The Committee on Tactical Combat Casualty Care (CoTCCC) recently reviewed many commercially available tourniquets to determine their effectiveness based on a predetermined set of standardized criteria. In early May 2019, the CoTCCC announced the findings of this extensive evaluation and added many new tourniquets to their recommended list. The primary goals of this tourniquet review were: (1) review the previously recommended tourniquets for effectiveness and; (2) determine if additional commercial tourniquets warrant CoTCCC recommendation; and (3) identify commercial tourniquets that require further development, or which tourniquets do not currently warrant recommendation based on the study criteria. Additionally this evaluation desired to establish a preferred features guideline for the research, development, and testing of limb tourniquets. Finally, CoTCCC wanted to establish a model for future reviews of CoTCCC-recommended devices and products on a recurring basis.

Background

The early and aggressive application of limb tourniquets has been the key pillar of TCCC since its inception. In the early years of TCCC implementation there were limited pre-fabricated limb tourniquet options available for units or the services to issue to troops. The device fielded by the Department of Defense medical logistics system since the 1960s was the simple strap-and-buckle tourniquet. This device was completely inadequate as a true limb tourniquet. The alternative was classic stick-and-rag improvised windlass limb tourniquets.

Through the efforts of innovative medics and physicians in the late 1990s and early 2000s, new concepts for prefabricated limb tourniquets began to emerge. While many quickly fell by the wayside, a few such as the Combat Application Tourniquet (C-A-T) and the Special Operations Forces Tourniquet –Tactical (SOFT-T) have endured for many years. The tourniquet innovation did not slow down as several manufacturers continued to develop, produce and market tourniquets to the point that there are dozens of options today. However, the efficacy of many of these tourniquet devices has not been evaluated through evidence-based research. Further, for the published evidence available, there has been a wide variance as to the efficacy study definitions, metrics and requirements.

 The first two tourniquets recommended by CoTCCC for use on the battlefield were the C-A-T and SOFT-T. These two tourniquets have performed well in combat casualty care since 2004, and this is the first update to the TCCC tourniquet guideline in 15 years.

 Even though other researchers have done tourniquet testing previously within the Department of Defense, these evaluations have not been comprehensive or standardized, making comparative quality assessments of the available tourniquet options more difficult. Several factors made it important to review and update the TCCC tourniquet recommendations within 2018-19 despite the lack of comprehensive standardized testing. These factors were:

 1. Although the C-A-T and the SOFT-T, the original two approved CoTCCC tourniquets, have performed for years, there were newer tourniquet technologies that offered advantages in cost, speed of application, ease of application, durability, ease of training, or other aspects of tourniquet performance over these two tourniquets previously recommended.

 2. Some tourniquets now commercially available have been shown to perform poorly in either in laboratory testing or in patient care; these tourniquets need to be identified so that agencies can be aware of these issues when making tourniquet purchasing decisions.

 3. The newer versions of the C-A-T and the SOFT-T need to be evaluated in comparison to other tourniquets to study the effect of post-2004 design changes on their performance.

 4. Tourniquet use is increasing in the US civilian sector as a result of the American College of Surgeons “Stop The Bleed” campaign. This campaign seeks to translate the survival benefit seen in US combat casualties after the TCCC-led introduction of modern tourniquets. Many civilian agencies are requesting guidance from CoTCCC about which tourniquets to acquire for their agencies and these large-scale tourniquet acquisitions should be based on the best evidence currently available.

Tourniquet Assessment Criteria

In September of 2018, a working group at the CoTCCC meeting outlined the critical criteria that would be used to further evaluate the available evidence. The working group prioritized the following assessment criteria going forward in this review and for CoTCCC preferred features of military limb tourniquets. In order to be included, all devices must be FDA approved as a tourniquet. At the time there were 1,627 devices approved by the FDA as tourniquets. For the purposes of this review, each component of tourniquet criteria was scored on a weighted scale of zero to five.

 A total of 19 tourniquets were evaluated in this CoTCCC review. The following were the standardized criteria applied to each tourniquet. There were 8 criteria applied to score each tourniquet.

