The Tourniquet

Tourniquet Boston Bombing 1

Boston Firefighter James Plourde carries an injured woman away from the scene after a bombing near the finish line of the Boston Marathon in April 2013. The woman has an improvised tourniquet on her left leg just below the knee.

By Warrior Publications, June 2, 2016

Tourniquet: A device, typically a tightly encircling bandage, used to check bleeding by temporarily stopping the flow of blood through a large artery in a limb… French : tourner, to turn (from Old French).”

The Free Dictionary

A tourniquet is a binding that is applied to an injured limb to stop arterial blood flow resulting from a severe injury (characterized by bright red spurting blood). Although it has been used on battlefields since at least the times of the Roman Empire, after World Wars 1 and 2 the tourniquet became a questionable, even dangerous technique that was to be used only as a last resort, if at all. Despite the apparent absence of any medical studies, the tourniquet was said to cause such severe nerve damage that it often resulted in amputations.

Warning: there are some graphic images in the following article.

Tourniquet improvised old school

Although it looks like a torture technique from the European Middle Ages, this is actually the definition of an old school tourniquet (although by most modern opinions the band is too narrow).

While it is difficult to find evidence of the need for amputations, some of the common practises taught to combat medics during the Second World War are no longer recommended. These include loosening the tourniquet every 20-30 minutes, which can reportedly result in greater bleeding. Some tourniquet designs from this era are also questionable, including one with a piece of rope and a wooden dowel, a design that almost seems intended to cause nerve damage. Others advised placing a hard firm object over the artery and tightening the tourniquet over it.

Tourniquet WW 2 1

German issued WW2 tourniquet.

Following WW2, it became established medical doctrine that tourniquets were a last resort item, and they were widely discouraged. Over time, this became public knowledge, and to this day many people will still insist that tourniquets shouldn’t be used at all.

Tourniquet WW2 5

TOP: US issued tourniquet during WW2, manufactured by Bauer & Black. BOTTOM: Another WW2 US issued tourniquet, manufactured by Davis Emergency Equipment Co., Inc. Photo: Med-dept.com

In 1996, after studying the primary causes of combat deaths, including those from the 1993 “Blackhawk” incident in Somalia (when 19 US soldiers were killed, along with over 1,000 Somalis), US Army medical officials established the Committee on Tactical Combat Casualty Care (CoTCCC). Among its early recommendations was the use of tourniquets as a first resort in treating severe arterial bleeding injuries to the limbs. Following the US invasion and occupation of Iraq, beginning in 2003, the US military also began issuing tourniquets as part of the Individual First Aid Kits (IFAKs) that were quickly assembled for deploying troops.

L0057276 Thigh tourniquet, Roman, 199 BCE-500 CE

Thigh tourniquet, Roman, 199 BCE-500 CE Credit: Science Museum, London.

Today, military and police forces around the world are issuing their members tourniquets, and there are now several manufacturers of “tactical tourniquets.” More emergency medical services are also including tourniquets for first responders. Despite this, most civilian medical institutions (such as the Red Cross and St John Ambulance) continue to assert that tourniquets are only to be used as a last resort, if at all.

Lessons from Iraq

Tourniquet Improv 3

A soldier with improvised tourniquets on legs, both of which have suffered amputation below the knee, Iraq.

In a widely cited study by the US Army Institute of Surgical Research, the use of tourniquets was examined during a 7 month period at a combat support hospital in Baghdad, in 2006. Here is an abstract of that study and its conclusions:

“Among 2,838 injured and admitted civilian and military casualties with major limb trauma, 232 (8%) had 428 tourniquets applied on 309 injured limbs. We looked at emergency tourniquet use, and casualties were evaluated for shock (weak or absent radial pulse) and prehospital versus emergency department (ED) tourniquet use. We also looked at those casualties indicated for tourniquets but had none used. We assessed survival rates and limb outcome.

“RESULTS: There were 31 deaths (13 %). Tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%).

fig 13

Injured US soldier with two CAT tourniquets on left leg, Iraq.

