MATCombat is a tourniquet that provides for emergency blood flow occlusion to the limbs. MATCombat was designed so that a casualty can apply it to themselves with one hand and with the distal portion of the extremity trapped or unexposed. These two capabilities are critical for self-rescue on the battlefield or in a disaster for a civilian emergency services first responder.

• Open C-Cuff design provides easy application to both arms and legs
• Buckle and Strap design provides fast, trapped limb application
• Turn Key system provides easy and safe tightening of the tourniquet in small, controlled increments, making it adjustable for various body types and sizes
• Turn Key Mechanical Advantage Mechanism ensures no slipping or loosening of the tourniquet
• Release Button, along with the buckle, provide for fast loosening, releasing, and re-application of the tourniquet

Tourniquets have been used as medical devices, in a variety of forms, for thousands of years. There are documented uses and commentaries by medical providers dating back to Greek and Roman times. The general use of tourniquets, types of tourniquets, when to use tourniquets, how to use tourniquets and clinical objective and anecdotal results of tourniquet usage have also been very controversial with commentaries varying from strong endorsements to outright vilification. Galen was one of the earliest recognized critics of tourniquet usage. Dr’s Fabry and Morel are both credited, by different studies, as using a tourniquet with the now familiar windlass design to tighten the actual constricting band. Dr’s Lister and Esmarch are credited with using tourniquets to perform “bloodless” surgery during the 1800’s. Dr. Cushing, the famous surgeon, demonstrated the first use of a pneumatic tourniquet in surgery in 1904.

(1,2) Tourniquets were included in surgery sets issued to physicians during the American Civil War (1861-1865) (1)

Literature and anecdotal commentaries during WW I and WW II were generally negative. In spite of this tourniquets of various forms were used during both wars. A review article written for the U.S. Army Medical Department in 1945, Dr.’s Wolfe and Adkins in their article “Tourniquet Problems in War Injuries” was in support of the use of tourniquets and negated concerns regarding most major complications. (2)

In two studies regarding casualties in the US-Vietnam conflict it was found that up to 38% of soldiers who died from extremity bleeding could have been saved by a tourniquet. The other study stated that 10% of combat deaths were caused by “uncontrolled hemorrhage from extremity wounds; many were due solely to ineffective field hemorrhage control methods.” (1,3)

Historically, tourniquets have been considered the medical device and hemostatic technique of last resort. There has been significant debate regarding when and how to use a tourniquet. The most common indications have been for amputations, partial amputations and moderate to severe extremity arterial bleeding. Most of the historically adverse commentaries about tourniquet usage are anecdotal and based on old battlefield reports. Many of these negative reports, studies and supposedly “documented” adverse clinical outcomes are due to many confounding variables and not directly attributable to the actual use of a tourniquet. Some of these negative confounding variables include but are not limited to: (1, 2, 4, 5)

1. Wound types that predominate on the battlefield that are rarely seen in civilian medicine
2. Poor training and education for medical and nonmedical personnel in appropriate tourniquet usage
3. Poor material and mechanical design of the tourniquet
4. Long evacuation times and delayed access to resuscitative surgery
5. Inadequate understanding and treatment of hypovolemic shock
6. Poor vascular surgery techniques
7. Lack of effective antibiotics until WWII

During the last 7 years there have been a number of well-designed studies and papers in support of appropriate tourniquet use. The positive results are due to many different factors. These factors include but are not limited to tourniquet engineering and materials, focused scenario based training for medical and nonmedical personnel, rapid evacuation to forward surgical teams and overall improvements in other battlefield healthcare systems.

The basic anatomic and physiologic principle of tourniquet usage for hemostasis is relatively simple biomechanics. However, hemostasis is a complex multistep process with multiple variables, the most important of which are flow volume and flow pressure. Other variables include but are not limited to concomitant morbidities, overall physiologic status (presence of hypothermia, acidosis, and effectiveness of the multistep coagulation cascade process) and the physiologic retraction/compression of muscles in and around the injured arteries and veins.

