What do the people who transport trauma patients know about tourniquets?

BACKGROUND: The primary study objectives were to gather information concerning the tourniquet knowledge, experience, training, protocols, preferences, and equipment of civilian prehospital providers. METHODS: This is a survey of 151 prehospital care providers. RESULTS: Survey respondents included 27 basic, 1 intermediate, and 75 paramedic emergency medical technicians; 1 registered nurse; 4 firefighters without medical certifications; 2 respondents not yet certified; and 1 respondent not listing certifications. Respondents had 2 months to 40 years of experience and came from emergency medical services in communities of 101 to 206,688 residents located 10 minutes to 103 minutes from a Level 1 or 2 trauma center. Twenty-five had used tourniquets: 5 in military and 22 in civilian settings. Civilian tourniquets were most frequently used for motor vehicle- then farm- and manufacturing-related injuries with severe bleeding. Tourniquet knowledge was poor for all groupings (with or without tourniquet experience, military experience, all certifications, all years of experience): 91% did not understand that wider tourniquets require less pressure for arterial occlusion, 69% did not know that stopping venous flow without arterial is harmful, and 37% did not know the correct tourniquet locations for distal limb injuries. Of the 81 on a service and without military experience, 44 had received any tourniquet training; 14 of the 44 had commercial emergency tourniquet access, and 27 indicated their service had a tourniquet protocol. Of the 37 on a service with no tourniquet training, 5 had access to a commercial emergency tourniquet, and 5 indicated their service had a tourniquet protocol. CONCLUSION: Civilian prehospital providers encounter situations for tourniquet use, but many do not know information important for optimal tourniquet use. Therefore, if surgeons want civilian prehospital care to include the use of effective, arterial flow occluding tourniquets at appropriate limb locations, they need to communicate with their emergency medical service providers concerning tourniquet knowledge, training, protocols, and appropriate equipment.

Tourniquets and occlusion: the pressure of design.

UNLABELLED: Nerve injuries result from tourniquet pressure. The objective was to determine arterial occlusion and completion pressures with the 3.8-cm-wide windlass Combat Application Tourniquet (CAT) and the 10.4-cm-wide Stretch, Wrap, and Tuck Tourniquet (SWAT-T). METHODS: Sixteen volunteers self-applied and had tourniquets applied to their thighs and arms (CAT and SWAT-T, random order, then blood pressure cuffs). RESULTS: Occlusion (Doppler signal elimination) pressures were higher than predicted (p < 0.0001), highest with the CAT (p < 0.0001), and often lower than completion pressures (completion median, range: CAT 360, 147-745 mm Hg; SWAT-T 290, 136-449 mm Hg; cuff 184, 108-281 mm Hg). Three CAT thigh and 9 CAT arm completion pressures were >500 mm Hg. Pressure decreases and occlusion losses occurred over 1 minute (pressure decrease: CAT 44 ± 33 mm Hg; SWAT-T 6 ± 8 mm Hg; cuff 14 ± 19 mm Hg; p < 0.0001; loss/initially occluded: CAT 17 of 61, SWAT-T 5 of 61, cuff 40 of 64, p < 0.01). CAT pressures before turn did not have a clear relationship with turns to occlusion. CONCLUSIONS: Limb circumference/tourniquet width occlusion pressure predictions are not good substitutes for measurements. The wider SWAT-T has lower occlusion and completion pressures than the CAT. Decreases in muscle tension lead to decreases in tourniquet pressure, especially with the nonelastic CAT, which can lead to occlusion loss.

Stretch and wrap style tourniquet effectiveness with minimal training.

UNLABELLED: The objective was to determine if proper application of the Stretch, Wrap, and Tuck Tourniquet (SWAT-T) would stop arterial flow and would occur with minimal training. METHODS: Fifteen undergraduates watched a 19 second video three times, practiced twice, and applied the tourniquet to volunteers at 10 locations: 3 above the elbow or knee and 2 below. RESULTS: Successful occlusion (60 second Doppler signal elimination) was more frequent than proper stretch (96 versus 75), more frequent on arms than legs (59 versus 37), and achieved before completed application (16 +/- 8 versus 33 +/- 8 seconds; each p < 0.05). Proper stretch (correct alteration of shapes printed on the tourniquet) was more frequent on legs than arms (30 versus 45; p <0.05). Applications were rated Easy (101), Challenging (37), Difficult (12) with discomfort None (53), Little (62), Moderate (34), Severe (1). The 8 appliers with <70% proper stretch rates received 10 minutes additional training and then retested at mid upper arm, mid-thigh, and below knee (24 applications) for improved proper stretch and occlusion (5 versus 18 and 10 versus 20; p < 0.01). CONCLUSIONS: Proper application of the SWAT-T is easy and can stop extremity arterial flow but requires some training for many appliers.

Lighting did not affect self-application of a stretch and wrap style tourniquet.

UNLABELLED: The objective was to determine the effects of darkness on self-application of a stretch and wrap style tourniquet. METHODS: Following training and practice, 15 volunteers self-applied the Stretch, Wrap, and Tuck-Tourniquet (SWAT-T) to their leg, thigh, dominant forearm, and dominate arm. Proper application in lighted conditions was followed by the same applications in darkness. Proper stretch was determined by alteration of shapes printed on the tourniquet. RESULTS: High rates of proper application and successful arterial occlusion (60 second Doppler signal elimination) occurred in darkness just as in lighted conditions (darkness: 56 proper and 60 successful of 60 applications, lighted: 57 proper and 53 successful of 60 applications). Lighting did not affect ease of application or discomfort. Males (8) and females (7) were similarly successful. Lower limb applications were predominantly rated easy (51 of 60). Upper limb applications had fewer easy ratings (15 easy, 32 challenging, 13 difficult ratings). Arterial occlusion took < 60 seconds in 112 of 113 successful applications; completion took < 60 seconds in 88 of all 120 applications. Upper limb applications took longer for completion. CONCLUSIONS: The SWAT-T stretch and wrap style tourniquet can be self-applied properly even in darkness. When properly applied, it can stop limb arterial flow.