Franz, Walter B.

Abstract Objective The American College of Surgeons (ACS) encourages clinicians to provide training to laypeople on tourniquet application. It is unclear whether clinicians are confident in their abilities and equipped with adequate knowledge, skills, and resources. This study aimed to determine surgical trainee knowledge and attitudes regarding tourniquet application and compare the effectiveness of instructions. Methods Thirty surgical trainees performed a tourniquet application simulation using a Combat Application Tourniquet and one of the three instructions sets developed by ACS, Department of Homeland Security, and the tourniquet manufacturer. Participants reported tourniquet knowledge, attitudes, and confidence and discussed the instructions. One instruction set was updated and compared to the original set with 20 new trainees. Results Participants with ACS instructions passed the greatest number of steps (p < 0.01) and completed the task significantly faster compared to those with manufacturer instructions (p < 0.01). Participants (80%) reported favorable views toward tourniquets but 30–60% did not align with to ACS tourniquet guidelines. Focus group participants suggested revisions to the ACS instructions. Comparing the original and revised version of these instructions resulted in no significant improvements. Conclusions ACS instructions provide guidance; however, improvements to tourniquet instruction are needed for success in controlling exsanguinating hemorrhage.

AbstractBackgroundCurrent military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models.MethodsFive different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet – Wide), SWAT-T (Stretch Wrap and Tuck – Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25” to 16.5”. Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable).ResultsIn both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75” circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25” and 15.5” circumference PVC pipes (age 7–12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes.DiscussionThe current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.

The American College of Surgeons (ACS) and the Department of Homeland Security (DHS) encourage the use of tourniquets as part of the “Stop the Bleed” campaign. Both have provided instructions for layperson tourniquet application in order to save the life of a hemorrhaging trauma victim. This study sought to compare the impact of using ACS and DHS instructions with manufacturer-provided instructions for the completion of simulated tourniquet application steps. Thirty surgical trainees completed a simulated tourniquet application with one of the three instruction sets. Their completion time and success for each step were measured. Participants that received ACS instructions failed the fewest number of steps (p < 0.01) and completed the task faster (Mean (SD) = 70 (33) seconds) compared to those with the manufacturer-provided instructions (p < 0.01). Tourniquet instruction sets need to be refined in order to optimize the success rate of just-in-time guidance for tourniquet application.