Use of Haemostatic Devices for the Control of Junctional and Abdominal Traumatic Haemorrhage: A Systematic Review

Abstract

Catastrophic haemorrhage accounts for up to 40% of global trauma related mortality and is the leading cause of preventable deaths on the battlefield. Controlling abdominal and junctional haemorrhage is challenging, especially in the pre-hospital setting or ‘under fire’, yet there is no haemostatic agent which satisfies the seven characteristics of an ‘ideal haemostat’. We conducted a systematic search of Embase, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science to evaluate the feasibility and efficacy of three types of haemostatic devices. Participants included any trauma patient in a pre-hospital setting, perfused human cadavers, or healthy human volunteer simulations. The haemostatic devices reviewed were REBOA, iTClampTM, and four junctional tourniquets: AAJT, CRoC, JETT, and SJT. The SJT had the best user survey performance of the junctional tourniquets, and the four junctional tourniquets had an overall efficacy of 26.6–100% and an application time of 10–203 s. The iTClampTM had an efficacy of 60–100% and an application time of 10–60 s. REBOA had an efficacy of 71–100% and an application time ranging from 5 min to >80 min. In civilian and military trauma patients the use of junctional tourniquets, iTClamp, or REBOA, mortality varied from 0–100%. All of these studies were deemed low to very low in quality, hence the reliability of data presented in each of the studies is called into question. We conclude that despite limited data for these devices, their use in the pre-hospital environment or ‘under fire’ is feasible with the correct training, portable imaging, and patient selection algorithms. However, higher quality studies are required to confirm the true efficacy of these devices.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient

“…98 Junctional tourniquets have been shown to be safe and to effectively compress junctional vessels, but their clinical utility and impact on patient outcome are poorly studied. 99 Hemostatic dressings have been shown to be safe and superior to nonimpregnated dressings for hemorrhage control and may be associated with a decrease in transfused products when used for preperitoneal pelvic packing. 100 Data demonstrating improved outcome, including reduced transfusion requirements and mortality, are lacking for pelvic binder use.…”

“…Tourniquet use has been shown to decrease hemorrhagic shock and improve mortality after major limb trauma, with low rates of complications (most common transient nerve palsy) 98 . Junctional tourniquets have been shown to be safe and to effectively compress junctional vessels, but their clinical utility and impact on patient outcome are poorly studied 99 . Hemostatic dressings have been shown to be safe and superior to nonimpregnated dressings for hemorrhage control and may be associated with a decrease in transfused products when used for preperitoneal pelvic packing 100 .…”

Toward Smart, Automated Junctional Tourniquets—AI Models to Interpret Vessel Occlusion at Physiological Pressure Points

“…These devices are designed to maintain ongoing pressure on the vessel, pending a definitive surgical solution. Currently, there are four junctional tourniquets that are approved by the Food and Drug Administration: abdominal aortic junctional tourniquet (AAJT), junctional emergency treatment tool (JETT), SAM ® junctional tourniquet, and Combat Ready Clamp (CRoC) [12][13][14]. The AAJT consists of a windlass mechanism to stabilize the device on the abdomen, axilla, or groin, where then a pneumatic bladder is inflated to occlude the artery.…”