1. Arterial occlusion

2. Time of application

   a. Time of occlusion < 60 seconds

   b. Time to complete < 90 seconds

3. Simplicity of application

   a. Usability/easy of use

   b. Steps to complete

4. Pressure

   a. Achieve initial occlusion

   b. Point of harm

5. Tourniquet specifications

   a. Width

   b. Length

   c. Locking mechanism

   d. Time recording

  e. Weight

6. Complications and Safety

   a. Reported failures/problems

   b. Safety Issues

7. Usage reports

   a. Combat usage reports

   b. Civilian usage reports

   c. User preferences

8. Logistics

   a. National Stock Number (NSN)

   b. Government Service Administration (GSA) cost per unit

   c. Commercial cost per unit

The outcome of this extensive tourniquet evaluation resulted in eight recommended non-pneumatic limb and two pneumatic tourniquets on the list of approved tourniquets by the CoTCCC. There were three previously approved tourniquets that remained on the list and seven new tourniquets added (Figure 1).

In the near future, an article by Montgomery et al on the CoTCCC tourniquet evaluation study will be published in the Journal of Special Operations Medicine. It will fully describe the study methods, results with scores for all criteria for each tourniquet, and a discussion of the recommended and not recommended tourniquets.

 The authors (BB/RC) are planning to give a lecture about the CoTCCC tourniquet evaluation study, and then provide a hands-on workshop with these new tourniquets at a future WMS conference. Recent research reports that the Stop The Bleed course is insufficient for many attendees to receive adequate preparation to use a tourniquet correctly (McCarty 2019). Thus, a thorough discussion will be provided in the workshop about the recommended application of tourniquets for managing severe hemorrhage in the backcountry.

Recommended Viewing:

• Up to date information on CoTCCC guidelines:

https://deployedmedicine.com/

• See CoTCCC videos on hemorrhage control methods from the deployedmedicine.com website: https://books.allogy.com/web/tenant/8/books/4be6ff66-d3d4-43e3-a408-50d39d4e35b9/

Recommended Reading:

• Beaven A, Ballard M, Sellon E, Parker PJ. The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet. J Spec Oper Med 2018;18(3):75-78.

• Bennett BL, Butler F, Wedmore I (Guest Editors). Editorial: Tactical Combat Casualty Care Lessons Learned: Transitioned to Other Austere Environments. Wilderness & Environ Med 2017;28:S3-S4.

• Bequette BW, Kragh JF Jr, Aden JK, Dubick MA. Belts Evaluated as Limb Tourniquets: BELT Study Comparing Trouser Supporters Used as Medical Devices in a Manikin Model of Wound Bleeding. Wilderness Environ Med. 2017;28(2):84-93.

• Dennis A, Bajani F, Schlanser V, Tatebe LC, Impens A, Ivkovic K, et al. Missing expectations: Windlass tourniquet use without formal training yields poor results. J Trauma Acute Care Surg. 2019 Jul 2. [Epub ahead of print]

• Drew B, Bennett, BL, Littlejohn L. Application of Current Hemorrhage Control Techniques for Backcountry Care: Part One, Tourniquets and Hemorrhage Control Adjuncts. Wilderness Environ Med. 2015; 26: 236-45.

• Littlejohn L, Bennett, BL, Drew B. Application of Current Hemorrhage Control Techniques for Backcountry Care: Part Two, Hemostatic Dressings and Other Adjuncts. Wilderness Environ Med. 2015; 26: 246-54.

• Kragh JF Jr , Dubick MA. Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science. Wilderness & Environ Med. 2017;28(S2):S25-S32.

• Kragh JF Jr, Newton NJ, Tan AR, Aden JK, Dubick MA. New and Established Models of Limb Tourniquet Compared in Simulated First Aid. J Spec Oper Med. 2018;18(2):36-41.

• McCarty JC, Caterson EJ, Chaudhary MA, Herrera-Escobar JP, Hashmi ZG, Goldberg SA, et al. Can they stop the bleed? Evaluation of tourniquet application by individuals with varying levels of prior self-reported training. Injury. 2019;50(1):10-15.

• Shackelford SA, Butler FK Jr, Kragh JF Jr, Stevens RA, Seery JM, Parsons DL, Montgomery HR, Kotwal RS, Mabry RL, Bailey JA. Optimizing the Use of Limb Tourniquets in Tactical Combat Casualty Care: TCCC Guidelines Change 14-02. J Spec Oper Med. 2015;15(1):17-31.

Acknowledgement:

Many thanks to MSG Monty Montgomery, SO-ATP, USA (Ret.) and his team of physicians and medics for undertaking the extensive CoTCCC tourniquet evaluation that resulted in 10 tourniquets now on the approved list. A large part of this article content comes from their study.