“Prehospital tourniquets were applied in 194 patients of which 22 died (11 % mortality), whereas 38 patients had Emergency Department application of which 9 died (24% mortality).

“The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used.

“Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet.

“No amputations resulted solely from tourniquet use.

“CONCLUSIONS: Tourniquet use when shock was absent was strongly associated with saved lives, and prehospital use was also strongly associated with lifesaving. No limbs were lost due to tourniquet use.

“Education and fielding of prehospital tourniquets in the military environment should continue.”

(“Survival with emergency tourniquet use to stop bleeding in major limb trauma,” US Army Institute of Surgical Research, Fort Sam Houston, TX, USA, January 2009)

http://naemt.org/docs/default-source/PHTLS-TCCC/0784_TCCC_Abstract_Kragh_Survival_with_Emerg_Tourniquets_Ann_Surg_2009.pdf

Boston Marathon Bombings

In April 2013, two bombs were detonated at the Boston Marathon. 170 people near the finish line were injured by the blasts. Three people died and 13 lost one or more limbs. An interesting side note to this attack was the use of improvised tourniquets by first aiders treating many of the injured. These included t-shirts, belts, as well as neck lanyards used to carry credentials by marathon organizers. Here’s what Dr. David Mooney, trauma Chief at Boston Children’s Hospital, said in an interview:

Tourniquet Boston Bombing 2

A man use a belt as an improvised tourniquet during the 2013 Boston Marathon bombings.

“My first thought was, ‘He’s really hurt. This isn’t just some EMS overcall,’” Mooney said. “Someone at the scene put on a big tourniquet. He had singed hair, singed eyebrows, soot all over his face.”

“The 9-year-old girl also was in bad shape and singed. “Whoever got to her first saved her life” by putting on a tourniquet, Mooney said. “If they hadn’t done that, she would have died.”

(“Without Tourniquets, Many Wouldn’t Have Survived,” by Marilynn Marchione, Firehouse.com, April 17, 2013)

http://www.firehouse.com/news/10922046/without-tourniquets-many-wouldnt-have-survived

Tactical Tourniquets

Tourniquet CAT 2

Tactical tourniquet in all black being applied to a US soldier.

There are a number of manufacturers of tourniquets, some of which are issued by military and police forces. They are called “tactical” due to the lack of high visibility colours and bright, shiny buckles. These types of manufactured tourniquets are also designed to be used with one hand if necessary (for self-aid). At least two tactical tourniquets are recommended by the US Army’s Committee on Tactical Combat Casualty Care (CoTCCC). It should be noted that military forces also issued tourniquets during both World Wars 1 and 2, some versions of which are not that different than those currently being issued.

If you purchase one of these tourniquets, it’s a good idea to train with it frequently in order to become proficient in their use, as each tourniquet has specific ways of being applied. If you can afford it, it’s always best to purchase one tourniquet specifically for training (as you can wear them down with repeated use). You should also purchase these types of tourniquets from authorized distributors, as there are now fake brand name tourniquets on the market (which are made of inferior materials and could fail in use).

Combat Application Tourniquet (CAT)

Tourniquet CAT 1

Combat Application Tourniquet, or CAT.

One of the first and best known of the tactical tourniquets is the CAT, made by Composite Resources, based in S. Carolina. The manufacturer claims that over 1 million CATs have been distributed to military personnel since 2004. The CAT consists of a black nylon web strap with buckles and a metal dowel rod (called a windlass) that is used to tighten the tourniquet down once it is secured. The windlass itself is placed in a C-shaped holder once it has been tightened to the point where arterial blood flow has stopped (referred to as occlusion). There is also a white band onto which the time that the tourniquet was applied can be written so that doctors at a hospital know how long the tourniquet has been on the patient.

