Page 71 - JSOM Summer 2019

The Use of the Abdominal Aortic and Junctional Tourniquet
Versus Combat Gauze in a Porcine Hemicorporectomy Model

Richard Schwartz, MD ; Stephen A. Shiver, MD ; Bradford Reynolds, MD *;
1
1
1
2
John Lowry, DMV, MPH, MS ; Steven Holsten, MD ; Troy Akers, DO ; Matthew Lyon, MD 1
3
2

ABSTRACT
Background: Junctional hemorrhage is a potentially prevent- Novel hemostatic agents, including the older powder agents
able cause of death. The Abdominal Aortic and Junctional and the newer kaolin-impregnated gauze agents, have been
Tourniquet (AAJT) compresses major vascular structures and developed to potentiate the coagulation cascade and augment
arrests blood flow in exsanguinating hemorrhage. In a human hemorrhage control. These hemostatic agents are highly ef-
6,7
model, the AAJT was effective in stopping blood flow in the fective when placed directly over the source of bleeding but
femoral arteries via compression of the distal aorta. This study seem to lose utility during massive hemorrhage or when the
compares the ability of AAJT and Combat Gauze (CG) to stop source of bleeding is difficult to identify. 8–10
hemorrhagic bleeding from a hemicorporectomy in a swine
model. Method: Six anesthetized swine were used. Carotid ar- To effectively treat hemorrhage caused by lower extremity
terial catheters were placed for continuous mean arterial pres- groin trauma, the Abdominal Aortic and Junctional Tourni-
sure (MAP) readings. A hemicorporectomy was accomplished quet (AAJT; Compression Works, http://compressionworks
with a blade lever device by cutting the animal through both .com) was designed to compress major vascular structures
femoral heads transecting the proximal iliac arteries and veins. and thereby arrest blood flow in the setting of exsanguinat-
Hemorrhage control was attempted with the AAJT and regu- ing hemorrhage. In a human model, the AAJT is effective in
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lar Kerlix gauze or CG packing and direct pressure followed stopping blood flow in the femoral arteries via external com-
by Kerlix gauze placed over the CG. The primary outcome pression of the distal aorta. The device can be used as a junc-
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measure was survival at 60 minutes. Results: The 60-minute tional tourniquet in the axilla or over the inguinal ligament,
survival was 100% for the AAJT and 0% for the CG group. or as a truncal tourniquet over the aortic bifurcation. 13,14 The
During the 60-minute monitoring period, only one CG ani- AAJT was designed to be quickly deployed and maintained
15
mal achieved hemostasis. For the AAJT group, the mean time by a single provider, and has been used by the US Army and
to hemostasis was 30 seconds. Initial MAP was higher in the other militaries around the world. In June 2013, the AAJT
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AAJT group (mean, 87mmHg) than the CG group (mean, was used on a patient in Afghanistan with traumatic bilat-
70mmHg). The mean 60-minute MAP was 73mmHg for the eral amputation of the lower extremities and was successful in
AAJT group. Mean blood loss at 5 minutes and mean total achieving life-saving hemostasis. 16
blood loss were greater in the CG group than in the AAJT
group. Conclusion: AAJT is superior to CG in controlling Given prior research of the AAJT, an investigation of its effec-
hemorrhage in a junctional wound in a swine model. tiveness compared with the current standard of care (i.e., direct
pressure and Combat Gauze [CG; Z-Medica, www.z-medica
Keywords: junctional hemorrhage; gauze; tourniquet .com/healthcare]) was warranted. Our objective was to com-
pare the ability of the AAJT in its abdominal position (trun-
cal tourniquet) with the ability of CG to stop significant
“worst case” hemorrhage in a traumatic hemicorporectomy
Introduction
swine model. Several junctional tourniquets were considered
Acute hemorrhage is the leading cause of death in the first 24 to be included in this model, namely, Combat Ready Clamp
1–3
hours in both civilian and military trauma. Since the intro- (Combat Medical Systems, http://www.combatmedicalsystems
duction of body armor after the Vietnam conflict, the cause .com), Junctional Emergency Treatment Tool (North Ameri-
of death resulting from penetrating wounds to the chest has can Rescue, http://www.narescue.com), Sam Junctional Tour-
dramatically decreased while death resulting from face, neck, niquet (SAM Medical Products http://www.sammedical.com
and groin injuries continues at pre-body armor levels. The re- /products). The hemicorporectomy creates an extremely prox-
cent resurgence in the use of rapid application tourniquets has imal injury, which is proximal to the recommended points of
further decreased incidence of death resulting from extrem- attachment and compression of the listed devices. For this
ity exsanguination. Junctional hemorrhage (i.e., neck, groin), reason, they were not included in the study design. We hy-
however, continues to be a source of preventable death, partic- pothesized that the AAJT would control hemorrhage from
ularly on the battlefield. 4,5 pelvic vascular injuries that are not amenable to control with
*Correspondence to Bradford Reynolds, MD, Department of Emergency Medicine and Hospitalist Services, Medical College of Georgia, Au-
gusta University, AF 2039, 1120 15th Street, Augusta, GA 30912; or breynolds@augusta.edu
1 Drs Schwartz, Shiver, Reynolds, and Lyon are at Department of Emergency Medicine and Hospitalist Services, Medical College of Georgia,
2
3
Augusta University, Augusta, GA. Drs Lowry and Akers are at Eisenhower Army Medical Center, Fort Gordon, GA. Dr Hosten is at Department
of Surgery, Medical College of Georgia, Augusta University.
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