Now that extremity tourniquets are in widespread use by the U.S. military, junctional hemorrhage is the most common cause of death from compressible hemorrhage. —Death on the Battlefield (2001-2011): Implications for the Future of Combat Casualty Care
Junctional hemorrhage represents a critical area of concern in combat casualty care as improvised explosives have evolved to create more devastating injuries while, at the same time, modern body armor protects the trunk and vital organs extremely well while leaving the inguinal and axillary areas exposed. This same pattern can be applied to law enforcement special operations, as teams move toward smaller plate carriers that offer more mobility wile protecting less of the junctional anatomy. Perhaps paradoxically, this at a time when we are seeing more use of explosives by extremist groups moving against civilian targets both domestically and abroad.
I recently had the opportunity to work with several junctional tourniquet designs and therefore was curious how these devices compare with one another and with the more “traditional” approach of wound packing with hemostatic gauze followed by direct pressure.
Fortunately, there has been an influx of research on the management of these injuries. Wound packing with hemostatic gauze is perhaps the most commonly practiced intervention, for good reason. Modern hemostatic dressings are small, inexpensive, and well supported by research and extensive use in combat operations. One such study, published this month in Military Medicine, looks at junctional hemorrhage control with various hemostatic gauze products and wound packing. The products were found to be of similar efficacy and the intervention in this model was highly successful, resulting in survival of 96% swine subjects after minimal training.
Research from 2013 published in the Journal of Trauma and Acute Care Surgery uses the same standardized swine hemorrhage model, and finds QuikClot Combat Gauze XL, Celox Trauma Gauze, and HemCon ChitoGauze somewhat more effective in the control of hemorrhage than standard QuikClot Combat Gauze, though the differences did not achieve statistical significance.
Also in 2013, the CoTCCC examined four FDA-cleared junctional tourniquets in a recommendation for TCCC guideline updates. The associated document is titled Management of Junctional Hemorrhage in Tactical Combat Casualty Care, and is highly recommended reading for anyone interested in the matter. The committee ultimately recommended three devices: the Combat Ready Clamp (CRoC), the Junctional Emergency Treatment Tool (JETT), and the SAM Junctional Tourniquet. They examined,but did not recommend, the Abdominal Aortic Tourniquet (AAT), due to the fact that it is primarily intended as a truncal device and is contraindicated in the setting of penetrating abdominal injury.
The committee relied heavily on data from this comparison of the devices published in the American Journal of Emergency Medicine, which used a mannikin model to simulate hemorrhage. This comparison is particularly interesting as it includes the interventions of digital, manual, and knee compression, as well as compression using a kettlebell (to simulate a rock or other improvised device).
Of the ToCCC recommended devices, I had the opportunity to use the CRoC and the JETT. Of the two, my team preferred the JETT, as we found the CRoC too easily subject to displacement when the patient was moved. Regrettably, a SAM Junctional Tourniquet was not available. The data on the SAM device look promising, as this device was the quickest to occlude hemorrhage in the mannikin research, and it’s also cleared by the FDA as a pelvic binder. As I already carry a pelvic binder in my bag, the SAM is attractive in that it would simply replace the existing pelvic binder, not consuming additional bag space, and serve in both functions.
Another recent development in junctional hemorrhage management, iTClamp, controls bleeding by clamping a wound closed so that a clot can form. One study from 2014 using a human cadaver model found that the device “significantly reduced fluid loss in all wounds studied (p < 0.05), and movement of the cadaver did not affect the function of the iTClamp.” More recent research, from August of this year, looked at use of the iTClamp alone and in combination with wound packing in a swine model. This study found sealing wounds with the clamp after packing with gauze was a viable, quicker alternative to manual compression. Am I adding an iTClamp to my bag? I don’t know. I’d like to see data on how the clamp performs against the combination of wound packing followed by the application of a pressure dressing or one of the junctional tourniquets discussed above.
In light of this evidence, it appears that some augmentation to junctional hemorrhage management in addition to wound packing with hemostatic gauze alone is warranted. Of the devices I have used, I prefer the JETT. The SAM device looks great on paper, but I’d like to get my hands on one before making a recommendation.
Update 1/20/15: I have had a chance to play with the SAM tourniquet, and found that it met my expectations. Hemostasis was quick, simple, and effectively stopped circulation to the extremity. It also stayed in place with casualty movement. It is a smaller package than dedicated pelvic binders, as well.