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BACKGROUND Civilians are often first-line responders in hemorrhage control; however, windlass tourniquets are not intuitive. Untrained users reading enclosed instructions failed in 38.2% of tourniquet applications. This prospective follow-up study replicated testing following Stop the Bleed (STB) training. MATERIALS AND METHODS One and six months following STB, first-year medical students were randomly assigned a windlass tourniquet with enclosed instructions. Each was given one minute to read instructions and two minutes to apply the windlass tourniquet on the TraumaFX HEMO trainer. Demographics, time to read instructions and stop bleeding, blood loss, and simulation success were analyzed. RESULTS 100 students received STB training. 31 and 34 students completed tourniquet testing at one month and six months, respectively. At both intervals, 38% of students were unable to control hemorrhage (P = 0.97). When compared to the pilot study without STB training (median 48 sec, IQR 33-60 sec), the time taken to read the instructions was shorter one month following STB (P

The American College of Surgeons Bleeding Control Course (B-Con) empowers bystanders with hemorrhage control skills to manage prehospital emergencies, but demonstrates poor skill retention. The point of care use of a free Stop the Bleed mobile phone application on the retention of hemorrhage control skills from the B-Con Course was explored.Convenience sample of college students previously trained in B-Con were randomized into mobile application (MA) or control groups. The use of a mobile application during a simulated emergency scenario with tourniquet and situational awareness skills was assessed. Wound packing skill retention without intervention was also assessed. Survey data allowed for comparison of participant perceptions of skills with actual performances.MA (n = 30) was superior to control (n = 32) in correct tourniquet application (62.5% versus 30.0%; P = 0.01) with longer placement times (163 sec versus 95 sec; P0.001) and in calling 911 (31.3% versus 3.3%, P = 0.004). Participants maintain inflated perceptions of their skills, but generally feel underprepared for a future bleeding emergency.Mobile apps improve tourniquet and situational awareness skills and may serve as potential aids to improve bystander hemorrhage control skills in real-time, but require further prospective investigation into its use.

Background and purpose - Tourniquet is widely used in orthopedic surgery to reduce intraoperative bleeding and improve visualization. We evaluated the effect of tourniquet application on peri- and postoperative cefuroxime concentrations in subcutaneous tissue, skeletal muscle, calcaneal cancellous bone, and plasma. The primary endpoint was the time for which the free cefuroxime concentration was maintained above the clinical breakpoint minimal inhibitory concentration (T > MIC) for Staphylococcus aureus (4 mu g/mL). Patients and methods - 10 patients scheduled for hallux valgus or hallux rigidus surgery were included. Microdialysis catheters were placed for sampling of cefuroxime concentrations bilaterally in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone. A tourniquet was applied on the thigh of the leg scheduled for surgery (tourniquet duration time [range]: 65 minutes [58-77]). Cefuroxime (1.5 g) was administered intravenously 15 minutes prior to tourniquet inflation, followed by a second dose 6 hours later. Dialysates and venous blood samples were collected for 12 hours. Results - A cefuroxime concentration of 4 mu g/mL was reached within 23 minutes in all compartments and patients. For cefuroxime the T > MIC (4 mu g/mL) ranged between 4.8 and 5.4 hours across compartments, with similar results for the tourniquet and non-tourniquet leg. Comparable T > MIC and penetration ratios were found for the first and second dosing intervals. Interpretation - Administration of cefuroxime (1.5 g) 15 minutes prior to tourniquet inflation is safe in order to achieve tissue concentrations above 4 mu g/mL throughout surgery. A tourniquet application time of approximately 1 hour did not affect the cefuroxime tissue penetration in the following dosing interval.

BackgroundGuidelines for venous blood sampling procedure (phlebotomy) discourage tourniquet use whenever possible. Here, we aimed to assess the Biomedical Scientists capability of not using the tourniquet in phlebotomy, which we hypothesized to be equal to 50% of the patients attended, and identifying the most frequent venipuncture site.Materials and MethodsWe selected and assigned two (BMS) with the same age (41 years) and experience (20 years) to record ten phlebotomy days, the first with prioritized and the latter with non-prioritized patients. In a simple record form, each acquired daily data for the number of attended patients, age and gender, the frequency of non-tourniquet usage and the punctured vein. To test our work hypothesis we used the two-tailed single sample t-test (p < 0.05). Differences between age-group means and non-tourniquet use means by each BMS were tested by two-tailed t-test for independent means (p < 0.05).ResultsIn 10 phlebotomy days 683 patients were attended, with males representing 43,2% of the population. We found no statistically difference between age-group means. The combined capability of non-tourniquet use was 50,5%, which did not differ from our null hypothesis, but the individual group-means were statistically different, being 33% and 66.9% in the prioritized vs non-prioritized group. The medial cubital vein was the most prone to be punctured (77,7%).ConclusionsWe have shown that performing phlebotomies without tourniquet use is possible and desirable in at least half of the attended patients, though being more limited in specific group populations. Our results provide room for quality improvement in the laboratory pre-analytical phase.Key points summaryWe assessed the capability of Biomedical Scientists not using the tourniquet in real life blood sampling procedures for diagnostic purposes.Blood was collected from at least half of the attended patients without tourniquet use.Biomedical Scientists were able to prioritize the antecubital veins without tourniquet application (medial cubital vein the most prone to be punctured - 78% of attempts).

