TissueDB/SELF/Tourniquet Simulator Training

The Tourniquet Simulator Training Module provides the pedagogical framework and operational guidance for using the Tourniquet Simulator to train prehospital first responders, military medics, nursing students, and emergency personnel in correct tourniquet application for life-threatening extremity hemorrhage. Hemorrhage is the leading cause of preventable death after trauma, responsible for up to 40% of deaths.^[1] Simulation-based training measurably improves tourniquet application skill and speed in military and medical trainees.^[2][3]

The build page (Tourniquet Simulator) contains construction instructions only. This module captures how to USE the simulator for training.

Procedure Focus: Extremity hemorrhage control via tourniquet application (Combat Application Tourniquet / CAT and equivalent devices)

Target Learners: Emergency Medical Technicians (EMTs), military medics, first responders, nursing students, trauma team members

Learner Level: Novice to Intermediate

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Learners completing this training module will demonstrate competency across three domains:

• Recognize indications for tourniquet application because uncontrolled arterial hemorrhage from extremities requires rapid pressure application to prevent death from blood loss.
• Identify anatomical landmarks for safe tourniquet placement because incorrect placement (too distal, over the wound site) fails to occlude the artery and allows continued hemorrhage. The published placement rule is measured from the wound: place the tourniquet 2–3 inches above the wound.^[4]
• Understand time-critical pressure requirements because the tourniquet must achieve adequate pressure to occlude distal pulses. The 60-second figure used throughout this module is the training benchmark from published tourniquet simulator assessment, in which success was defined by three parameters measured by the simulator: applied pressure ≥ 200 mmHg, time to stop bleeding ≤ 60 seconds, and placement up to 7.5 cm above the amputation.^[5] It is not a published standard of care.
• Recall tourniquet effectiveness assessment criteria because visual and palpable feedback (absence of bleeding, loss of distal pulse) confirms proper application.
  • Caution — do not teach a specific distal colour sign from this page. Pallor and cyanosis are not the same sign: cyanosis distal to a tourniquet can indicate venous outflow obstruction from a tourniquet that is too loose, rather than successful arterial occlusion. No source currently supports naming one expected colour change, so teach absence of bleeding and loss of the distal pulse as the effectiveness criteria until a sourced colour sign is confirmed.

• Apply tourniquet to achieve adequate pressure because insufficient tightening allows continued blood flow and trainer provides real-time feedback via simulated blood flow resistance.
• Place tourniquet proximal to the wound because this placement occludes the artery and prevents slippage during transport. Measure from the wound: the model carries no bone landmark to place over.
• Secure tourniquet to prevent migration because loose application leads to loss of pressure, return of bleeding, and clinical failure.
• Mark tourniquet application time legibly because hospital staff must track ischemia duration and tourniquet removal timing depends on knowing exact application time. Verbalising the need to note the time of application is a scored item in the published assessment for this simulator.^[1]
• Assess and respond to tourniquet failure because learners must recognize that flow has continued or returned and know to re-tighten or reapply. On this model that sign is the water flow: it produces neither bleeding nor a distal pulse.

• Apply tourniquets in simulated extremity hemorrhage scenarios because learners must integrate anatomy, pressure requirements, and assessment in realistic trauma contexts.
• Communicate tourniquet application to receiving hospital staff because clear verbal and written handoff ensures continuity of care and allows surgeons to plan tourniquet management.
• Manage team dynamics during tourniquet application because prehospital response often involves two-person teams that must communicate clearly and cross-check decisions.

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Before learners begin training, prepare the simulator as follows:

Fill and pressurise: Fill the hand-pumped sprayer with clean tap water and put the free end of the latex hose into the collecting bottle.

Calibrate the flow: The published method calibrates the model with a blood pressure cuff, so the simulated flow can be stopped with reasonable force from a tourniquet.^[1]

Check Spring Tension: Verify that the spring-compression mechanism (which simulates arterial resistance) moves freely without binding. Press gently on the spring-loaded section and observe smooth compression and rebound. If movement is stiff or irregular, the spring may need replacement.

