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The Tactical Tourniquet

 

Although many dogmas relating to tourniquet use persist, tourniquets have reemerged in Tactical Emergency Medical Support (TEMS) as the standard of care in the tactical environment due to their ease of use, rapid application, and complete stoppage of blood loss.

Instead of viewing the use of the tourniquet as last resort, as has been the case in the past with civilian Emergency Medical Services (EMS) and emergency room physicians, the new Tactical Combat Casualty Care (TCCC) protocol considers the military tourniquet as an initial lifesaving intervention to control massive hemorrhage from an extremity.

TCCC guidelines differ from the Advanced Trauma Life Support (ATLS) guidelines on which civilian trauma care has been based in most countries in the ATLS model; injuries are diagnosed and treated in accordance with the ABCDE sequence: Airway, Breathing, Circulation, Disability, Environment and exposure. In the TCCC model, injuries are diagnosed and treated in accordance with the MARCH sequence: Massive hemorrhage, Airway, Respirations, Circulation, Head injury.

While recognizing that civilian law enforcement operations differ from military combat operations, the National Tactical Officers Association (NTOA) believes that “TCCC should serve as a foundation for TEMS protocols, practices and procedures.”

TCCC has three goals: 1) treat the casualty; 2) prevent additional casualties; and 3) complete the mission. There are three phases to combat casualty care: 1) Care Under Fire; 2) Tactical Field Care; and 3) Combat Casualty Evacuation Care.

The TCCC Basic Plan for Care Under Fire is: 1) return fire and take cover, 2) direct or expect the wounded to remain engaged as a combatant, 3) direct the wounded to move to cover and apply self-aid, 4) try to keep the wounded from sustaining additional wounds, and 5) airway management should be delayed until the Tactical Field Care phase.

Finally, 6) stop life-threatening external hemorrhage if tactically feasible by directing the wounded to control hemorrhage by self-aid, use a tourniquet for hemorrhage that is anatomically amenable to tourniquet application, and apply the tourniquet above the wound high on the extremity, over the uniform, and tighten to stop arterial bleeding or until pulse is lost. Move the wounded to cover.

 

Guidelines for Bleeding Control

The Committee on Tactical Combat Casualty Care (CoTCCC) Tactical Combat Casualty Care Guidelines has guidelines for bleeding. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.

For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours), use combat gauze as the hemostatic agent of choice. Combat gauze should be applied with at least three minutes of direct pressure. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet from over uniform and apply directly to skin 2–3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding.

When time and the tactical situation permit, a pulse check should be accomplished. If a pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the pulse. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

 

Recommended Tourniquets

The Composite Resources Combat Application Tourniquet® (C-A-T) and Tactical MedicalSolutions SOF Tactical Tourniquet® (SOF-TT) are the only two CoTCCC recommended tactical tourniquets. The COTCC based its recommendation on a 2004 study of nine battlefield tourniquets conducted by the U.S. Army Institute of Surgical Research. Seven of these were commercially available and two were prototype systems.

Three tourniquets were identified that were 100 percent effective in stopping arterial blood flow.  These were the C-A-T, the SOF-TT, and the Emergency and Military Tourniquet (EMT). The EMT is an inflatable pneumatic device that is best suited for aid stations and hospitals. The C-A-T and SOF-TT are both windlass-type devices. The C-A-T and SOF-TT are lightweight and reasonably inexpensive. Due to its lighter weight and it being slightly easier to use, the C-A-T was selected as the primary tourniquet, followed by the SOF-TT.

There have been a number of recent enhancements to the C-A-T. The C-A-T tourniquet strap now features a red elliptical tip to aid users in threading it. It has a polymer windlass and reinforced windlass clip that is secured with Velcro®. The windlass rod is twice as strong. The windlass clip has a highly visible security tab and includes a writable area to record time of application. North American Rescue is the sole distributor for the C-A-T in the U.S.

Tactical Medical Solutions has recently come out with a new version, the SOF Tactical Tourniquet Wide (SOF-TT-W). The SOF-TT-W is the result of a two-year study that compiled end user research and laboratory studies to develop a more effective tourniquet for all environments. Tac Med Solutions was able to reduce the weight of the tourniquet by 25 percent while enhancing performance. It’s faster and easier to apply and stronger. The SOF-TT-W features a snap-lock buckle for rapid, easy application and wider 1.5-inch strap for additional arterial compression. Aluminum alloy components are utilized in all areas of critical function.