Tourniquet CAT 3The CAT has been revised over the years, with the early plastic windlass being replaced with a metal one (in fact the CAT is currently in its seventh generation). Although the CAT is the most commonly issued and used tourniquet, there are still reports of failures. These include the windlass breaking and a re-opening of blood flow due to muscle relaxation (see the report “Tourniquets and Occlusion: The Pressure of Design,” published in Military Medicine, March, 2013).

http://publications.amsus.org/doi/pdf/10.7205/MILMED-D-12-00490

The CAT is one of the tourniquets recommended by the CoTCCC, and also the most expensive of the tactical tourniquets, retailing for around $35-$40 (in Canada).

CAT website: http://combattourniquet.com/

Special Operations Forces Tactical Tourniquet (SOFT-T)

Matt and Ria Hydrick

SOF Tactical Tourniquet.

The SOFT Tourniquet, made by Tactical Medical Solutions based in South Carolina, is similar in design to the CAT, with a black nylon webbing strap, buckles and a metal windlass. It has been recently revised with a wider 1.5 inch strap, known as the SOF Tactical Tourniquet-Wide (SOFTT-W). Like the CAT, the SOFT-T is one of the tourniquets recommended by the CoTCCC. The SOFT-T and W version retail for around $30-$40 (in Canada).

SOFT-T website: https://www.tacmedsolutions.com/product/sof-tactical-tourniquet-wide/

Stretch Wrap And Tuck Tourniquet (SWAT-T)

The SWAT-T is made by TEMS Solutions, based in Virginia, USA. It consists of a 4 inch wide band of black latex-free rubber that is stretched, wrapped and tucked around the injured limb. It is the least expensive (at around $13 in Canada) and also the least bulky of the tactical tourniquets. In one study, it was found that the SWAT-T was the most comfortable when compared to the CAT, because of the broad width of the rubber band (Military Medicine, March 2013). The SWAT-T can also be used as a pressure wrap over a dressing, as an elastic bandage (for sprains, etc), and for securing splints. The main complaint of the SWAT-T is that it can be difficult to apply one handed (as in self-aid, when one arm is injured).

Tourniquet SWAT 1

SWAT Tourniquet.

Tourniquet SWAT 2In the spring of 2015, a St Petersburg, Florida, police officer was shot and injured. Although his department had purchased some $23,000 worth of CAT tourniquets, he and up to 30 percent of the force did not carry them because they were too bulky to wear on the patrol belt. He improvised a tourniquet using a garden hose. That same day, it is reported, the St Petersburg police ordered 500 SWAT Tourniquets as an addition (not replacement) for the CATs, which many officers simply kept in their patrol cars. The logic behind this was that at least the cops would carry the slimmer SWAT-T, which would work better than a garden hose (see “St. Petersburg police to start using new trauma tool,” by Melissa Eichman, Bay News 9, May 28, 2015).

http://www.baynews9.com/content/news/baynews9/news/article.html/content/news/articles/bn9/2015/5/28/supplemental_trauma_.html

SWAT-T website: http://www.swattourniquet.com/

Rapid Application Tourniquet System (RATS)

The RATS is the product of Jeff Kirkham, a US Army Special Forces member. The RATS is comprised of a narrow half inch strap made of a vulcanized rubber core with a nylon outer (similar to a flat bungee cord), and a metal locking mechanism (a cleat) that secures the strap after it is wrapped around the affected limb. By spacing the strap as it is wrapped, it is possible to achieve the 1.5-2 inch compression width recommended for tourniquet use.

Tourniquet RATS 1

RATS tourniquet.

Tourniquet RATS 2

RATS tourniquet applied to an arm.

Compared to the CAT and SOFT-T style of tourniquets, most reviewers find the RATS much easier and generally faster to use. After the SWAT-T, the RATS is the second least expensive tactical tourniquet (at around $15), and also easily carried.

RATS website: http://ratstourniquet.com/

Ratcheting Medical Tourniquets (RMT)

Tourniquet RMT 1

RMT tourniquet.

Tourniquet RMT 2

RMT applied a leg.

