soft exoskeletons. BACKGROUND: Excessive mechanical loading of tissues can cause discomfort and soft tissue injury. Most ergonomic studies on exoskeletons are of interface pressure, but soft exoskeletons apply circumferential pressures similar to tourniquet cuffs by way of cuff inflation pressure. This study details the relationship between interface and cuff inflation pressures for pneumatic tourniquet cuffs. METHOD: Pneumatic cuffs of different widths were inflated to target pressures on (A) a rigid cylinder, (B) the dominant thigh and calf, and (C) knee of healthy participants standing still. Interface pressures were measured under the cuffs using a pressure-sensing mat. Average interface pressures were then compared to cuff inflation pressures. The influence of cuff width, cuff inflation pressure, and participants' anthropometric data on pressure transmission was assessed. RESULTS: A strong linear relationship between cuff inflation pressures and interface pressures was observed. Interface pressures were generally higher than cuff inflation pressures. The efficiency of pressure transmission to the lower limb depended on assessment site, adipose tissue thickness, cuff size, cuff inflation pressure, and possibly limb circumference. Regression equations were developed to predict interface pressures at the thigh, calf, and knee. CONCLUSION: Interface pressures under pneumatic cuffs are influenced by the cuff size, cuff inflation pressure, and tissue compressibility. Predicted interface pressure from cuff inflation pressure and vice versa can be used to aid the design of soft exoskeletons.

Assessment of the Efficacy and Safety of a Novel, Low-Cost, Junctional Tourniquet in a Porcine Model of Hemorrhagic Shock.

INTRODUCTION: Commercially available junctional tourniquets (JTQs) have several drawbacks. We developed a low-cost, compact, easy to apply JTQ. The aim of this study was to assess the tourniquets' safety and efficacy in a swine model of controlled hemorrhage. MATERIALS AND METHODS: Five pigs were subjected to controlled bleeding of 35% of their blood volume. Subsequently, the JTQ was applied to the inguinal area for 180 minutes. Afterwards, the tourniquet was removed for additional 60 minutes of follow up. During the study, blood flow to both hind limbs and blood samples for tissue damage markers were repeatedly assessed. Following sacrifice, injury to both inguinal areas was evaluated microscopically and macroscopically. RESULTS: Angiography demonstrated complete occlusion of femoral artery flow, which was restored following removal of the tourniquet. No gross signs of tissue damage were noticed. Histological analysis revealed mild necrosis and infiltration of inflammatory cells. Blood tests showed a mild increase in potassium and lactic acid levels throughout the protocol. CONCLUSIONS: The tourniquet achieved effective arterial occlusion with minimal tissue damage, similar to reports of other JTQs. Subjected to further human trials, the tourniquet might be a suitable candidate for widespread frontline deployment because of its versatility, compactness, and affordable design.

Low-cost synthetic tourniquet training model. / Modelo sintético de baixo custo para treinamento do uso de torniquete.

OBJECTIVE: to present a low-cost model for bleeding control training with the use of a tourniquet and the results of the training evaluation. METHOD: low-cost and easy-to-purchase materials, such as upholstery foam, ethylene-vinyl acetate (EVA) sheet, plastic propulsion pump, saline container, water, school paint, serum equipment, rubber tubing for tourniquet, and a leg and an arm of a ghost mannequin, were used. In the model assembly, we created an active bleeding simulation system, which could only be controlled with the correct application of the tourniquet. The model was submitted to professional and academic evaluation. RESULTS: the model was similar to human anatomy, proved to be practical in the bleeding control training with the use of a tourniquet, and had low cost. CONCLUSION: the model for bleeding control training had excellent acceptability, was considered viable for educational purposes of tourniquet use, and had low cost.

OBJETIVO: apresentar um modelo de baixo custo para treinamento de controle de sangramento com o uso de torniquete e os resultados da avaliação do treinamento. MÉTODO: foram utilizados materiais de fácil aquisição e de baixo custo, como espuma de estofado, placa de etileno-acetato de vinila (EVA), bomba plástica de propulsão, recipiente de soro fisiológico, água, tinta escolar, equipos de soro, tubo de látex para garrote e manequins comerciais de perna e de braço. Na montagem, foi criado um sistema de simulação de sangramento ativo que só podia ser controlado com aplicação correta do torniquete. O modelo foi submetido à avaliação de profissionais e acadêmicos. RESULTADOS: o modelo teve semelhança com a anatomia humana, mostrou-se prático no treinamento da contenção de sangramento com uso de torniquete e teve baixo custo financeiro. CONCLUSÃO: o modelo para treinamento de controle de sangramento teve excelente aceitabilidade, foi considerado viável para fins educacionais do uso de torniquete e teve baixo custo.

Clinical Impact of Routine Complete Blood Counts Following Total Knee Arthroplasty.

BACKGROUND: Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA. METHODS: Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables. RESULTS: Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient). CONCLUSION: Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention.

Rubber tourniquet technique: A simple, safe, and cost-effective method of hepatic resection in neonates and infants.

