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.

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.
• Understand time-critical pressure requirements because tourniquet must achieve adequate pressure to occlude distal pulses within 60 seconds to meet standard-of-care expectations.
• Recall tourniquet effectiveness assessment criteria because visual and palpable feedback (absence of bleeding, loss of distal pulse, limb color change from pink to pale/cyanotic) confirms proper application.

• 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 wound over bone because this placement ensures arterial occlusion and prevents slippage during transport.
• 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.
• Assess and respond to tourniquet failure because learners must recognize continued bleeding or return of distal pulses and know to re-tighten or reapply.

• 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 Fluid Reservoir: Fill the internal water reservoir to the marked line using clean tap water. The reservoir circulates through the pump mechanism to simulate arterial blood flow through the extremity.

Prime the Circulation Pump: Activate the pump mechanism and run one full cycle (approximately 30–60 seconds) with no tourniquet applied. Observe water flow through the transparent section of the simulator. This priming step removes air bubbles and ensures steady, consistent flow during training.

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:

Table Height: Position the simulator on a table at elbow height (approximately 91 cm / 36 inches). This height allows learners to apply tourniquets without excessive bending and approximates realistic prehospital positioning where an extremity lies on a stretcher or ground surface.

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

Supply Staging: Arrange tourniquets, elastic bandages, markers, and assessment tools (pulse oximeter or doppler, if available) within arm's reach of the simulator. Include both simple and advanced tourniquet designs (CAT, SOFTT, etc.) if training multiple device types.

Visual Reference: Post an anatomical diagram of the lower extremity showing the proximal femur and tibial landmarks. Learners should reference this diagram when identifying correct placement sites.

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

Drain Hose: Open the drain valve at the simulator base and allow all water to drain completely into a collection basin. This prevents stagnant water and removes any debris.

Refill Fresh Water: After draining, refill the reservoir with fresh tap water to the marked line. Do not reuse water from previous sessions.

Inspect and Replace Springs (if needed): Examine the spring mechanism for permanent deformation, cracks, or corrosion. Springs that no longer return to original shape should be replaced. Spring replacement kits are available from the simulator manufacturer.

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.

Release Spring Tension: If the simulator will not be used for more than one week, gently compress the spring mechanism and secure it in a partially compressed state using a velcro strap (do not over-compress). This rests the spring and extends its lifespan.

Drain Reservoir: Open the drain valve and allow all remaining water to drain completely. Do not leave standing water in the system between sessions.

Store Horizontally: Place the simulator on a flat, level surface in a cool, dry room. Store horizontally (not tilted or at an angle) to prevent internal component drift.

Protect from Extreme Temperatures: Store away from direct sunlight and heat sources. Ideal storage temperature is 15–25°C (59–77°F). Avoid freezing conditions, which may crack hoses or the water chamber.

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This simulator is designed to support the following fidelity domains:

Learning Objective	Fidelity Domain	Simulator Feature
Identify anatomical landmarks for tourniquet placement	Visual	Leg-shaped model with clear bony prominences (simulated femoral head, tibia) allowing learners to practice landmark palpation and tourniquet positioning
Apply appropriate tightening force	Tactile	Spring-resistance mechanism provides feedback when tourniquet is tightened; resistance increases as pressure adequate to stop flow is approached
Stop simulated blood flow	Functional	Spring compression stops water flow through the circulation pump when tourniquet achieves adequate pressure; learners verify success by observing flow cessation
Recognize successful application	Feedback	Real-time visual feedback (water flow stops), palpable feedback (spring resistance changes), and optional pressure gauge reading (if available) confirm learner has achieved adequate tourniquet pressure

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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 palpates the simulated leg, locates the proximal femur or proximal humerus (depending on extremity), and marks the location where tourniquet will be applied. Correct placement is over bone and proximal to the wound site.
3. Apply tourniquet using correct technique — Learner wraps the tourniquet around the leg at the marked site and begins tightening the windlass mechanism. 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 (spring reaches compression threshold) and observes water flow stop in the transparent circulation chamber. This provides visual confirmation of success.
5. Assess distal perfusion changes — Learner observes the limb distal to the tourniquet and notes expected color change (from pink to pale or cyanotic). 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 any loose ends, and uses an indelible marker to write the application time on the tourniquet or on the simulated limb.
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 identification of anatomical landmarks before placing tourniquet
• 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:

• Landmark Identification: Learner correctly palpates and identifies the proximal femur (lower extremity) before tourniquet placement. Score: Pass / Fail
• Tourniquet Application Time: Learner applies tourniquet and achieves adequate pressure within 60 seconds of starting. 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
• Distal Assessment: Learner checks for expected color change distal to tourniquet and verifies absence of distal pulses (palpation or doppler). 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) to occlude the artery above the bleeding. Have learner re-palpate landmarks and reposition.
• 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, directly on skin over bone.
• 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 — Tourniquet placed across a knee joint will not function effectively. Have learner measure up from the knee and place tourniquet at the proximal thigh, 2–3 inches above the knee.
• Losing time through hesitation or indecision — Tourniquet application must be rapid in real trauma (within 60 seconds). If learner hesitates, provide feedback: "In real bleeding, delay costs the patient blood volume. Tourniquet must go on fast. 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
• Anatomical reference chart showing femoral and humeral landmarks
• Optional: Doppler device or pulse oximeter for distal perfusion assessment
• Optional: Pressure gauge (if simulator is equipped with sensor) for confirming pressure threshold

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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 $50 USD for the simple version, making it accessible in low-resource settings
• 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: March 2026*