BACKGROUND: Dilated veins are associated with increased success of peripheral intravenous cannulation, due to their improved visibility and palpability. We compared three strategies to achieve venodilation (tourniquet, electrical stimulation, or a combined strategy) on increase in venous size.METHODS: A total of 54 volunteers participated in this cross-over observational study with healthy adults, measuring venous cross-sectional area and diameter at six different sites of the upper extremity. Measurements were performed with ultrasound after performing any dilation strategy and compared with non-dilated venous size. An increased cross-sectional area of 25 square millimeters was denoted as clinically relevant, which was detected with paired t-test, Wilcoxon signed rank test, or ANOVA.RESULTS: The cephalic vein was the greatest at all sites (t=12.43, df=39, PCONCLUSIONS: In general, the largest sized veins are situated in the upper arm, of which the cephalic vein has the largest cross-sectional area and diameter. The combination of electrical stimulation followed by tourniquet application resulted in the greatest increase in venous size and is therefore considered as the most effective to improve peripheral intravenous cannulation success.

Tourniquets are commonly used during foot and ankle surgery to provide a bloodless operative field and increase surgical comfort, despite the potential risks associated with it. This study compared postoperative outcomes of tourniquet-assisted and non-tourniquet-assisted operative fixation of calcaneal fractures via the sinus tarsi approach. A retrospective study from March 2015 to December 2018 revealed 131 patients with closed calcaneal fractures who underwent minimally invasive surgery at our hospital. Visualization, operating time, blood loss, and postoperative pain were collected. Patients in the tourniquet group (n = 62) were compared with patients in the non-tourniquet group (n = 69). The visibility of the surgical field was fair/poor in 2 cases in the tourniquet group and fair/poor in 19 cases in the non-tourniquet group (P

Pneumatic tourniquets are used in total knee arthroplasty (TKA) for surgical field visualization and improved cementation; however, their use is controversial. This study aimed to assess the effects of tourniquet application on faster recovery post-TKA. Our hypothesis was that inflammation and limb function would be similar with different tourniquet applications. A prospective randomized double-blinded trial assessed tourniquets effects on postoperative pain, swelling, and early outcome in TKA. In present study, 50 TKAs were enrolled in each group as follows: full course (FC), cementation through closure (CTC), and no tourniquet (NT), CTC as treatment group while FC and NT as control groups. Topical blood samples of 3 mL from the joint cavity and drainage bags were obtained at special time point. At last, all samples such as tumor necrosis factor-a (TNF-a), C-C motif chemokine ligand 2 (CCL2), pentraxin 3 (PTX3), prostaglandin E2 (PGE2), superoxide dismutase 1 (SOD1), and myoglobin (Mb) were detected by ELISA. Active and passive range of motion (ROM) values, pain score by the visual analog scale (VAS), change of thigh circumference were recorded at special time point as well. In topical blood, the change of inflammatory factors, such as TNF-a, PTX3, CCL2, PGE2, SOD1, and Mb, was lower in CTC and NT groups than in FC group (p 0.05), the perimeter growth rate was lower, pain scores (VAS) were reduced, and ROM values were improved in CTC and NT groups compared with FC group at T4, T5, and T6 postoperatively (p