Tourniquets work on the basic principle of compressing muscle and other tissues that surround an artery. This leads to the closure or compression of the arterial lumina and cessation of arterial flow distally. In general a wider constricting band is more effective than a narrow one. (1)

Many different military publications cite severe hemorrhage as the #1 preventable cause of death on the battlefield. Many different military and civilian publications cite extremity hemorrhage as a common cause of significant military and civilian morbidity and mortality. In a study in Houston (published in 2005) “57% of those dying in metropolitan Houston is due to isolated penetrating extremity trauma had bleeding sites amenable to tourniquet therapy.” (1, 3, 6, 7, 9 )

There is general agreement from multiple sources for the initial management of extremity hemorrhage. Generally the first step in the control of rapid extremity bleeding is to provide direct pressure at the site of bleeding. Raising the extremity or the bleeding site above the level of the heart might also aid in hemostasis. Elevation decreases the hydrostatic pressure of venous and arterial bleeding and allows the normal physiologic mechanisms of hemostasis and coagulation to begin. Another technique to aid in hemostasis for extremities is the use of pressure points. This is done by applying strong deep pressure to the artery proximal to the site of bleeding. Traditionally pressure is applied to the brachial, axillary, femoral or popliteal artery as appropriate. There are a variety of hemostatic dressings, made of different substances that have become available over the last 8 years for use in the civilian and military communities that also can be used to stop the bleeding from extremities. (4, 5)

The factors that affect the use of a tourniquet are dependent on:

1. Effective training of the user
2. The type of wound or hemorrhage that is present
3. Transport time to resuscitative surgery or trauma center
4. Medical situation (i.e. battlefield, mass casualty event, complex disaster, traditional civilian emergency medical system response)

According to Advanced Trauma Life Support “In the worst cases, tourniquets are used. While there is a real risk of limb loss with a tourniquet, blood loss must be stopped to save the life of the patient.” (4)

This does not mean that a step wise progression of hemostasis intervention is appropriate; one does not apply direct pressure, elevate the limb, use pressure points and then place a tourniquet. If there is moderate to severe extremity bleeding a tourniquet should be placed on the casualty immediately. It should be placed close to the hemorrhage site as possible and tightened to the point where distal bleeding ceases. Once a tourniquet is applied it should be left in place until the casualty reaches a hospital or a location with resuscitative surgery capability. (2, 6, 7, 8)

Tactical Combat Casualty Care is the current U.S. military medical doctrine for medical and non-medical personnel on the battlefield. This doctrine states…“The temporary use of a tourniquet to manage life threatening extremity hemorrhage is recommended. Direct pressure and compression dressings are less desirable than tourniquets in this setting because their application at the site of injury may result in delays getting the casualty and rescuer to cover and they may provide poorer control of hemorrhage while the casualty is being moved.” (5, 8)

Dr. John Kragh, a U.S. military surgeon, studied tourniquet use in Iraq in 2006 and published a series of papers in support of tourniquet use for moderate to severe extremity hemorrhage. 97% of the tourniquets were applied for the appropriate indications. In this series of studies, 862 tourniquets were applied to 651 limbs of 499 wounded service members. These were very severe multiple wounds and of this group was an 87% survival rate. Survival rate was analyzed by when the tourniquet was applied; by the first responder/prehospital versus applied in the emergency department of the field hospital. 60% of the tourniquets were applied by the first responder/prehospital environment. The first responder/prehospital survival rate was 89% with tourniquet usage. When the tourniquet was applied in the emergency department the survival rate was 78%. Tourniquet use before shock (closely related to first responder/prehospital tourniquet application) saves more lives than tourniquets applied aftershock (in the emergency department). Another finding was that improvised tourniquets were better than no tourniquets at all. Complications, normally or anecdotally associated with tourniquet were about 1.7%. Most of these were transient nerve palsy. There were no amputations as a result of tourniquet usage. (9, 10, 11)

The U.S. military is a firm supporter of early tourniquet usage based on Kragh’s articles and others. Every service member is deployed with a tourniquet as part of their first aid kit. There are standardized training programs that are given to medical and non-medical personnel (including Tactical Combat Casualty Care) during initial and pre-deployment training.

A number of articles have advocated that it is time to reconsider civilian EMS usage based on recent US military experiences. “Emergency medical personnel, both civilian and military, should be trained in and equipped for the proper use of tourniquets…” This is especially true during manmade or naturally caused mass casualty events (MCE). The use of tourniquets in a MCE extends resources; the tourniquet can be applied and tightened and the patient’s life can be saved. A pressure dressing requires manual pressure for 5-15 minutes and the application of any type of pressure dressing does not ensure that the appropriate amount of direct pressure is applied at the correct location. (1, 2, 6, 8)

A study was conducted at the Boston Medical Center from January 1999 and April 2006. This study reviewed the presentation, treatment and outcomes of patients that came to the emergency department with a prehospital tourniquet in place. All patients were taken to the operating room for definitive care. The conclusion of the study was that “prehospital tourniquets can be appropriately applied to control life-threatening hemorrhage from an extremity injury and that their use is not associated with neurovascular complications.” (3)

A series of independent, protocol regulated, studies were conducted on a variety of commercially available tourniquets by U.S. Naval Sea Systems Command, Navy Experimental Dive Unit, between November 2005 and April 2007. In these studies the MAT® average application time was 51 seconds (with dominant hand 50 seconds, non-dominant hand 53 seconds). The MAT® was preferred by the test group users over all other tourniquets tested.

