http://www.tacticalcasualtyrescue.com

I agree with Warthog about the flap – there is no need to create a situation where it is necessary to create another injury in the patient in a wilderness/tactical environment by having to use a cric needle (if its avoidable). The risk of infection and life-threatening mistakes are too high. If you do carry one – make sure you get proper training and know how to do it in your sleep.

Another minor point I’d like to make is about the NPA. It is very important to size this thing properly – otherwise you’ll shove the thing too far down and cause damage/gagging/vomiting (which really defeats the purpose). I noticed that the ETA kit ITS tactical provides is the largest size possible. This is good for obvious reasons. However – make sure you measure and trim that thing down before putting it in anyone (pre-cut yours if you wanna be fancy). Measurement of the NPA is from the nostril of insertion to the same side’s earlobe. When you trim it, make sure you remake the bevel.

Great article ITS – would love to seem more articles on wilderness/tactical medicine!

Direct pressure and elevation is the key. For the pneumo? Leave a flap.

For the record, I am a former Paramedic who worked most of his career in and around Detroit.

“If a tourniquet is to be used for over two hours, where higher echelon care is not immediately available, it’s recommended to release pressure for five minutes every half hour to prevent muscle and nerve damage due to compression.”

This had previously resonated from wilderness medicine, and older first aid courses. With the enormous use of pre hospital TQ’s during the GWOT, many of the anecdotal guidelines have been dispelled. The Committee on TCCC has also included this topic within their curriculum.

The CoTCCC does not recommend this or teach “reperfusion intervals”even if TQ time is lengthy. Although when examining the This is from their current presentation,
“Tourniquets Points to Remember
•All unit members should have a tourniquet at a standard location on their battle gear.
•When a tourniquet has been applied, DO NOT periodically loosen it to allow circulation to return to the limb.
• Causes unacceptable additional blood loss.
• This practice caused at least one near-fatality in 2005.”

Dr. Kragh, in his 2007 paper “Extended (16-hour) Tourniquet Application After Combat Wounds: A Case Report and Review of Current Literature” which discusses the extended TQ application on a pilot during Operation Anaconda, states the following concerning periodic reperfusion,

“The practice of intermittent reperfusion is common in surgical practice and can significantly extend the duration of safe tourniquet application. However, in battlefield applica- tions there is generally no ability to limit hemorrhage during intermittent reperfusion, and no ability to administer blood products to replace lost volume. History has shown the practice to be ill advised, resulting in many deaths due to incremental exsanguination and current use guidelines expressly forbid the practice.

Conversion is always a possibility during transition periods (CUF – TFC- TACEVAC). One other point to bring up is the documented efficacy of placing two TQs side by side, which increases surface area and decreases pressure needed to cease bleeding and distal pulse. This is currently recommended when tactically feasible while no longer in Care Under Fire (CUF), although some are doing it first line when injury is amendable to technique and tactically reasonable.

We have an opportunity to work with a few members of the Committee on TCCC (CoTCCC) on a regular basis, and through many years of research and phenomenal work from ISR, specifically Dr. John Kragh there has been a huge shift on the opinions of TQ use, especially in the civilian sector. Many solid caveats are contained in his papers, “Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma”(2008), “BATTLE CASUALTY SURVIVAL WITH EMERGENCY TOURNIQUET USE TO STOP LIMB BLEEDING” (2009), and “Use of Tourniquets and Their Effects on Limb Function in the Modern Combat Environment” (2010).

Also (sorry for being long winded), one of the “hot topics” out there in both the DoD and civilian tactical arenas, is the new (about 2 months old) investigation that the USMC performed on C-A-T tourniquet failures. For years we have heard of broken windlass issues and velcro failures, but this is the first paper to publish an “official” investigation. At the surface it doesn’t appear too damning, although when you sit back and look at what it actually says and suggests, it is very problematic for the C-A-T and places doubt into those who carry it. If anyone needs a copy of the study feel free to e-mail me.

We wrote the following reaction to this study for ITRAMS (International Tactical Rescue and Medicine Society).

Reaction to MARCORSYSCOM C-A-T Message

This document has obviously been a “hot” topic since it was released. At first look two things hit the reader immediately concerning the MARCORSYSCOM investigative conclusion of the reported effectiveness and failures of the Combat Application Tourniquet. If the operational effectiveness and failures of the C-A-T is due to “improper use” (user error) and improper storage then 1) Is the C-A-T too complex to be utilized in combat while under survival stress? There doesn’t appear to be any complaints or claims similar to this concerning the SOFT-T (the only other CoTCCC recommended tourniquet), or the TK-4 the other TQ used by the USMC, so why utilize a TQ that has documented failures in combat chalked up to user error, when we know the amount of stress the user will be under while applying a life-saving piece of kit. 2) Improper storage is expounded on in section 7 and 8 of the document. It is here that they state the following;

7. ALL TOURNIQUETS SHOULD BE STORED IN A DRY ENVIRONMENT AND MAXIMUM TEMPERATURE NOT TO EXCEED 180 DEGREES F.

A. STORAGE OR PRE-STAGING THE C-A-T ON AN INDIVIDUAL’S BODY ARMOR, EXPOSED TO THE ELEMENTS, LIKELY DEGRADES THE MATERIAL AND EFFECTIVENESS OF THE TOURNIQUET.

