Page 108 - JSOM Winter 2018

Efficacy of the Abdominal Aortic Junctional Tourniquet–Torso Plate
in a Lethal Model of Noncompressible Torso Hemorrhage

1,2
1†
1†
Alicia M. Bonanno, MD ; Heather E. Hoops, MD ; Todd L. Graham, BS ;
2
Benjamin L. Davis, MD ; Belinda H. McCully, PhD ; Lauren N. Wilson, BS ;
3
1,2
1,2
Brianne M. Madtson, CVT ; James D. Ross, PhD *
1,2
ABSTRACT
Background: The Abdominal Aortic Junctional Tourniquet, Recent interventions to address NCTH, including intraaortic
when modified with an off-label, prototype, accessory pressure balloon occlusion (IABO), have shown some promise but have
distribution plate (AAJT-TP), has the potential to control non- significant limitations in tactical settings, including the need
compressible torso hemorrhage in prolonged field care. Meth- for complex vascular access, lack of imaging confirmation,
6
ods: Using a lethal, noncompressible torso hemorrhage model, and proper training for placement. IABO has also been as-
24 male Yorkshire swine (81kg–96kg) were randomly assigned sociated with complications during blind placement, signifi-
into two groups (control or AAJT-TP). Anesthetized animals cant ischemia-reperfusion injury, and potential complication
7–9
were instrumented and an 80% laparoscopic, left-side liver lobe for limb ischemia. In addition, the therapeutic window for
transection was performed. At 10 minutes, the AAJT-TP was occlusion catheters like IABO is likely less than 30 minutes in
applied and inflated to an intraabdominal pressure of 40mmHg. the context of severe hypovolemia. There remains a need for
10
At 20 minutes after application, the AAJT-TP was deflated, but an easily deployable solution for NCTH in the setting of PFC.
the windlass was left tightened. Animals were observed for a
prehospital time of 60 minutes. Animals then underwent dam- The abdominal aortic and junctional tourniquet (AAJT; Com-
age control surgery at 180 minutes, followed by an intensive pression Works; http://compressionworks.com) is a US Food
care unit–phase of care for an additional 240 minutes. Survival and Drug Administration–approved device used for con-
was the primary end point. Results: Compared with Hextend, trol of axillary, pelvic, and lower-extremity junctional hem-
survival was not significantly different in the AAJT-TP group orrhage. 11,12 There have been several studies in both human
(p = .564), nor was blood loss (3.3L ± 0.5L and 3.0L ± 0.5L, and swine populations that demonstrated the effectiveness at
respectively; p = .285). There was also no difference in all physi- reducing peripheral blood flow with AAJT. 11–13 Case reports
ologic parameters between groups at the end of the study or end have also described its use, including application during pre-
of the prehospital phase. Three of 12 AAJT-TP animals had an hospital care to control severe hemorrhage in a casualty with
inferior vena cava thrombus. Conclusion: The AAJT-TP did not traumatic bilateral amputation of the lower extremities. 14,15
provide any survival benefit compared with Hextend alone in The AAJT may be a promising intervention in combat trauma
this model of noncompressible torso hemorrhage. during situations of PFC and temporary control of NCTH.

Keywords: noncompressible torso hemorrhage; junctional The AAJT, when modified with an off-label, prototype, acces-
tourniquet; swine; Sus scrofa; hemorrhage control; trauma; sory pressure-distribution plate (AAJT-TP), has the potential
prolonged field care to address the lethal injury complex in PFC (Figure 1). Our
purpose for this study was to assess the efficacy of the AA-
JT-TP on survival in a lethal model of NCTH in swine and
Introduction evaluate the physiologic dyshomeostasis associated with its
application. We hypothesized that the use of AAJT-TP would
Noncompressible torso hemorrhage (NCTH) remains a lead- be efficacious in the management of NCTH, as evidenced by
ing cause of potentially survivable prehospital deaths in mil- increased prehospital survival and reductions in prehospital
itary and civilian trauma. The approach to management blood loss.
1–3
of NCTH in situations where nondefinitive care is extended
over hours or days involves complex medical decision-making
with a shift of focus to prolonged field care (PFC) paradigms. Methods
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Rates of death from extremity hemorrhage have significantly Institutional Animal Care and Use Committee approval for
decreased in this phase of care, due to widespread tourniquet this study was obtained before initiation. Experiments were
use since 2005; however, there remains a challenge in control carried out in a facility accredited by the Association for As-
of junctional and torso hemorrhage. 5 sessment and Accreditation of Laboratory Animal Care at
*Correspondence to James D. Ross, PhD, Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health &
Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239; or rosja@ohsu.edu
1 Dr Bonanno, Dr Hoops, Mr Graham, Ms Wilson, Ms Madtson, and Dr Ross are at Department of Surgery, Oregon Health and Science Uni-
2
versity, Portland, OR. Mr Graham, Dr McCully, Ms Wilson, Ms Madtson, and Dr Ross are at Division of Trauma and Acute Care Surgery,
3
Oregon Health and Science University, Portland, OR. Dr Davis is with University of Arkansas for Medical Sciences, Division of Acute Care
Surgery, Little Rock, AK.
† These authors contributed equally to this work.
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