Another new tourniquet that is gaining interest in the tactical community is TEMS Solutions unique SWAT-Tourniquet™. Of stretch-retention design, the SWAT-T (Stretch, Wrap and Tuck) is exceptionally versatile. It may be employed as a tactical tourniquet, pressure dressing, and elastic bandage. In testing conducted by trauma surgeon Sydney Vail, MD, the SWAT-T has proven 100 percent effective in stopping arterial blood flow. The SWAT-T is lightweight, easy to apply, and reusable. It has been applied 5,000 times, used in the sub-zero temps of Antarctica, and boiled in water with no strength degradation.

H& H Associates’ Tourni-Kwik™-4 (TK-4) and Tourni-Kwik-4L (TK-4L) are also popular tactical tourniquets. The TK-4 was one of the top-performing tourniquets in the Naval Experimental Diving Units (NEDU) evaluation of self-applied tourniquets for combat applications. The TK4L improved upon the TK-4 for use on lower extremities by adding a tensioner at one end to allow more force to be applied. The TK-4 and TK-4L are stretch-retention tourniquets. They are compact, lightweight, and are quick and easy to apply, as well as inexpensive.

 

Hemostatic Agents

Hemostatic agents are wise companions in your blow-out kit in addition to a tourniquet. A hemostatic agent is the first line of treatment for a life-threatening hemorrhage on external wounds that are not amendable to tourniquet placement. Z-Medica QuikClot® Combat Gauze™ was chosen by the CoTCCC as the hemostatic product to be carried by all branches of the U.S. military for the temporary external control of life-threatening traumatic hemorrhage.

QuikClot Combat Gauze combines surgical gauze with an inert mineral called kaolin. Kaolin is a white aluminosilicate that initiates the clotting cascade upon contact with blood by activating Factor XII, Factor XI and prekallikrein. Kaolin-based QuikClot gauze is the most effective product among the dressings tested, allowing the least amount of hemorrhage and resulted in the highest survival rate. The hemostasis time for kaolin-based QuikClot gauze was typically five minutes.

Unlike previous QuikClot products, which were zeolite-based, kaolin-based QuikClot products generate no heat. The new generation of QuikClot products also stops arterial and venous bleeding more rapidly than the earlier Z-Medica products.

Combat Gauze is a soft, white, sterile, non-woven 3-inch by 4 yards rolled gauze. It also comes in a z-folded version called Combat Gauze LE.  Z-Medica also makes QuikClot Sport™ and QuikClot Sport Silver™ Advanced Clotting Sponges™. Like Combat Gauze, they come in a foil pouch and employ kaolin. QuikClot Sport Silver has ionic silver to prevent the growth of bacteria and fungi until more advanced medical care is available. They all come in a vacuum-packed easy-tear-opening aluminum pouch.

 

Easy Access

Consider carrying one tourniquet in your blow-out kit and one where you can quickly access it.  Keep one of the tourniquets close to the centerline of the combat vest or chest rig. In this position, it is easy to access the tourniquet with either hand. Another popular place to keep a tourniquet is on the belt. Standardize on the position of the tourniquet, and make certain that others with you know where it’s located.

The smart solution is to carry your tourniquet in a pouch, one that fully protects your tourniquet and also affords easy access, such as T3 Tourniquet Pouch, Gen 2 for the combat tourniquet, BLACKHAWK! Pop Up Tourniquet Pouch, North AmericanRescue C-A-T Holder, and Tac Med Solutions Tourniquet Case. All are MOLLE compatible and available in several colors.

Tac Med Solutions also makes a Stealth Tourniquet Holster (STH). It mounts on the inside of a police duty belt, saving space on the outside. Although the STH is designed for the SOF-T-W, it will accommodate other tourniquets as well. Tourniquet pouches should be marked with a T, TK, TQ or a red cross to clearly identify it.

The rules have changed on tourniquet use. Always carry a tourniquet, one that is easily accessed and protected from the elements. Know how and when to use it. Always carry a good hemostatic agent. The life you save may be your own.

 

Eugene Nielsen provides investigative and tactical consulting services and is a former officer. He may be reached at eugene.nielsen@live.com.


Published in Law and Order, Jul 2014

Rating : Not Yet Rated


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Related Companies

BLACKHAWKNorth American RescueNTOA (National Tactical Officers AssociationT3Tactical Medical SolutionsZ-Medica
 

Related Products

ABCs (Airway Breath and Circul)Advanced Trauma Life Support (ATLS)ATLSBleedingCPREMSGunshot WoundsHemorrhageHemostatic AgentsSWAT-T TourniquetTactical Emergency Medical Support (TEMS)Tactical TourniquetsTCCC (Tactical Combat Casualty Care)TEMS UnitTourniquets
 

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