Protocol Guide: For the use of an emergency mechanical advantage tourniquet on patients suffering from moderate to severe hemorrhage. Organizational protocol is at the discretion of your Medical Director. New protocols for tourniquet use continue to evolve as Medical Directors seek to improve survival rates for these high risk patients.

Product Description: MATCombat Tourniquet. A one-handed tourniquet that stops moderate to severe extremity blood loss.

Use: Adults and Children Outcomes:

1. Lowered rate of morbidity/mortality.
2. Decreased blood loss and hemorrhage.
3. Application to arm or legs and trapped limbs in less than 10 seconds.
4. Provides 100% blood flow occlusion in less than 30 seconds.

Indications: Used in the initial treatment to temporarily control life-threatening limb hemorrhage or amputation.

Application: MATCombat can be easily placed by all levels of trained personnel in any environment. MATCombat should be applied and removed in accordance with your organizational protocols. Place the MATCombat cuff around the limb, proximal to the injury site, and with the housing facing upwards. Attach the buckle, which is located on the strap, to the hook on the tourniquet. Once the hook is in place, pull down on the strap snugly. Once the strap is snug and secured, rotate the Turn Key to tighten. The Turn Key should be tightened until bleeding from the injured extremity stops, indicating that blood flow has been occluded. To secure MATCombat, wind the strap around the Turn Key stem and fold the Turn Key down, or wrap the strap over the Turn Key and tuck the remaining strap underneath MATCombat. On the space provided on the Turn Key, record the application date and time. To release the MATCombat, press the red Release Button and the Turn Key will automatically unwind, push the pressure gate on the buckle to allow the strap to slowly slide through or, lift the buckle up and off its hook to release.

Considerations:

1. Apply MATCombat proximal to the wound and not over any joints.
2. Patients clothing should be cut away from where the MATCombat is applied so that it is clearly visible. Never cover up the tourniquet and ensure that it is visible at all times.
3. Monitor pulse and blood pressure in accordance with your organizational protocols.
4. At the time of patient transfer, document and communicate MATCombat application. If the patient is conscious, they should be instructed to let everyone they come in contact with know that they have a tourniquet in place.
5. Monitor injury site for recurrent hemorrhage and adjust MATCombat tightness if necessary.
6. Leave MATCombat in place until under conditions where the hemorrhage can be directly controlled.
7. Children under 50 lbs (23 kg) may be too small for MATCombat to fit a 4” diameter forearm.

Moderate to severe bleeding from the extremities has been cited in numerous articles as the most common cause of preventable death on the battlefield. And many different military and civilian publications cite extremity hemorrhage as a common cause of significant morbidity and mortality.

Tourniquets have been used as medical devices, in a variety of forms, for thousands of years. The US military has changed its approach to tourniquet usage during the last 8 years, now advocating early and aggressive use of tourniquets to control moderate to severe bleeding of the extremities. This policy is being adopted by civilian tactical medicine (SWAT) and routine pre-hospital trauma care algorithms.

Historically, tourniquets have been considered the medical device and hemostatic technique of last resort. This has been due to many negative reports, studies and supposedly “documented” adverse clinical outcomes with regard to tourniquet usage.

In fact, many of the “studies” were poorly researched and documented. Many of the supposed adverse outcomes were due to many confounding variables of the injuries, evacuation times and historical surgical techniques and not directly attributable to the actual use of a tourniquet. During the last 7 years there have been a number of well-designed studies and papers that support the use of tourniquets in appropriate situations.

The traditional initial management of extremity bleeding is to apply direct pressure, elevation of the extremity and the use of pressure points. Hemostatic dressings, available in a variety of forms, are also being used in the military and civilian medical communities.

The US military has found that well trained medics applying tourniquets early in the casualty care process saves lives with minimal adverse side effects.

Tourniquets are also very beneficial in mass casualty situations. First responders can rapidly place a tourniquet on a patient and then go help another patient.

Pyng Medical’s Mechanical Advantage Tourniquet (MATCombat) is a tourniquet that provides for emergency blood flow occlusion to the limbs. MATCombat was designed so that a casualty can apply it to themselves with one hand and with the distal portion of the extremity trapped or unexposed. These two capabilities are critical for self-rescue on the battlefield or in a disaster for a civilian emergency services first responder.