Low-cost synthetic tourniquet training model.

the results of the Objective: to present a low-cost model for bleeding control training with the use of a tourniquet and the results of the training evaluation. Method: low-cost and easy-to-purchase materials, such as upholstery foam, ethylene-vinyl acetate (EVA) sheet, plastic propulsion pump, saline container, water, school paint, serum equipment, rubber tubing for tourniquet, and a leg and an arm of a ghost mannequin, were used. In the model assembly, we created an active bleeding simulation system, which could only be controlled with the correct application of the tourniquet. The model was submitted to professional and academic evaluation. Results: the model was similar to human anatomy, proved to be practical in the bleeding control training with the use of a tourniquet, and had low cost. Conclusion: the model for bleeding control training had excellent acceptability, was considered viable for educational purposes of tourniquet use, and had low cost.

In civil setting, the strategy of care with an initial priority in the control of the exsanguinating external injury has been inspired by this military approach.

The current editions of Advanced Trauma Life
Support®/ATLS® (10th edition) and Prehospital Trauma Life Support®/PHTLS® (9th edition) comment on the importance of early bleeding control and tourniquet use. In particular, PHTLS® has instituted XABCDE (where "X" corresponds to the immediate control of external hemorrhage 11,12 ) for civil prehospital care.
Given these new guidelines of initial trauma care, it becomes necessary to strengthen education through quality trainings, using efficient teaching and learning strategies. One of these tools is the application of anatomical models for training the use of tourniquets. In developing countries such as Brazil, it is desirable that educational equipments be economically accessible 13,14 . Thus, the aim of this study is to present a low-cost model for bleeding control training with the use of a tourniquet and the results of the training evaluation.

Original Article
Low-cost synthetic tourniquet training model.

METHODS
The model of this paper was elaborated by its authors, who are members of League of Trauma, Emergency, and Intensive Medicine/Fortaleza University.
In order to construct the model, they invested an amount of R$49,60 (U$ 11.50), destined to the acquisition of the necessary materials. The main used materials were: a leg of a ghost mannequin (functioning as anatomical support), a plastic saline container (to hold simulated blood), one meter of rubber tubing (serving as blood vessels), a simple manual air pump (as a blood propellant), a serum equipment (to control blood flow volume and pressure), 50cm upholstery foam (to simulate musculature and subcutaneous fat), a 60X40cm ethylene-vinyl acetate (EVA) sheet (simulating the the "skin" of the model), and 250ml of red school paint and water (simulating blood).
Initially, an opening was made in the anterior region of the plastic mannequin's leg to simulate a penetrating wound with vascular lesion. Then, two proximal holes to the initial opening were performed, at a distance of 5cm and 7cm with a rubber tubing passing through the leg in the proximal opening (wound), externalizing through the hole which was 7cm distant from the initial opening and entering the plastic leg through the next hole. The end of the tubing was positioned in the opening that simulated the lesion. After these steps, the interior of the plastic leg was filled with upholstered foam and the exterior was coated with EVA to simulate the skin. In the final stage, the school paint was mixed with water to achieve near-blood consistency and then this mixture was stored in a plastic container with an inlet for the air pump and an outlet for the serum equipment, which was connected to the rubber tubing. Thus, by activating the pump, the simulated blood was ejected from the container, passed to the equipment, where its flow could be adjusted, entered the rubber tubing, and gushed at the site of the simulated injury.
To be effective, the tourniquet should be applied between 5cm and 7cm from the site of the simulated bleeding in gush, produced by air pump effect.
The tourniquet used was the Combat Application Tourniquet® (CAT®). The assembled device ready for use can be seen in figure 1.

DISCUSSION
Simulators are inanimate models developed for practical training of technical and/or motor skill, contributing to the development of professional competence, especially during undergraduation.
One of the advantages of the simulation and training using models is that they allow the practice repetition, making it easier for the trainee to reach the desired level of expertise. In general, they are classified as low-, medium-, and high-fidelity models, these latter with high cost and greater complexity in handling [14][15][16][17] . The model of this study was not difficult to be built, besides having a viable educational applicability proposal and low cost.