Saturday night turns into Sunday morning, and the ER waiting area finally starts to thin out when a panicked call comes in after a mass shooting at a nearby nightclub. Police have secured the scene and ambulances are heading your way. Multiple patients are brought in, with gunshot wound victims quickly overwhelming your department. One patient stands out—a 20-year-old male with a significant wound from a high-powered round to the right inguinal region. You quickly recognize that he is in hypovolemic shock. You apply pressure to the wound, but the bleeding won’t stop. You attempt to place a tourniquet, but the wound is too high to get the tourniquet proximal enough for it to work. You know that without immediate hemorrhage control he will not survive long enough to make it to the operating room.
In 2016, terrorist attacks in developed countries increased by 650% and killed over 15,320 people [1,2]. On June 16, 2016, the worst mass shooting in US history happened at an Orlando nightclub, only three blocks away from the sole Level I trauma center for central Florida. There were 49 killed and 53 wounded. Foreign- and home-born terrorist attacks are a sad part of our reality. Without rapid intervention of penetrating injuries, death may occur within minutes.
Junctional injuries occur at the junction of the trunk, limbs and neck. These injuries are not amenable to standard tourniquet application and may be challenging to control. A little more than a decade ago, the only therapeutic options in the prehospital setting were digital pressure, compression bandages and pneumatic garments. Non-surgical, hospital-based interventions included direct pelvic packing, vessel ligation, Foley or extravascular balloon tamponade, and iatrogenic abdominal cavity insufflation [3]. These methods, however, were neither available nor considered effective for the US military during the conflicts in Afghanistan and Iraq. Consequently, in 2003 novel hemostatic agents were fielded, later improved by impregnating them into bandages with some demonstrated efficacy in controlling junctional hemorrhage, but with limitations [3-5]. Junctional tourniquets (JTQ) were developed to fill this gap with the first device released in 2010.
Junctional Tourniquet (JTQ) Devices
The first JTQ produced was the Combat Ready Clamp manufactured by Combat Medical® pictured above. It resembles a vice and can be applied to a single inguinal or axillary wound, but does not stabilize the pelvis. The Junctional Emergency Treatment Tool (JETT pictured below) developed by North American Rescue®, is a pelvic binder with built-in bilateral compression devices that can be used for inguinal hemorrhage. Finally, further below is the SAM® Medical offers the SAM JTQ (SJT), which is a pelvic binder with detachable, pneumatic compression pieces that may be used on inguinal and axillary injuries.
How effective are JTQs for hemorrhage control?
Having only been cleared by the FDA for use in 2010, commercial junctional tourniquets are a relatively new arrival to the world of emergency and pre-hospital medicine. Real-world application of these devices has been limited, with few published case reports detailing their effectiveness in the field. Both the SJT and the CRoC tourniquets achieved effective hemostasis in case reports [6,7]. Data pending publication has found more mixed results.
Laboratory testing demonstrated 75-100% hemorrhage control rates at the inguinal regions of human and mannequin models [8-13]. However, laboratory-based testing does not always simulate real-world challenges. Most of the literature has found relatively equal efficacy between these three devices, each with its own set of nuances [8,10-13]. The Committee on Tactical Combat Casualty Care considers all three as viable options [13]. Reports from the end-users generally preferred the SJT and CroC devices [8,10-13]. Abdominal Aortic and Junctional Tourniquets have been proposed as an alternative technology, but that technology has not made its way onto the battlefield yet.
Take-Home Point
In civilian settings, over 64% of potentially survivable deaths were attributed in some way to hemorrhage [14]. Junctional hemorrhage presents unique challenges as traditional hemorrhage-control methods may be ineffective against such rapid exsanguination. JTQ can quickly control hemorrhage at these challenging anatomical locations. These lightweight, portable devices may soon find their way into your ambulances, emergency departments and tactical EMS bags.
Disclaimer
Opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, or the Department of Defense.
REFERENCES
- Withnall, A., Global Terrorism Index 2016: Developed countries suffer dramatic rise in terrorism-related deaths, in The Independent. 2016.
- Yourish, K.W., Derek; Giratikanon, Tom; Lee, Jasmine, How Many People Have Been Killed in ISIS Attacks Around the World, in The New York Times. 2016.
- Neuffer, M.C., et al., Hemostatic dressings for the first responder: a review. Mil Med, 2004. 169(9): p. 716-20.
- Conley, S.P., et al., Control of Junctional Hemorrhage in a Consensus Swine Model With Hemostatic Gauze Products Following Minimal Training. Mil Med, 2015. 180(11): p. 1189-95.
- Wedmore, I., et al., A special report on the chitosan-based hemostatic dressing: experience in current combat operations. J Trauma, 2006. 60(3): p. 655-8.
- Klotz, J.K., et al., First case report of SAM(r) Junctional tourniquet use in Afghanistan to control inguinal hemorrhage on the battlefield. J Spec Oper Med, 2014. 14(2): p. 1-5.
- Tovmassian, R.V., et al., Combat ready clamp medic technique. J Spec Oper Med, 2012. 12(4): p. 72-8.
- Chen, J., et al., Testing of Junctional Tourniquets by Medics of the Israeli Defense Force in Control of Simulated Groin Hemorrhage. J Spec Oper Med, 2016. 16(1): p. 36-42.
- Kheirabadi, B.S., et al., In vivo assessment of the Combat Ready Clamp to control junctional hemorrhage in swine. J Trauma Acute Care Surg, 2013. 74(5): p. 1260-5.
- Kragh, J.F., et al., Performance of Junctional Tourniquets in Normal Human Volunteers. Prehosp Emerg Care, 2015. 19(3): p. 391-8.
- Kragh, J.F., et al., Assessment of Groin Application of Junctional Tourniquets in a Manikin Model. Prehosp Disaster Med, 2016. 31(4): p. 358-63.
- Kragh, J.F., Jr., et al., Testing of junctional tourniquets by military medics to control simulated groin hemorrhage. J Spec Oper Med, 2014. 14(3): p. 58-63.
- Meusnier, J.G., et al., Evaluation of Two Junctional Tourniquets Used on the Battlefield: Combat Ready Clamp(R) versus SAM(R) Junctional Tourniquet. J Spec Oper Med, 2016. 16(3): p. 41-46.
- Davis, J.S., et al., An analysis of prehospital deaths: Who can we save? J Trauma Acute Care Surg, 2014. 77(2): p. 213-8.