1. The Benefits of Commercial Tourniquets
“The fate of the wounded lies in the hands of one who apply the first dressing”
Nicholas Senn, MD

2. Bleeding from the Arms and Legs
Bleeding from wounds to the extremities can be controlled by direct pressure and/or a commercial tourniquet

3. Stop the Bleeding
A victim who is bleeding from an artery can die in as little as 3 minutes
Serious bleeding from an extremity is the most frequents cause of preventable death from injury.
If you can do only ONE thing for the injured patient: stop him or her from bleeding to death.
If you can ONE thing for the injured patient : stop him or her from bleeding to death.

4. The Commercial Tourniquet
A commercial tourniquet is a device that stops the flow of blood.
If applied correctly, the tourniquet stops arterial blood flow
Tourniquets are devices that put pressure on blood vessels near a serious wound so the victim loses less blood.
When a victim loses too much blood, he or she can go into shock. Shock occurs when the body cannot deliver enough blood to all the organs

5. Tourniquet Pain Tourniquets HURT when applied effectively
Does not necessarily indicate a mistake in application
Does not mean you should take it off!
Manage pain prehospital with analgesics when the situation allows.
It is expected that tourniquet application will cause some pain, but it will also save your casualty’s life.

6. Tourniquet Mistakes to Avoid!
Not using one when you should
Using a tourniquet for minimal bleeding
Putting it on too proximally
Taking it off when the casualty is in shock or has only a short transport time to the hospital
Not making it tight enough to eliminate the distal pulse
Not using a second tourniquet if needed
Waiting too long to put the tourniquet on
Periodically loosening the tourniquet to allow blood flow to the injured extremity
These are common mistakes made by first responders applying tourniquets.
* These lessons learned have been written in blood. *

7. Tourniquets in Action Fort Hood Shooting 12 dead; 31 wound
Officer Kim Munley
The hero of the Ft. Hood shooting, she was shot in both legs and had major bleeding. Her colleagues applied pressure to the wound to try to stop the bleeding, but it was not effective. Ultimately, an Army medic used a combat application tourniquet (C-A-T) to stop the bleeding and save her life.
Officer Kim Munley, the hero of the Fort Hood shootings, was shot in both lower extremities and experienced major bleeding. Her colleagues applied pressure to the wound to try to stop the bleeding, but it was not effective. Ultimately, an Army medic used a CAT tourniquet to stop the bleeding and save her life.

8. Commercial Tourniquet Types
There are many types of commercial tourniquets. The tourniquets shown here been studied by the U.S. Military and have shown to be efficient and effective.
Studied by the U.S. Military and have shown to be efficient and effective

9. Care Under fire
Other Tourniquets
4/12/2017
The SOF®TT is also recommended by Institute for Surgical Research (ISR) and the CoTCCC. It was found to be 100% effective in stopping arterial flow in arms and legs in laboratory testing. Anecdotal reports say the SOF®TT may be more effective than the C-A-T ® in individuals with large legs. It is not fielded as widely as the C-A-T® at present, but feedback from medics regarding it’s use has been good.
The SOF® Tactical Tourniquet (SOF®TT) by Tactical Medical Solutions, Inc.
Photo courtesy TMS, Inc.
DRAFT

10. Parts of the Tourniquet
The C-A-T uses a Sel-adhering Band and a Friction Adaptor Buckle to fit a wide range of extremities combined with a one-handed windlass system. The windlass uses a free-moving internal band to provide true circumferential pressure to an extremity. The windlass is then locj=ked in place: this requires only one hand, with the Windlass Clip. The CAT also has a Hook-and –loop Windlass Strap for further securing of the windlass during patient transport.
The Combat Application Tourniquet (C-A-T) (Patient Pending) is a small and lightweight one-handed tourniquets that can completely occlude atrial blood flow in an extremity

11. Vietnam
Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. These casualties had no other injuries.
25 years later, we had still not learned the tourniquet lesson in Vietnam.
2500 preventable deaths from extremity hemorrhage were the result.
Surely, we would have learned the lesson after this experience.

12. Tourniquets in U.S Military Mid-1990s
Old strap-and-buckle tourniquets were still being issued.
Medics and corpsmen were being trained in courses where they were taught not to use them.
Amazingly, by the 1990’s, we were still making the same mistakes about tourniquets that we had been in World War II.

13. Causes of Death in Combat
Viet Nam:
Casualties suffered in ground combat
9% died from bleeding from extremity wounds
5% died from tension pneumothorax
1% died from airway obstruction
This slide depicts a study that was done on Soldiers who died in Vietnam.
We can use this data to help us understand what types of injuries are seen in combat and which may or may not be survivable.
The circled causes are those that are potentially preventable with appropriate medical care in the field

14. Tourniquets – Beekley et al Journal of Trauma 2008
31st Combat Support Hospital in 2004
165 casualties with severe extremity trauma
67 had prehospital tourniquets placed; 98 did not
7 deaths
4 of the 7 deaths were potentially preventable if a commercial tourniquet had been placed.
We were still losing people to extremity bleeding in 2004.
Notice the makeshift tourniquets used here.
At about this point, the military had started a very strong effort to push tourniquets forward.
Since this study, preventable deaths from extremity hemorrhage have now been minimized due largely to issuing a new individual first aid kit (IFAK) and training individuals to use it.

15. Safety of Tourniquet Use Kragh - Journal of Trauma 2008
Remember at the start of the GWOT, we were still losing casualties to extremity hemorrhage.
We’re doing much better now.
This study documented 232 LIVES SAVED in this ONE hospital in a ONE-YEAR period.
MINIMAL complications from tourniquet use.
Combat Support Hospital in Baghdad
232 patients with tourniquets on 309 limbs
CAT was best field tourniquet
No amputations caused by tourniquet use
Approximately 3% transient nerve palsies

16. Impact of Tourniquet Use Kragh - Annals of Surgery 2009
Ibn Sina Hospital, Baghdad, 2006
31 lives saved in this study by applying
tourniquets prehospital rather than in the ED
Better survival when tourniquets were applied
BEFORE casualties went into shock
Survival if applied before shock develops – 96%
Survival if applied after shock develops – 4%
Most important – apply tourniquets ASAP when they are needed.
Survival improved if shock prevented.
Tourniquet application prior to the onset of shock in life threatening extremity bleeding results in an approximate survival rate of 96%.
Survival drops sharply if the tourniquet is applied after the onset of shock. A casualty suffering the same wound now has a 4% chance of survival if the tourniquet is placed while in shock!

17. Deaths in the Global War On Terror
Factors That Might Have Changed Outcomes
Study evaluated 82 fatalities
12 were potentially survivable
Commercial Tourniquets (3)
Hemostatic dressings/direct pressure (2)
Airway management (1)
Needle Thoracostomy (1)
And we paid a price for that when the GWOT (Global War on Terror) started.
This paper on Special Ops deaths showed 3 out of 12 potentially preventable deaths were due to extremity hemorrhage.
Note the makeshift tourniquets used here.

18. CAT Tourniquet Application to the Arm

19. CAT Tourniquet Application to the Leg

20. Tactical Combat Causality Care
Thank you!
Felix J. Marquez, PMD, BA
Tactical Combat Causality Care
State Coordinator