Made by M2 Inc, based in Vermont. The tourniquet includes a buckle & ladder strap with 1.5″ webbing. The buckle features a two-piece mechanism. The outer frame is a tightening lever, by raising and lowering it, the tourniquet gets tighter. Several versions are produced including a tactical one, K9, a 2 inch wide version, etc. The RMT scored well in the US Navy Experimental Diving Unit evaluation and retails for around $40.

RMT website: http://www.ratchetingbuckles.com/applications/military/medical-tourniquets/

Tourni-Kwik 4 (TK4) Tourniquet

Tourniquet TK 4 1

TK-4 tourniquet.

Tourniquet TK 4 2Made by H & H Associates in Virginia, the TK-4 is a stretch-retention tourniquet. It consists of an elastic wrap roughly 40” long by 2” wide, with two metal hook fasteners on each end, and looks similar to a bag sling. The TK-4 is one of the lightest and least expensive of the tactical tourniquets, costing between $5-$10. Although it scored moderately well in the US Navy Experimental Diving Unit evaluation, it was condemned by the US Army Medical Materiel Agency (USAMMA) in July 2014 for substandard quality and the risk of catastrophic failures using the TK-4.

https://www.naemt.org/docs/default-source/phtls-tccc/10-29-14-tccc-updates/mmqc-14-1686—condemnation-of-tk-4-tq—31jul14.pdf?sfvrsn=2

There is also the TK-4L, which has a modified metal hook that resembles an open sided carabiner and is intended primarily for use on the legs.

TK-4 website: http://gohandh.com/tk-4-one-handed-compression-strap

TK-4L website: http://gohandh.com/tk-4l-one-handed-tourniquet-for-legs

Carry and Deployment of Tactical Tourniquets

The basic concept of tactical tourniquets is that they are to be used immediately for severe wounds on the extremities with the goal of stopping arterial bleeding as soon as possible.

Tourniquet Pouch 1

A typical tourniquet pouch.

The most common practise among military forces is that the tourniquet you carry is the one that will be used on you, either by a buddy, a medic, or as self-aid. The reasoning is that if you render aid to another soldier and you use your tourniquet, when the injured soldier is medevaced, they will take both their own tourniquet as well as yours.

Tourniquet Pouch 3

Another example of a tourniquet pouch, this one by Blue Force Gear. You can see dirt and wear on the tourniquet from being exposed to the elements.

The tourniquet must be accessible and easily deployed. When a person suffers a severe injury and they must self-apply their tourniquet, they may have only one hand to use. They may also lose fine motor skills and have difficulty opening plastic packaging, unravelling velcro straps and buckles, etc. So along with training and setting up a tourniquet for rapid use, the tourniquet itself must be carried in such a manner that it is easily deployed.

In Iraq and Afghanistan, many NATO soldiers began to carry their tourniquets on their vests, often kept in place with elastic bands so they could be easily grabbed. It is common practise for these to be replaced every 3 months or so, due to the wear and tear from abrasion, dirt, rain, and sun. But unless you are issued tourniquets or can afford to keep buying new ones, you will want to protect them from the elements to ensure they are serviceable when needed. For this reason, it is worth purchasing a tourniquet pouch that fully covers the tourniquet and yet can still be quickly and easily deployed.

Use of a Tourniquet

Tourniquets should be:

  • only used on limbs (arms and legs), never on the torso, neck or head.
  • used immediately on amputations to stop arterial bleeding.
  • used for severe injuries resulting in arterial bleeding, identified by bright red spurting blood. They are also used when other methods, such as pressure bandages, have failed.
  • 1.5 to 2 inches wide; thinner straps or rope will cut into the skin, cause greater nerve damage, and require more pressure to stop bleeding than a wider tourniquet.
  • Tightened until the distal pulse and bleeding has stopped.
  • Placed 3-4 inches above the wound or amputation. If the injury is just below an elbow or knee it should be placed above the joint.

The following additional advice is from Outdoor Self Reliance:

  1. In case of an amputation, leave the tourniquet in place, DO NOT REMOVE! If there is a tourniquet on a non-amputation, release slowly after a few minutes to see whether or not bleeding can be controlled via direct pressure and dressing. If not, reapply tourniquet and leave in place.
  2. On the patients forehead, write the letter “T” and the time the tourniquet was applied.
  3. Make no attempt to remove a tourniquet, if it has been in place for 6 or more hours. Let the MTF (Medical Treatment Facility) do that.