Aim: The aim of the study is to investigate the pathologies related with lower extremity venous systemfollowing total knee arthroplasty (TKA) and to evaluate the effect of tourniquet usage on the venousvascular system.Materials and Methods: The study cohort comprised 82 patients who underwent TKA due to primaryknee osteoarthritis and was divided into the patients performed TKA with using tourniquet (Group 1,n=42 patients) and without using tourniquet (Group 2, n=40 patients). Two groups were compared inthe respect of parameters inluding preoperative great saphenous vein (GSV) diameter, clinical venousinsufficieny level, operation time, tourniquet application time, tourniquet pressure, mean systolic bloodpressure and performed type of anesthesia. Results: No significant difference was determined between the groups in respect of venous thromboembolic disease (VTED. Postoperativeleg swelling was found to be significantly higher in the group 1 (p=0.02). Tourniquet application time >49.5 min [odds ratio (OR) 2.48, 95% confidance interval (CI) 0.48–0.91], tourniquet pressure > 275 mmHg [OR 1.98, 95% CI 0.23–0.84], preoperative GSV reflux > 1 sec [OR 1.23, 95% CI 0.32–0.93], operation time > 65 min [OR 1.13, 95% CI 0.11–0.58] were identified as independent risk factors for leg swelling following TKAConclusion: We think that it is very important to individualize the tourniquet application in the orthopedic interventions involving lowerextremity such as TKA and to evaluate tourniquet time, tourniquet pressure and preoperative venous vascular system for avoiding postoperative leg swelling and other related complications., Amaç: Total diz artroplastisi (TDA) sonrasında meydana gelen alt ekstremite venöz sistem kaynaklıpatolojileri incelemek ve cerrahisi sırasında uygulanan pnömatik turnikenin venöz damarların üzerineolan etkisini değerlendirmektir.Gereç ve Yöntemler: Primer diz osteoartriti nedeni ile turnike kullanılarak TDA uygulanan 42 (Grup1) , turnike kullanılmadan TDA uygulanan 40 (Grup 2) olmak üzere toplam 82 hasta retrospektif olarakdeğerlendirilip çalışmaya alındı. İki grup arasında preoperatif vena sefana magna (VSM) çapı, klinikvenöz yetmezlik derecesi ve intraoperatif operasyon süresi, turnike uygulama zamanı, uygulananturnike basıncı, ortalama sistolik kan basıncı, uygulanan anestezi yöntemi parametreleri kıyaslandı.Bulgular: İki grup arasında venöz tromboembolik hastalık (VTEH) açısından fark bulunmadı. Grup 1’depostoperatif bacak ödemi anlamlı derecede yüksekti (p=0.02). Çok değişkenli regresyon analizine göre;turnike kullanılan hasta grubunda, turnike süresi >49.5 dk [odds değeri (OD) 2.48, 95% güven aralığı(GA) 0.48–0.91], turnike basıncı (mmHg) >275 mmHg [OD 1.98, 95% GA 0.23–0.84], preoperatif VSMreflü >1 sn [OD 1.23, 95% GA 0.32–0.93], ameliyat süresi >65 dk [OD 1.13, 95% GA 0.11–0.58] bacaködemi gelişimi açısından bağımsız risk faktörü olarak belirlendi.Sonuç: TDA gibi alt ekstremiteyi ilgilendiren ortopedik girişimlerde turnike kullanımının hastaya görebireyselleştirilmesinin; turnike süresi, turnike basıncı ve preoperatif venöz vasküler sistemin detaylıdeğerlendirilmesinin, postoperatif bacak ödemi ve diğer komplikasyonlardan kaçınma açısından önemarz ettiğini düşünmekteyiz.

Introduction: Uncontrolled bleeding is a preventable cause of death in rural trauma. Herein, we examined the appropriateness, effectiveness, and safety of tourniquet application for bleeding contro...

BACKGROUND Life-threatening hemorrhage is a major cause of preventable mortality in trauma. Studies have demonstrated the effectiveness and safety of commercial tourniquets when used by adult civilians. However, there are no data about tourniquet application by children.This study's goal is to determine which of three commercially available tourniquets is most effective when used by children. METHODS A randomized crossover study was conducted in four elementary schools in Montreal to compare three commercially available tourniquets. The study population is primary school children aged 10 to 12 years (5th-6th grade). A total of 181 students were invited to participate; 96 obtained parental approval and were recruited. Participants underwent a short 7-minute video training on the use of three commercial tourniquets and were subsequently given a 2-minute practice period. Students were evaluated on their ability to successfully apply the tourniquet and the time to complete application. After applying all three tourniquets, the students selected their favorite model. The primary outcome is the proportion of successful applications per tourniquet model. Secondary outcomes include time to successful application for each tourniquet model and tourniquet model preference. RESULTS The mechanical advantage tourniquet (MAT) outperformed the combat application tourniquet (CAT) and the stretch wrap and tuck tourniquet (SWATT) in terms of success rate (MAT, 67%; CAT, 44%; SWATT, 24%; p < 0.0001), time to application (MAT, 57 seconds; CAT, 80 seconds; SWATT, 90 seconds; p < 0.0001), and preference (MAT, 64%; CAT, 30%; SWATT, 6%; p < 0.0001). CONCLUSION In this study, the MAT performs better in terms of success rate, time to application, and preference when used by school-aged children. This study can be helpful when facilities are purchasing tourniquets for use by students.

Background Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place. Discussion An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient. Conclusion These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.

Background Snakebite is a time decisive medical emergency requiring contact with health facility at the earliest. Many snakebite victims yet seek care from traditional healers (THs) or village quacks (VQs) before reaching an appropriate facility, which leads to adverse consequences. This study was conducted to assess care-seeking behaviour and pathways followed in reaching appropriate facilities among suspected snakebite cases and to identify associated factors. Methods A hospital-based cross-sectional study was conducted at a medical college in West Bengal. All suspected snakebite cases admitted during a reference period of two months were studied. Study subjects and/or accompanying persons were interviewed for care-seeking behaviours and pathways followed. Results Among the 393 study participants, most were ≤30 years of age, men, agricultural workers, of lower middle and lower socioeconomic class and only 69.5% had formal schooling. The commonest place of occurrence was the agricultural field (40.7%), and the commonest biting site was the lower extremity (77.6%). Only half of participants (55.2%) used immediate correct measures at the biting site. Incorrect practices included tourniquet application (29.5%), use of herbal preparation (7.1%), blade shaving at site (2.8%) etc. As first care-seeking points, 15% and 24.9% of cases visited THs and VQs, respectively. Pathway analysis revealed that unfavourable pathway was followed by 39.9% participants. Two unfavourable points were consulted by 3.8% of participants. The care-seeking pathway was significantly associated with religion, caste, education and socioeconomic class. Conclusions Findings of this study highlight the urgent need for behaviour change interventions addressing the myths and misconceptions of people regarding snakebite.