B. IT IS RECOMMENDED THAT PERSONNEL KEEP THE TOURNIQUET IN ITS ORIGINAL PROTECTIVE PACKAGING.

8. IF THE TOURNIQUET HAS BEEN OPEN FOR AN UNDETERMINED AMOUNT OF TIME, IT IS RECOMMENDED TO HAVE THE TOURNIQUET REPLACED.

This seems to be the most controversial and catastrophic blow to the C-A-T. This now brings up a multitude of issues. The C-A-T must be kept in a dry environment, in its original wrapper, and not on an individual’s body armor or exposed to elements. Is this TQ now even compatible with the tactical or combat environment? As stated before, there does not appear to be any complaints or claims against the SOFT-T about improper storage leading to failure, apparently you can carry and store the alternate TQ anyway you want including being exposed to the elements, without degrading the piece of kit. The TQ is a first –line piece of gear. We don’t keep our primary weapon in its case while going through a door or our ammo in the box until the second we need to pull the trigger, then quickly open the box, load a magazine and charge our weapon and pull the trigger in a split second to save our lives from a threat.

The majority of TCCC trainers, if not all preach to always remove the TQ from its wrapper, and attach to the outside of your kit (not in an IFAK) in an area that you can access rapidly with either hand. There have been cases where users have had tremendous difficulty getting the TQ out of an IFAK and wrapper while under severe survival stress, with bloody hands, when seconds make the difference. I will let Cris Cook expound on this in his response.

If this is how the manufacturer suggests that the C-A-T be stored, does it still meet its claim of being one-handed? It is if I fold it in its one handed configuration, and then store it outside of its “original protective packaging” on the outside of my kit and exposed to the elements. It will take me two hands to remove from my medical kit (as stated in section 6 C), and then it also takes two hands to remove the C-A-T from the “original protective packaging”. This no longer allows the C-A-T to claim to be a “one-handed” tourniquet, which interferes with its stated compliance to the DoD / Biomedical engineers seven absolute requirements and five desirable features of a combat TQ. These requirements and features are as follows;

Seven Absolute Requirements
• Occlusion of arterial blood flow in a thigh 26.7” in diameter.
• Easy application to both upper and lower extremities.
• Will not slip during or after tightening.
• Easy release and subsequent reapplication.
• Weigh less than 230 grams.
• No power or electricity to operate.
• Shelf life of greater than 10 years.

Five Desirable Features
• 2” width
• One handed application to upper extremity
• Ability to be applied to entrapped limbs
• Protection from over-tightening
• Large scale production cost of $25

The portion that strikes many odd is section 8. It states that if the C-A-T has been open for an undetermined amount of time, it is recommended to have the tourniquet replaced. This seems a bit crazy for a TQ that was to be designed for utilization in the harshest conditions, which by the tone of this document it may not have been. Also since most of us that have this TQ do not utilize these storage techniques, and we decide to stay with this TQ, then someone will be making frequent visits to the bank with the amount of re-ordering about to occur.

As a side note, due to where the C-A-T originated from, by no means am I implying that the original design and concept was not specifically designed for the harshest combat conditions, although the end product seems to have some substantial limitations if these investigative conclusions are valid.

The last portion of this document that is unique occurs in section 6, which explains how to fold the C-A-T for one-handed storage. This seems odd since I obviously do not need to know this technique since we are instructed to keep it in its original protective packaging so it doesn’t degrade.

There have been numerous lives saved with the C-A-T, and I doubt the users of this kit adhered to the specified storage instructions listed in this document. The issue becomes that there were reported failures in the tactical environment, an investigation was completed, and the conclusions bring up some very concerning issues. The simple statement in 7 A, “Storage or pre-staging the C-A-T on an individual’s body armor, exposed to the elements, Likely degrades the material and effectiveness of the tourniquet” is troubling to say the least considering the intended AO of its use. Considering there is an alternative TQ that is recommended by the CoTCCC that doesn’t have the same concerns forces a decision to be made.

Many have made statements or blogged about the “great tourniquet debate”. The C-A-T is always mentioned and many either love or hate it. Failures mentioned are anything from the windlass snapping to the Velcro not adhering. Others have saved lives or their own with it. Some argue the C-A-T is a little wider (1.5”) and more effective compared to the SOFT-T (1”). This claim is not true and has a built in fallacy. The C-A-T uses a constricting band (attached to windlass), which travels inside a tubular piece of nylon. The constricting band is only 1”, which is the portion applying all the pressure. The added width of the tubular carrier does not add width to the compression. When applying tension you will actually see the outside tubular portion slant upward, obviously not applying pressure. If you threaded a 1/4” piece of bungee through a 3” section of tubular webbing and pulled the bungee circumferentially around an object tight, you would still only get the ¼” of pressure to occlude.

Finally, whichever tourniquet you decide to utilize train on it incessantly, under a full-spectrum of operational conditions because when you need it you will only have one chance to get it right.