“There is some confusion on how long a tourniquet can be in place before a loss of limb will occur. Some say forty-five minutes and CLS (Combat Life Saver) manual says two hours without major complications. Tourniquets are often used in hospitals during surgery on limbs and left in place for longer than 4 hours, at times, without significant damage. That is not our call to make, however. Let the hospital make that decision. Bottom line, the loss of a limb is nothing compared to the loss of a life.

“The use of a tourniquet is in no way a substitute for getting help. It is used as a means to extend life, while getting the casualty to a Medical Treatment Facility.”

(“The Tourniquet (how to apply),” by Outdoor Self Reliance, April 17, 2013)

http://outdoorselfreliance.com/the-tourniquet-how-to-apply/

Improvised Tourniquets

Tourniquet Improv 2

Example of an improvised tourniquet using a triangular bandage and stick.

Outside of the military, the most commonly used tourniquets are not manufactured tactical tourniquets, but improvised ones. Many different types of materials are used for improvised tourniquets, but some of the most commonly used are belts, shirts, neckties, socks, and triangular bandages. In many cases it does not appear that improvised tourniquets are applied using a windlass to tighten them, but most people who have training and experience with tourniquets assert that it can be very difficult to actually stop arterial blood without one, especially on the legs.

Thin straps or cord are not good tourniquets as they can bite into the skin, causing greater nerve damage and even cuts. They are also more painful for the casualty.

Tourniquets that are at least 1.5 to 2 inches wide are not only more comfortable and cause less nerve damage, they are also more effective:

“Previous investigators have clearly demonstrated an inverse relationship between

tourniquet width and the minimum pressure required to occlude arterial blood flow: as

the width of a tourniquet decreases, the pressure required to occlude arterial blood flow

increases.”

(Evaluation of Self-Applied Tourniquets for Combat applications, Second Phase, Navy Experimental Diving Unit, US Navy, April 2007)

http://docslide.us/documents/evaluation-of-self-applied-tourniquets-for-combat-applications-second-phase1.html

Triangular Bandage

Tourniquet improvised

How to use a folded triangular bandage (or other wide material) as a tourniquet.

Tourniquet Improv 1

Another version of applying an improvised tourniquet, in this case above a wound that has a pressure dressing applied below the knee.

If you have a first aid kit, one of the most useful items to include are multiple triangular bandages. Applied as a 2-3 inch wide folded bandage, it can be wrapped around the injured limb, tied down, and tightened with a windlass (a dowel made of a stick, a screw driver, or any other similarly shaped strong material). The windlass can be secured either with the remaining bandage material or a separate bandage. Using this method for self-aid can be very difficult, however, if one of your arms is injured.

Conclusion

Today, tourniquets are known to save lives by stopping arterial bleeding injuries on the arms and legs, a significant cause of death in combat. Tourniquets are also credited with saving lives in the aftermath of the Boston Marathon bombings. In more remote rural and wilderness areas, where medical services may be delayed, tourniquets can also save lives resulting from hunting accidents, (including the accidental discharge of firearms), accidents involving a chainsaw or axe, as well as motor vehicle accidents.

There are many types of tourniquets now being manufactured, ranging in price from $10 to $40. If it’s within your budget, I would highly recommend adding a tourniquet to your first aid kit. I would also advise that you practise applying tourniquets using various improvised materials, including the triangular bandage.

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Posted on June 3, 2016, in Gear Reviews, Warrior Fieldcraft and tagged , , , . Bookmark the permalink. 2 Comments.

  1. great research, can we have names of the leading companies that manufacture and supply approx 4 inch wide to 6 inch wide tourniquet for tactical field use

  1. Pingback: The Writer’s Guide to Bleeding and Shock, Part 2: Stopping the Bleeding – ScriptMedic

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