IntroductionHemorrhage is the leading cause of preventable death on the battlefield, and hemostasis is particularly challenging to achieve at junctional sites such as the axillary or inguinal regions. Mission-oriented protective posture (MOPP) gear, as worn most recently in Syria to guard against chemical weapons, can make the performance of technical skills more challenging still. The objective of this study was to evaluate how wearing MOPP gear affects the application time of the SAM Medical Junctional Tourniquet (SJT) by U.S. Army combat medics.Materials and MethodsWe conducted a prospective, randomized control trial evaluating time for SJT application between participants wearing MOPP versus those not wearing MOPP. Secondary outcomes included SJT application success rate and participant appraisal of SJT application difficulty assessed with five-point Likert items, between groups. Participants placed SJTs on robotic simulation mannequins with a penetrating inguinal injury.ResultsIn April 2019, we enrolled 49 combat medics. Most participants were male (77.5%), had a median age of 25 (interquartile range 23–28), and in the grade of E4 or less (63.3%). Mean SJT application times in seconds were higher among those wearing MOPP versus those who were not (223.1 versus 167.2; 95% confidence interval for difference in means 5.293, 106.374; P = 0.03). Participants wearing MOPP had a less successful application rate overall, but this difference was not statistically significant (64.3% versus 81.0%, P = 0.34). Compared to participants not wearing MOPP, those wearing MOPP agreed that SJT application was difficult (4 versus 3, P = 0.03), what they were wearing affected SJT application (4 versus 2, P = 0.01), and it was difficult to use their hands during SJT application (4 versus 1, P ConclusionsWearing military MOPP gear significantly prolongs the amount of time required for combat medics to apply an SJT on a simulated casualty with a penetrating inguinal injury. This study highlights the importance of incorporating MOPP gear into medical training scenarios to improve skills competency while wearing these protective garments.

Early application of tourniquets has reduced injury death rates. At the end of 2013, the Israel Defense Forces Medical Corps completed a military-wide introduction of the Combat Application Tourniquet as the standard-issued tourniquet. The accompanying clinical practice guideline encouraged combat soldiers and medical teams towards a liberal use of tourniquets for extremity injuries, even when in doubt.This study aimed to assess the effects of the wide introduction of advanced tourniquets on the rate of tourniquet applications, the type of tourniquet applied, and the differences in hospitalisation outcomes following the introduction.The study population was composed of hospitalised military casualties with an extremity injury treated by military medical teams between 2006 and 2015. Prehospital data were extracted from the Israel Defense Forces Trauma Registry and matched to corresponding hospital data from the Israeli National Trauma Registry. Two periods were compared: 2006-2013 "pre-intervention period" and 2014-2015 "post-intervention period".A total of 1,578 casualties were recorded during the study period. Of these, 320 (20.3%) occurred between 2014-2015. Characteristics of casualties in the post-intervention period were similar to those in the pre-intervention period including the rate of traumatic amputations (2.5% vs 2.2%, p = 0.93) and Injury Severity Score of 16 or above (12.8% vs 14.9%, p = 0.40). The rate of tourniquet application was more than four-fold in the post-intervention period compared to the pre-intervention period (22.8% vs 5.5%, p 0.001). Nevertheless, rates of in-hospital amputations (1.6% vs 1.6%, p = 1.00) and death (0.9% vs 1.3%, p = 0.53) were similar in the two periods.Following the IDF military-wide introduction of advanced tourniquets, the tourniquet application rate rose sharply, the use of old tourniquets ceased over time, and in-hospital amputation rate did not increase. These findings suggest that the awareness for haemorrhage control using advanced tourniquets rose.

Introduction The American College of Surgeons’ Stop the Bleed program has trained more than 1 million individuals to recognize and treat external hemorrhage. Central to this training is tourniquet application. No published studies review the retention of this skill after initial class participation. Methods One hundred fourteen volunteers agreed to participate. A random sample of 57 was selected and 46 participated. Upon return 6 months later, each participant demonstrated tourniquet application. An observer compared the application process with steps on a checklist. Each step completed correctly was tallied, and the total score for all 10 steps was computed as a percentage correct between 0% and 100%. Results The baseline score on the tourniquet skill test was 100% following initial training. At 6 months, mean scores were lower, 69% (SD = 31%) (χ2 = 52.09, df = 1, P Discussion At 6 months, 39% of participants were unable to successfully apply a tourniquet, and 26% were unable to control life-threatening bleeding. This study demonstrates that refresher training is needed within 6 months of initial training.

Background: Pneumatic tourniquet is an effective tool to achieve hemostatic control of the surgical field in upper extremity (UE) operations. Elevated pressures have been associated with adverse effects despite various methods of pressure determination. We aim to demonstrate the usage of reduced tourniquet pressures and examine factors associated with achieving reduced pressures. Methods: A prospective study was conducted (2016–2018) at a Level 1 Trauma Center and an Outpatient Surgical Center, totaling 226 operations, involving a reduction of cuff pressures over time from a standard baseline of limb occlusion pressure for UE operations. Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < 0.05). 4.5% of cases resulted in breakthrough bleeding, but did not reliably occur with any pressure thresholds, patient demographics, or operative factors (p > 0.05, for all). Conclusions: Reduced tourniquet pressures can mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require a tourniquet.