BACKGROUND: Despite the improvements in patient care, understanding of surgical anatomy of liver and surgical techniques, liver resection is a high-risk procedure specifically in infants and neonates; whose blood volume is limited (80 ml/kg). This report shares the experience of hepatic resection with "Rubber tourniquet technique" in patients less than 6-months of age. METHODS: Hepatic resection in a 4-month-old pair of Conjoined twins with shared liver and a 3-day old baby with large Congenital Hepatoblastoma was performed using Penrose rubber drain as a tourniquet around the liver parenchyma to reduce blood loss. RESULTS: Blood loss was minimal (<20CC) and all the three babies survived the procedure without complications. CONCLUSION: Rubber tourniquet technique is simple, safe and cost-effective for liver resections in neonates and infants with hepatic lesions and separation of conjoined twins with shared liver and it can easily be employed in resource constraint settings.

Modelo sintético de baixo custo para treinamento do uso de torniquete / Low-cost synthetic tourniquet training model

RESUMO Objetivo: apresentar um modelo de baixo custo para treinamento de controle de sangramento com o uso de torniquete e os resultados da avaliação do treinamento. Método: foram utilizados materiais de fácil aquisição e de baixo custo, como espuma de estofado, placa de etileno-acetato de vinila (EVA), bomba plástica de propulsão, recipiente de soro fisiológico, água, tinta escolar, equipos de soro, tubo de látex para garrote e manequins comerciais de perna e de braço. Na montagem, foi criado um sistema de simulação de sangramento ativo que só podia ser controlado com aplicação correta do torniquete. O modelo foi submetido à avaliação de profissionais e acadêmicos. Resultados: o modelo teve semelhança com a anatomia humana, mostrou-se prático no treinamento da contenção de sangramento com uso de torniquete e teve baixo custo financeiro. Conclusão: o modelo para treinamento de controle de sangramento teve excelente aceitabilidade, foi considerado viável para fins educacionais do uso de torniquete e teve baixo custo.

ABSTRACT Objective: to present a low-cost model for bleeding control training with the use of a tourniquet and the results of the training evaluation. Method: low-cost and easy-to-purchase materials, such as upholstery foam, ethylene-vinyl acetate (EVA) sheet, plastic propulsion pump, saline container, water, school paint, serum equipment, rubber tubing for tourniquet, and a leg and an arm of a ghost mannequin, were used. In the model assembly, we created an active bleeding simulation system, which could only be controlled with the correct application of the tourniquet. The model was submitted to professional and academic evaluation. Results: the model was similar to human anatomy, proved to be practical in the bleeding control training with the use of a tourniquet, and had low cost. Conclusion: the model for bleeding control training had excellent acceptability, was considered viable for educational purposes of tourniquet use, and had low cost.

Design and implementation of the Western Pennsylvania regional Stop the Bleed initiative.

BACKGROUND: Hemorrhage is the leading cause of preventable death in trauma, and nearly 40% of prehospital deaths can be attributed to blood loss. The Stop the Bleed program provides a structured curriculum for teaching hemorrhage control and the use of bleeding control kits. To overcome implementation barriers and to achieve the goal of making education on bleeding control as common as cardiopulmonary resuscitation, widespread implementation with outreach to the public and law enforcement is necessary. METHODS: We provide a description and analysis of the implementation of a regional Stop the Bleed program, which includes a step-by-step guide to the design of this program provided as a template to guide attempts at large-scale Stop the Bleed program development. RESULTS: Combining the efforts of regional trauma and nontrauma centers as a hub-and-spoke design, a region covering four states, 72 counties, and 30,000 square miles was targeted. A total of 27,291 individuals were trained in a 21-month period including 3,172 trainers, 19,310 lay public, and 4,809 law enforcement officers. A total of 436 bleeding control kits were distributed to 102 public schools, and tourniquets were provided to 4,809 law enforcement officers. Program development and community outreach resulted in official recognition of the program by the Pennsylvania State Senate. CONCLUSIONS: With the use of a multicenter outreach program design with emphasis on law enforcement and public education while developing a train-the-trainer program, widespread and rapid dissemination of Stop the Bleed teaching is feasible. The general steps described in this manuscript may serve as a template for new or developing programs in other areas to increase the national exposure to Stop the Bleed. LEVEL OF EVIDENCE: Economic/Decision study, level IV.

Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit.

BACKGROUND: Noncompressible truncal hemorrhage (NCTH) after injury is associated with a mortality increase that is unchanged during the past 20 years. Current treatment consists of rapid transport and emergent intervention. Three early hemorrhage control interventions that may improve survival are placement of a resuscitative endovascular balloon occlusion of the aorta (REBOA), injection of intracavitary self-expanding foam, and application of the Abdominal Aortic Junctional Tourniquet (AAJT™). The goal of this work was to ascertain whether patients with uncontrolled abdominal or pelvic hemorrhage might benefit by the early or prehospital use of one of these interventions. METHODS: This was a single-center retrospective study of patients who received a trauma laparotomy from 2013 to 2015. Operative reports were reviewed. The probable benefit of each hemorrhage control method was evaluated for each patient based on the location(s) of injury and the severity of their physiologic derangement. The potential scope of applicability of each control method was then directly compared. RESULTS: During the study period, 9,608 patients were admitted; 402 patients required an emergent trauma laparotomy. REBOA was potentially beneficial for hemorrhage control in 384 (96%) of patients, foam in 351 (87%), and AAJT in 35 (9%). There was no statistically significant difference in the potential scope of applicability between REBOA and foam (ρ = .022). There was a significant difference between REBOA and AAJT (ρ < .001) and foam and AAJT™ (ρ < .001). The external surface location of signs of injury did not correlate with the internal injury location identified during laparotomy. CONCLUSION: Early use of REBOA and foam potentially benefits the largest number of patients with abdominal or pelvic bleeding and may have widespread applicability for patients in the preoperative, and potentially the prehospital, setting. AAJT may be useful with specific types of injury. The site of bleeding must be considered before the use of any of these tools.