Run Test Cycle: Run one complete test cycle with a practice tourniquet applied by an instructor. Verify that adequate tourniquet pressure stops simulated flow. Learners should observe during this test to understand expected behavior.

Set up the training environment to maximize learning and safety:

Lighting: Ensure adequate overhead and task lighting so learners can clearly see the tourniquet placement, the spring tension indicator and the water flow changes that signal successful application.

Supply Staging: Arrange tourniquets and markers within arm's reach of the simulator.

After each learner completes practice, reset the simulator as follows:

Empty the water: Empty the collecting bottle and the sprayer tank into a sink or basin.

Refill Fresh Water: Refill the sprayer with fresh tap water. Do not reuse water from previous sessions.

Inspect the springs: Examine the four springs for permanent deformation or corrosion. Springs that no longer rebound are replaced by cutting a new 30 cm spring into four, as in the build.

Clean External Surfaces: Wipe down the external skin of the simulator with a damp cloth to remove sweat, dirt, and water residue from multiple learner hands.

At the end of the training day, prepare the simulator for storage:

Dry All Components: Use absorbent towels to dry all external surfaces, hoses, and the pump chamber. Pay particular attention to the connection points where water might accumulate.

Empty the water: Empty the sprayer tank and the collecting bottle. Do not leave standing water in the hose between sessions.

Store flat: Place the simulator flat on a level surface in a dry room.

Keep it dry and out of the sun: Store away from direct sunlight and heat sources.

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This simulator is designed to support the following fidelity domains:

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The simulator supports practice of the following critical procedures:

1. Assess bleeding severity and decide tourniquet indication — Learner observes the simulator flowing water (simulating arterial hemorrhage) and decides whether tourniquet application is required. The simulator allows learners to practice this decision-making in a low-stakes environment.
2. Identify correct placement site — Learner places the tourniquet proximal to the simulated wound. The published assessment scores this as positioning the tourniquet in the proper location,^[1] and the published placement rule measures 2 to 3 inches from the wound.^[4]
3. Apply tourniquet using correct technique — Learner wraps the tourniquet around the leg at the marked site, pulls the self-adhering band tight and fastens it back on itself, secures the strap so the band does not adhere past the windlass clip, then twists the windlass rod until bleeding stops and locks the windlass in its clip.^[1] The simulator's spring mechanism provides resistance feedback as the learner applies force.
4. Achieve adequate pressure to stop flow — Learner continues tightening the windlass until the resistance changes and the water flow stops.
5. Confirm the pressure threshold — In an advanced simulator with pressure sensing, a gauge or connected device confirms pressure threshold reached.
6. Secure and mark the tourniquet — Learner ensures the tourniquet is snugly applied without slippage, secures the windlass time tag across the clip, and verbalises and records the time of application.^[1] In the published assessment this step was the one novices most often omitted — only 20% of pre-training novices and none of the experts verbalised the need to note the time of application.^[1]
7. Recognize and respond to tourniquet failure — Instructor simulates failure scenarios (loose tourniquet causing water to resume flowing) and learner practices re-tightening or reapplication steps.

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Observe learners during simulator practice and provide real-time feedback on the following:

• Correct placement, measured 2 to 3 inches from the wound, since the model carries no anatomical landmark
• Proper hand positioning on the tourniquet device
• Appropriate force application rate (not sudden or jerking motions)
• Recognition of resistance changes as adequate pressure is approached
• Timely observation of flow cessation in the simulator
• Correct verbal communication of tourniquet application time and site
• Proper marking of tourniquet with legible time and date

Assess learner competency using the following checklist:

• Tourniquet Application Time: Learner applies tourniquet and achieves adequate pressure within 60 seconds of starting — the training benchmark, not a standard of care.^[5] Score: Pass / Fail
• Pressure Adequacy: Learner achieves sufficient pressure to stop simulated blood flow (observed water flow cessation). Score: Pass / Fail
• Tourniquet Securing: Tourniquet is applied snugly without slippage and is secured in place. Score: Pass / Fail
• Time Documentation: Learner writes application time legibly on tourniquet or leg using indelible marker. Score: Pass / Fail
• Placement: Tourniquet is positioned proximal to the simulated wound, 2 to 3 inches from it.^[4] Score: Pass / Fail

Learners must achieve Pass on all criteria to demonstrate competency.

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Trainers should watch for and address the following common errors:

• Placing tourniquet too distal (near the wound site) — The tourniquet must be placed proximal, away from the wound. Have the learner reposition further from the wound.
• Applying insufficient pressure — Learner tightens tourniquet incompletely, and water continues to flow through the simulator. Provide feedback: "The simulator is still flowing. Keep tightening until the flow stops completely."
• Applying tourniquet over clothing or at an angle — Twisted or tilted application reduces effective pressure and may cause slippage. Coach learner to apply tourniquet straight across the limb, flat against the surface.
• Failing to mark the time — Learner forgets to write the application time. Stress that in real trauma, hospital staff cannot manage the tourniquet properly without knowing exact application time. Make time-marking a mandatory final step.
• Loosening the tourniquet immediately after application — Learner tightens the tourniquet, observes flow stop, then relaxes pressure to "check" if it worked. Caution: "Once you tighten the tourniquet and stop the flow, do not loosen it. In real trauma, loosening restarts bleeding and wastes time."
• Applying tourniquet over a joint — A tourniquet placed across a knee joint will not function effectively. Move off the joint onto the thigh and place the tourniquet 2–3 inches above the wound — the published rule measures the gap from the wound, not from the knee, and placements closer than 2 inches to the wound were classed unsatisfactory.^[4]
• Losing time through hesitation or indecision — Speed matters, and 60 seconds is the training target this module scores against; no source on file sets a 60-second requirement for real trauma care.^[5] For reference, measured times to control bleeding on a low-cost tourniquet simulator averaged 96.3 s for untrained novices, 49.5 s for those same novices after training, and 50.3 s for experienced providers.^[1] If a learner hesitates, provide feedback: "In real bleeding, delay costs the patient blood volume. Practice until you can do it without hesitation."

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• Tourniquet Simulator (Build page: Tourniquet Simulator)
• Multiple tourniquets (Combat Application Tourniquet / CAT, SOFTT, or equivalent): at least 2–3 devices per session
• Elastic wrap or athletic tape for alternative applications (if practicing multiple tourniquet types)
• Indelible marker (permanent marker) for writing application time
• Absorbent towels for drying simulator between uses
• Collection basin for drain water
• Advanced version only: the pressure sensor and a device running the CrashSavers VR app.

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For simulator construction and technical specifications, see: Tourniquet Simulator

The build page contains:

• Materials list and costs
• Step-by-step assembly instructions
• Component specifications (spring tension, water reservoir capacity, pump specifications)
• Maintenance and troubleshooting guidance

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This module is part of the SELF (Simulation-based Education for Low-resource Facilities) framework, which focuses on practical, reproducible, low-cost simulation for training in resource-limited settings.

The Tourniquet Simulator exemplifies SELF principles:

• Low Cost: Approximately US$50 for the simple version, making it accessible in low-resource settings^[6]
• Reproducible: Uses off-the-shelf components available worldwide; no specialized engineering required to assemble
• Clinically Relevant: Addresses a life-critical procedure (hemorrhage control) that trainees must master regardless of setting
• Immediate Applicability: Skills practiced on the simulator transfer directly to real-world prehospital trauma response

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• SELF Module — Tourniquet Simulator Training*
• Cross-reference: Tourniquet Simulator (Build Page)*
• Last Updated: August 2026*