Background: School nurses play an integral part in prehospital care for life-threatening bleeding in educational environments. This study evaluated the efficacy of Stop the Bleed training for improving school nurses' knowledge, hands-on skill, self-confidence, and belief in school preparedness for responding to a life-threatening bleeding emergency. Method: Sixteen northeastern U.S. public school nurses completed a 1-hour seminar on appropriate life-threatening bleeding intervention with written and hands-on pre- and postassessments. Written assessments measured bleeding control knowledge, self-confidence, and perceptions of school preparedness. Hands-on assessments measured tourniquet application and wound-packing skills. Results: After training, participants scored significantly higher on the written assessment measuring basic bleeding control knowledge. The written postassessment showed significantly higher levels of self-confidence and belief in school preparedness ( p ≤ .05, n = 16). Hands-on skill for tourniquet application and wound packing also significantly increased following training ( p ≤ .05, n = 16). Conclusion: The Stop the Bleed training was effective in improving school nurses' basic knowledge about life-threatening bleeding control and improved tourniquet application and wound-packing skills. [ J Contin Educ Nurs . 2019;50(11):501–507.]

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.

Hemorrhage is the leading cause of preventable death after trauma. Junctional and extremity hemorrhage can be temporized with direct pressure and tourniquet application, but noncompressible torso hemorrhage has traditionally required operative or angiographic intervention. Retrograde endovascular balloon occlusion of the aorta (REBOA) can temporize patients with hemorrhage below the diaphragm long enough to enable definitive surgery. REBOA is increasingly available in US trauma centers but prospective, randomized demonstration of efficacy is not yet available. Emergency perfusion and resuscitation is an investigational therapy, limited to use in patients with cardiac arrest due to hemorrhage.

BackgroundCurrent 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.

Background This project involved the development and evaluation of a new visual bleeding feedback (VBF) system for tourniquet training. We hypothesized that dynamic VBF during junctional tourniquet training would be helpful and well received by trainees. Materials and Methods We designed the VBF to simulate femoral bleeding. Medical students (n = 15) and emergency medical service (EMS) members (n = 4) were randomized in a single-blind, crossover study to the VBF or without feedback groups. Poststudy surveys assessing VBF usefulness and recommendations were conducted along with participants' reported confidence using a 7-point Likert scale. Data from the different groups were compared using Wilcoxon signed-rank and rank-sum tests. Results Participants rated the helpfulness of the VBF highly (6.53/7.00) and indicated they were very likely to recommend the VBF simulator to others (6.80/7.00). Pre- and post-VBF confidence were not statistically different (P = 0.59). Likewise, tourniquet application times for VBF and without feedback before crossover were not statistically different (P = 0.63). Although participant confidence did not change significantly from beginning to end of the study (P = 0.46), application time was significantly reduced (P = 0.001). Conclusions New tourniquet learners liked our VBF prototype and found it useful. Although confidence did not change over the course of the study for any group, application times improved. Future studies using outcomes of this study will allow us to continue VBF development as well as incorporate other quantitative measures of task performance to elucidate VBF's true benefit and help trainees achieve mastery in junctional tourniquet skills.

Application of extremity tourniquets is a central tenet of multiple national initiatives to empower laypersons to provide hemorrhage control (HC). However, the efficacy of the general population who self-report prior first-aid (FA) or HC training on individual's ability to control bleeding with a tourniquet remains unknown. Therefore, the objective of this study was to assess the effectiveness of laypeople with self-reported prior FA or HC training to control bleeding with a tourniquet.Employees of a stadium were assessed via simulation in their ability to apply a Combat Application Tourniquet. As a subgroup analysis of a larger study, participants who self-reported: 1) No prior training, 2) FA training only or 2) FA + HC training were compared. Logistic regression adjusting for age, gender, education, willingness-to-assist, and comfort level in HC was performed.317 participants were included. Compared to participants with no prior training (14.4%,n = 16/111), those with FA training only (25.2%,n = 35/139) had a 2.12-higher odds (95%CI:1.07-4.18) of correct tourniquet application while those with FA + HC (35.8%,n = 24/67) had a 3.50-higher odds (95%CI:1.59-7.72) of correct application. Participants with prior FA + HC were more willing-to-assist and comfortable performing HC than those without prior training (p 0.05). However, reporting being very willing-to-assist [OR0.83,95%CI:0.43-1.60] or very comfortable [OR1.11,95%CI:0.55-2.25] was not associated with correct tourniquet application.Self-reported prior FA + HC training, while associated with increased likelihood to correctly apply a tourniquet, results in only 1/3 of individuals correctly performing the skill. As work continues in empowering and training laypeople to act as immediate responders, these findings highlight the importance of effective layperson education techniques.

