Missing expectations: Windlass tourniquet use without formal training yields poor results

Abstract

BACKGROUND Despite significant attempts to educate civilians in hemorrhage control, the majority remain untrained. We sought to determine if laypersons can successfully apply one of three commercially available tourniquets; including those endorsed by the United States Military and the American College of Surgeons. METHODS Preclinical graduate health science students were randomly assigned a commercially available windless tourniquet: SAM XT, Combat Application Tourniquet (CAT), or Special Operation Forces Tactical Tourniquet (SOFT-T). Each was given up to 1 minute to read package instructions and asked to apply it to the HapMed Leg Tourniquet Trainer. Estimated blood loss was measured until successful hemostatic pressure was achieved or simulated death occurred from exsanguination. Simulation survival, time to read instructions and stop bleeding, tourniquet pressure, and blood loss were analyzed. RESULTS Of the 150 students recruited, 55, 46, and 49 were randomized to the SAM XT, CAT, SOFT-T, respectively. Mean overall simulation survival was less than 66% (65%, 72%, 61%; p = 0.55). Of survivors, all three tourniquets performed similarly in median pressure applied (319, 315, and 329 mm Hg; p = 0.54) and median time to stop bleeding (91, 70, 77 seconds; p = 0.28). There was a statistical difference in median blood loss volume favoring SOFT-T (SAM XT, 686 mL; CAT, 624 mL; SOFT-T, 433 mL; p = 0.03). All 16 participants with previous experience were able to successfully place the tourniquet compared with 81 (62%) of 131 first-time users (p = 0.008). CONCLUSION No one should die of extremity hemorrhage, and civilians are our first line of defense. We demonstrate that when an untrained layperson is handed a commonly accepted tourniquet, failure is unacceptably high. Current devices are not intuitive and require training beyond the enclosed instructions. Plans to further evaluate this cohort after formal “Stop the Bleed” training are underway.

The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation

“…A recent study of military cadets with three different tourniquets demonstrated 35%, 68%, and 73% success in obtaining hemorrhage control. 9 Our previous studies on tourniquet training and usage efficacy found similar success rates in those without formal training (65%, 72%, and 61%) 10 and 1 month after formal Stop The Bleed Training (63%, 70%, and 58%) using the same tourniquets. 11 There are a number of studies evaluating tourniquet application in simulated settings, 8,12,13 but these investigations do not represent the interaction between a first responder and actively hemorrhaging patient.…”

Stopping extremity hemorrhage: More than just a tourniquet

“…As with many advancements in trauma care, lessons learned from the military environment have been translated to the civilian setting, and the same can be said about tourniquet use. The windlass combat-type application tourniquet is most commonly used, but it does require formal training to be effective [ 4 ]. Tourniquets can be applied in the prehospital setting, the emergency department, or the operating theater, and time of application must be recorded.…”

Development and Characterization of a Self-Tightening Tourniquet System

“…While TKTs are critical, life-saving medical devices, they can be challenging to apply properly [6,7]. For extremity TKTs, cases of incorrect application or insufficient tightening occur, thus failing to control bleeding in a timely fashion, particularly among untrained users [7]. Even among trained personnel, TKT application can be variable depending on experience and skill level [6].…”