Assessment of the Pneumatic Ischemia Technique Using the Limb Occlusion Pressure During Upper Limb Surgery.

PURPOSE: The purpose of our study was to evaluate effective ischemia and its associated complications using the limb occlusion pressure technique versus standard pneumatic ischemia technique. DESIGN: Single-centered randomized, controlled clinical trial. METHODS: One hundred sixty participants were randomized into two equal and parallel groups: (1) intervention group-LOP technique, and (2) control group-standard pneumatic ischemia technique. FINDINGS: Anesthetic incidences (need to administer analgesics for pain and/or hypnotics for anxiety) were similar in both groups. Statistically significant differences were observed for pain, hyperemia, and hospitalization, with higher values in the control group. Patients in the intervention group had, at 95% confidence, a 2.9 times greater chance of having optimal ischemia (assessed as 9 on the analog scale) than patients in the control group (odds ratio, 2.9; 95% confidence interval, 1.4 to 6.1). CONCLUSIONS: Intervention group patients had lower indexes of hyperemia, pain, and hospital stay.

Assessment of User, Glove, and Device Effects on Performance of Tourniquet Use in Simulated First Aid.

BACKGROUND: The effects of users, glove types, and tourniquet devices on the performance of limb tourniquet use in simulated first aid were measured. MATERIALS AND METHODS: Four users conducted 180 tests of tourniquet performance in eight glove groups compared with bare hands as a control. RESULTS: Among tests, 99% (n = 179) had favorable results for each of the following: effectiveness (i.e., bleeding control), distal pulse stoppage, and tourniquet placement at the correct site. However, only 90% of tests ended with a satisfactory result, which is a composite outcome of aggregated metrics if all (patient status is stable, tourniquet placement is good, and pressure is good) are satisfactory. Of 18 unsatisfactory results, 17 (94%) were due to pressure problems. Most of the variance of the majority of continuous metrics (time to determination of bleeding control, trial time, overall time, pressure, and blood loss) could be attributed to the users (62%, 55%, 61%, 8%, and 68%, respectively). Glove effects impaired and slowed performance; three groups (cold gloves layered under mittens, mittens, and cold gloves) consistently had significant effects and five groups (examination gloves, flight gloves, leather gloves, glove liners, and glove liners layered under leather gloves) did not. For time to bleeding control and blood loss, performance using these same three glove groups had worse results compared with bare hands by 26, 18, and 17 seconds and by 188, 116, and 124mL, respectively. Device effects occurred only with continuous metrics and were often dominated by user effects. CONCLUSION: In simulated first aid with tourniquets used to control bleeding, users had major effects on most performance metrics. Glove effects were significant for three of eight glove types. Tourniquet device effects occurred only with continuous metrics and were often dominated by user effects.

Assessment of Trainer Skill to Control Groin-Wound Bleeding: Use of Junctional Tourniquet Models on a Manikin.

BACKGROUND: The purpose of this study was to assess the skills of trainers using different junctional tourniquet models to control groin bleeding in a manikin. MATERIALS AND METHODS: In 204 assessments, 17 trainers used four junctional tourniquet models three times each to control simulated hemorrhage. The models included the Combat Ready Clamp (CRoC), Junctional Emergency Treatment Tool (JETT), Abdominal Aortic and Junctional Tourniquet (AAJT), and SAM Junctional Tourniquet (SJT). The criteria of assessment included effectiveness (i.e., control [yes-no]), time to stop bleeding, total blood loss, and bleeding rate. RESULTS: All uses were effective. By model, the results of mean blood loss and time to stop bleeding were different with varying levels of statistical significance: control was worst with the JETT and AAJT, moderate with the AAJT and SJT, and best with the SJT and CRoC. The means sharing a level were not significantly different, but a mean in more than one level was not different from itself. The composite outcome results were 90% good for CRoC and 67% good for JETT, whereas results for the SJT and AAJT were in between, and only the result of the CROC and JETT comparison was significant. The ease of use varied significantly; JETT was more difficult to use and all others were easier. The analysis attributed to the users 19% of the variance of results for time, 44% for blood loss volume, and 67% for bleeding rate. Most users preferred the SJT (53% before and 70% after assessment). CONCLUSION: Effectiveness was attained by all users with each of the four models of junctional tourniquet. The analysis demonstrated that up to 67% of the variance of performance results could be attributed to the users.