Objective The purpose of this study was to compare laypeople’s and professional first responders’ ability to perform tourniquet application and cardiopulmonary resuscitation (CPR) during calm and stressful circumstances. Background Life-threatening bleeding is a major cause of death that could be prevented by fast and appropriate first aid interventions. Therefore, laypeople are now being trained in bleeding control skills, transforming them from bystanders to immediate responders. However, critics have questioned whether laypeople are able to perform during more stressful conditions. Method Twenty-four laypersons and 31 professional first responders were tested in two conditions: a calm classroom scenario and a stressful scenario consisting of paintball fire and physical exertion. Stress and workload were assessed along with task performance. Results The experimental manipulation was successful in terms of eliciting stress reactions. Tourniquet application performance did not decline in the stressful condition, but some aspects of CPR performance did for both groups. First responders experienced higher task engagement and lower distress, worry and workload than the laypeople in both the calm and stressful conditions. Conclusion Stress did not affect first responders and laypeople differently in terms of performance effects. Stress should therefore not be considered a major obstacle for teaching bleeding control skills to laypeople. Application Tourniquet application can be taught to laypeople in a short amount of time, and they can perform this skill during stress in controlled settings. Concerns about laypeople’s ability to perform under stress should not exclude bleeding control skills from first aid courses for civilian laypeople.

Background: Tourniquets are commonly used during foot and ankle surgery to provide a bloodless operative field and for the sake of the surgeon`s comfort, despite the potential risks associated with it. This study was performed to compare postoperative outcomes of tourniquet-assisted to non-tourniquet-assisted operative fixation of calcaneal fractures.Methods: A total of 131 patients with closed calcaneal fracture who underwent minimally invasive surgery of calcaneal fractures between March 2015 and December 2018 were reviewed retrospectively. Patients for whom a tourniquet was used intraoperatively (n = 62) were compared to those without (n = 69). Operating time and visualization, blood loss, postoperative pain according to visual analogue scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, and hospital length of stay were recorded for all the patients.Results: Statistical analysis of the results showed significant differences between tourniquet and non-tourniquet groups in the mean operation time, visibility of the surgical field, mean estimated intraoperative and postoperative blood loss, and mean VAS pain scores 24 H, 48 H, 72 H postoperatively (P < 0.05), whereas no significant difference between two groups in the mean Serum CPK levels, post-operative swelling, mean length of stay, AOFAS score, wound and fracture healing time, and the mean time for return to work.Conclusion: Our study demonstrated that tourniquet application during minimally invasive surgery of calcaneal fractures can significantly shorten the operation time, improve surgical visualization, and reduce intraoperative blood loss. However, adverse events associated with the use of tourniquet include increased postoperative pain, and more amount of postoperative bleeding. Due to higher postoperative pain and more amount of postoperative bleeding, more attention should be paid on the postoperative phase for those who tourniquet was used. The surgeon's decision to use a tourniquet during calcaneal fractures surgery should be carefully considered.

To the Editor It was with great interest that we read the informative and groundbreaking report by Wahal et al .[1][1] in which they describe the pathway of hypertension following tourniquet application. This is an important paper, because the pathway and mechanism they describe is in principle

Background Traumatic injuries were the most common reason for admission of pediatric patients to military hospitals during the recent wars in Iraq and Afghanistan. We compare survival and interventions between female and male pediatric casualties. Materials and Methods This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. We requested pediatric encounters from January 2007 to January 2016 within Iraq and Afghanistan. We separated casualties by sex to compare injury and mortality patterns. Results Our initial dataset included 3439 pediatric encounters—784 (22.8%) females and 2655 (77.2%) males. Females were less likely to sustain injuries by explosive (38.0% versus 44.5%) but more likely to sustain injuries via alternative mechanisms of injury (28.9% versus 21.5%). Both sexes had similar ISS (females median 10 [5-17], males 10 [4-17]). Fewer females underwent tourniquet application (4.2% versus 7.2%; all findings were significant). In unadjusted and adjusted regression analyses, females under age 8 had lower odds of survival to hospital discharge (OR 0.67, 95% CI 0.51-0.89) compared to males. Conclusions Among pediatric patients treated by U.S. medical personnel in Iraq and Afghanistan, females had a lower survival to hospital discharge despite similar severity of injury. Further studies are necessary to elucidate causes for this finding.

Background Massive transfusion is frequently a component of the resuscitation of combat casualties. Because blood supplies may be limited, activation of a walking blood bank and mobilization of necessary resources must occur in a timely fashion. The development of a risk prediction model to guide clinicians for early transfusion in the prehospital setting was sought. Study design and methods This is a secondary analysis of a previously described data set from the Department of Defense Trauma Registry from January 2007 to August 2016 focusing on casualties undergoing massive transfusion. Serious injury was defined based on an Abbreviated Injury Scale score of 3 or greater by body region. The authors constructed multiple imputations of the model for risk prediction development. Efforts were made to internally validate the model. Results Within the data set, there were 15540 patients, of which 1238 (7.9%) underwent massive transfusion. In the body region injury scale model, explosive injuries (odds ratio [OR], 3.78), serious extremity injuries (OR, 6.59), and tachycardia >120/min (OR, 5.61) were most strongly associated with receiving a massive transfusion. In the simplified model, major amputations (OR, 17.02), tourniquet application (OR, 6.66), and tachycardia >120 beats/min (OR, 8.72) were associated with massive transfusion. Both models had area under the curve receiver operating characteristic values of greater than 0.9 for the model and bootstrap forest analysis. Conclusion In the body region injury scale model, explosive mechanisms, serious extremity injuries, and tachycardia were most strongly associated with massive transfusion. In the simplified model, major amputations, tourniquet application, and tachycardia were most strongly associated.

