Junctional Hemorrhage Control for Tactical Combat Casualty Care

Abstract

During historic, as well as more recent, conflicts, most combat casualties who die from their injuries do so in the prehospital setting. Although many of the injuries incurred by these casualties are nonsurvivable, a number of injuries are still potentially survivable. Of those injuries that are potentially survivable, the majority are truncal, junctional, and extremity hemorrhage. Novel and effective approaches directed toward prehospital hemorrhage control have emerged in recent years, some of which can prove useful in the management of junctional hemorrhage whether in a military or civilian setting. An initial comprehensive review of junctional tourniquets was conducted by the Department of Defense Committee on Tactical Combat Casualty Care in 2013. The objective of this article is to provide an updated review of junctional hemorrhage control efforts and devices as they apply primarily to military prehospital trauma management and Tactical Combat Casualty Care and to prompt further consideration and application of these devices in nonmilitary prehospital, austere, and wilderness environments. Four junctional tourniquets are currently cleared by the Food and Drug Administration (FDA) for junctional hemorrhage control, and 1 junctional tourniquet is also FDA-cleared for pelvic stabilization. As junctional hemorrhage control efforts progress, scientists need to continue to conduct research and clinicians need to continue to monitor the performance of junctional tourniquets, especially in conjunction with morbidity and mortality outcomes, for both military and civilian trauma patients.

Continuum of the United States military’s traumatic brain injury care: adjusting to the changing battlefield

“…During the last decade, several clamp-type devices have been introduced for the control of junctional hemorrhage (e.g., pelvic or shoulder) and are available for larger deployed units. 10 Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently been introduced as a means for the temporary control of hemorrhage from intraabdominal injuries, and deploying surgeons have the opportunity for REBOA training. This intervention has been shown to effectively stabilize some casualties with severe liver or splanchnic hemorrhage, but it cannot be inflated for more than a few hours.…”

Topical hemostatics for bleeding control in pre-hospital setting: Then and now

“…Among the injuries that caused death, 67.3% were truncal, 19.2% were junctional (neck, axilla, and inguinal regions), and 13.5% were located on the extremities. [1,2] This data reveals the paramount importance of hemorrhage control to save lives with proper scientific and technical measures. Topically applied hemostatic agents mainly aim to help those with junctional hemorrhage because they are not suitable for tourniquet application, such as extremity wounds.…”

Combat lifesaver-trained, first-responder application of junctional tourniquets: a prospective, randomized, crossover trial

“…As of June 2018, four devices are approved by the US Food and Drug Administration (FDA) for junctional hemorrhage: The Abdominal Aortic and Junctional Tourniquet (AAJT, Compression Works, Birmingham, Alabama, US), the Combat Ready Clamp (CRoC, Combat Medical Systems, Fayetteville, North Carolina, US), the Junctional Emergency Treatment Tool (JETT, North American Rescue, Greer, South Carolina, US), and the SAM Junctional Tourniquet (SJT, SAM Medical Products, Portland, Oregon, US). The AAJT is the only device with a contraindication, since it exerts its compressive forces onto the abdomen [ 4 ]. The CRoC is effective, but feedback from military prehospital providers indicates that it is too bulky [ 9 ].…”

“…The JETT and SJT are the least expensive [ 9 ]. The SJT is the only junctional tourniquet (JTQ) that is FDA approved for pelvic stabilization [ 4 ].…”