Purpose: Pneumatic tourniquets are used in total knee arthroplasty (TKA) for surgical field visualization and improved cementation; however, their use is controversial. This study aimed to assess the effects of tourniquet application on enhanced recovery post-TKA. Methods: A prospective randomized single-blinded trial assessed tourniquet’s effects on postoperative pain, swelling, and early outcome in TKA. One-hundred and two patients with knee osteoarthritis were randomized to full-course (FC) and second half-course (SHC) application ( n = 51/group). Tumor necrosis factor-alpha (TNF-α), C-C motif chemokine ligand 2(CCL-2), pentraxin-3 (PTX-3), prostaglandin E-2 (PGE-2), superoxide dismutase-1 (SOD-1), and myoglobin (Mb) were assessed by enzyme-linked immunosorbent assay, while the visual analog scale (VAS), range of motion (ROM), and thigh circumference growth rate were recorded. Results: Average tourniquet duration significantly differed between the SHC (37.5 ± 5.1 min) and FC (66.4 ± 7.2 min) groups ( p < 0.01); VAS and thigh circumference growth rate in the SHC group were much lower compared with the FC group, while ROM was higher within 48 h of tourniquet removal ( p < 0.01). Blood TNF-α, PTX3, CCL2, PGE2, SOD-1, and Mb were lower in the SHC group than the FC group ( p < 0.01). Additionally, intraoperative blood loss was significantly elevated in the SHC group than the FC group ( p < 0.01), with lower postoperative blood loss in the drain ( p = 0.001). Postoperative drainage volume was reduced in the SHC group compared with the FC group ( p < 0.01); five and two patients in the FC and SHC groups required blood transfusion, respectively ( p = 0.025). Hospital stay tended to be shorter in the SHC group ( p = 0.023), and no tourniquet-related complications were recorded. Conclusion: Improved therapeutic outcome was observed in the SHC group, indicating patients should routinely undergo TKA with SHC tourniquet application.

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22087 Background: Application of tourniquet and herbs has been practiced since a long time in patients with different reptiles’ and arthropods’ bite at rural areas of the country, despite various cases of cellulitis and gangrene. Objective: To report a case of limb gangrene following tourniquet and herb application for snake bite. Case: A 20-years old farmer, who was bitten by a snake, presented to the Emergency department with complaints of blackish discoloration of his left forearm and hand. After clinical evaluation and investigations, patient underwent surgical intervention. Twelve days following snake bite, patient felt pain, noticed bleeding from bite site, swelling over his left hand, palpitation, shortness of breath and inability to speak. For which, he sought help from a traditional healer who applied a tourniquet over his left elbow and some herbs over the bite site. He noticed blackening of his fingers, which rapidly progressed to involve his left hand and forearm up to the site of tourniquet. He underwent surgery for the gangrenous limb. Conclusion: Development of gangrene following tourniquet is an unusual finding in modern day medicine. This case report shows the danger related to tourniquet application and need for measures to prevent such incidents in future. Keywords: Amputation, Gangrene, Snake Bite, Tourniquet

Objective: The aim of this study was to determine whether an early increase in intracranial pressure (ICP) following the deflation of a tourniquet is related to the tourniquet time (TT) or tourniquet pressure (TP) and to identify a safe cut-off value for TT or TP. Materials and Methods: Patients who underwent elective orthopedic lower-extremity surgery under general anesthesia were randomized into 2 groups: group A (inflation with a pneumatic TP of systolic blood pressure + 100 mm Hg; n = 30) and group B (inflation using the arterial occlusion pressure formula; n = 30). The initial and maximum TPs, TT, and sonographic measurements of optic-nerve sheath diameter (ONSD) and end-tidal CO2 values were taken at specific time points (15 min before the induction of anesthesia, just before, and 5, 10, and 15 min after the tourniquet was deflated). Results: The initial and maximum TPs were found to be significantly higher in group A than in group B. At 5 min after the tourniquet deflation, there was a significant positive correlation between TT and ONSD (r = 0.57, p = 0.0001). When ONSD ≥5 mm was taken as a standard criterion, the safe cut-off value for the optimal TT was found to be < 67.5 min (sensitivity 87% and specificity 59.5%). Conclusion: The ICP increase in the early period after tourniquet deflation was well correlated with TT but not with TP. TT of ≥67.5 min was found to be the cut-off value and is considered the starting point of the increase in ICP after tourniquet deflation.

Background The “Stop the Bleed” campaign in the United States advocates for nonmedical personnel to be trained in basic hemorrhage control and that “bleeding control kits” be available in high-risk areas. However, it is not clear which tourniquets are most effective in the hands of laypersons. Objectives The objective of this pilot study was to determine which tourniquet type was the most intuitive for a layperson to apply correctly. Methods This project is a randomized study derived from a “Stop the Bleed” education initiative conducted between September 2016 and March 2017. Novice tourniquet users were randomized to apply one of three commercially available tourniquets (Combat Action Tourniquet [CAT; North American Rescue, LLC, Greer, SC], Ratcheting Medical Tourniquet [RMT; m2 Inc., Winooski, VT], or Stretch Wrap and Tuck Tourniquet [SWAT-T; TEMS Solutions, LLC, Salida, CO]) in a controlled setting. Individuals with formal medical certification, prior military service, or prior training with tourniquets were excluded. The primary outcome of this study was successful tourniquet placement. Results Of 236 possible participants, 198 met the eligibility criteria. Demographics were similar across groups. The rates of successful tourniquet application for the CAT, RMT, and SWAT-T were 16.9%, 23.4%, and 10.6%, respectively (p = 0.149). The most common causes of application failure were: inadequate tightness (74.1%), improper placement technique (44.4%), and incorrect positioning (16.7%). Conclusion Our pilot study on the intuitive nature of applying commercially available tourniquets found unacceptably high rates of failure. Large-scale community education efforts and manufacturer improvements of tourniquet usability by the lay public must be made before the widespread dissemination of tourniquets will have a significant public health effect.

We report a rare case of acute dermal capillary rupture secondary to tourniquet application during hand surgery, which presented as severe purpuric rashes (Rumpel–Leede phenomenon) distal to the tourniquet site. The likely cause was capillary fragility subsequent to diabetic microangiopathy and hypertension.

BACKGROUND Over the past decade, there has been a resurgence of tourniquet use in civilian and military settings. Several key challenges include assessment of limb perfusion and adequacy of tourniquet placement, particularly in the austere or prehospital environments. We investigated the utility of thermal imaging to assess adequacy of tourniquet placement. METHODS The FLIR ONE smartphone-based thermal imager was utilized. Ten swine underwent tourniquet placement with no associated hemorrhage (n = 5) or with 40% hemorrhage (n = 5). Experiment 1 simulated proper tourniquet application, experiment 2 had one of two tourniquets inadequately tightened, and experiment 3 had one of two tourniquets inadequately tightened while simulating blackout-combat conditions. Static images were taken at multiple time points up to 30 minutes. Thermal images were then presented to blinded evaluators who assessed adequacy of tourniquet placement. RESULTS The mean core temperature was 38.3 °C in non-hemorrhaged animals versus 38.2 °C in hemorrhaged animals. Hemorrhaged animals were more hypotensive (p = 0.001), anemic (p < 0.001), vasodilated (p = 0.008), and had a lower cardiac output (p = 0.007) compared to non-hemorrhaged animals. The thermal imaging temperature reading decreased significantly after proper tourniquet placement in all animals, with no difference between hemorrhaged and non-hemorrhaged groups at 30 minutes (p = 0.23). Qualitative thermal image analysis showed clearly visible perfusion differences in all animals between baseline, adequate tourniquet, and inadequate tourniquet in both hemorrhaged and non-hemorrhaged groups. Ninety-eight percent of blinded evaluators (n = 62) correctly identified adequate and inadequate tourniquet placement at 5 minutes. Images in blackout conditions showed no adverse impact on thermal measurements or in the ability to accurately characterize perfusion and tourniquet adequacy. CONCLUSIONS A simple handheld smartphone-based forward looking infrared radiometry device demonstrated a high degree of accuracy, reliability, and ease of use for assessing limb perfusion. Forward looking infrared radiometry also allowed for rapid and reliable identification of adequate tourniquet placement that was not affected by major hemorrhage or blackout conditions.

The accuracy of the identification of anatomical landmarks with versus without tourniquet application and its effect on implant positioning remained unknown. Therefore, the hypothesis of the present study was that tourniquet application did not affect the accuracy of the reconstruction of the mechanical leg alignment, the joint line level, and the patellar height. The prospective randomized monocentric trial (Clinical-Trials.gov NCT02475603) included a total of 86 patients scheduled to undergo primary TKA. The patients were allocated to receive TKA with (Group A, n = 43) or without tourniquet (Group B, n = 43). The mechanical leg alignment, the joint line level (modified Kawamura), and the patellar height (Plateau-patella angle, Insall Salvati index, and modified Insall Salvati index) were measured pre- and postoperatively on standardized calibrated digital radiographs. Mean, SEM, median, range, and p value were calculated for each parameter. There was no statistical difference between the groups with regard to demographics, preoperative deformity, implant design, and surgical technique (n.s.). The mechanical leg alignment, the joint line level, and the patellar height revealed, in both groups, similar results pre- and postoperatively (n.s.). The mechanical leg alignment, the joint line level, and the patellar height could be accurately reconstructed with and without tourniquet use. With respect to clinically relevant surrogate parameters of implant positioning, TKA can safely be performed without a tourniquet. Available data do not support a routine use of tourniquet during TKA and might justify a change of the clinical pathway. Level I.

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.