Page 16 - Journal of Special Operations Medicine - Summer 2014

Abdominal Aortic and
Junctional Tourniquet Controls Hemorrhage

From a Gunshot Wound of the Left Groin

John Croushorn, MD, FACEP

ABSTRACT
“Junctional hemorrhage” is defined as bleeding from surgery. The patient successfully survived the surgery
the areas at the junction of the trunk and its append- and recovered to walk out of the hospital. 5
ages. This is an important cause of potentially prevent-
able deaths on the battlefield and a difficult condition In December 2013, the AAT was renamed Abdominal
to treat in the civilian prehospital setting. Having a so- Aortic and Junctional Tourniquet (AAJT) (http://www
™
lution to definitively treat the condition decreases the .compressionworks.net) and received new indications
mortality and morbidity of these injuries. The Abdomi- from the U.S. Food and Drug Administration to treat
nal Aortic and Junctional Tourniquet is (1) a Food and pelvic bleeding and bleeding in the inguinal region and
™
Drug Administration–cleared device that is currently axilla. The device placement also was changed to allow
indicated for pelvic, inguinal, and axillary bleeding; (2) for individual groin application and axillary placement,
the only junctional tourniquet with an indication for as outlined in the previously described case study.
pelvic bleeding; (3) the only junctional tourniquet re-
ported with a successful axillary use; and (4) effective at The present case report describes an on-label use of the
lower tissue pressures than other junctional tourniquets AAJT in the groin and demonstrates its safety and ef-
available. fectiveness in stopping hemorrhage from a challenging
wound.
Keywords: Abdominal Aortic and Junctional Tourniquet,
hemorrhage, gunshot wound
Case Presentation
A 21-year-old man was driven to the main entrance of
the emergency department. The patient had sustained
Introduction
three gunshot wounds to his lower extremities. His
Junctional hemorrhage is defined as bleeding from the right leg sustained two of these wounds, and his left leg
areas at the junction of the trunk and its appendages. sustained the third wound. The right leg wounds were
This is an important cause of potentially preventable not bleeding: They were to the right ankle and right
deaths on the battlefield and a difficult condition to treat mid-inner thigh. The latter had only one wound, and
in the civilian prehospital setting. Having a solution to radiography demonstrated a retained bullet. The left leg
definitively treat the condition decreases the mortality wound was to the proximal thigh. A small entry wound
and morbidity resulting from these injuries. was located laterally, and a large exit wound was lo-
cated in the proximal medial thigh. A large amount of
The U.S. military has identified junctional hemorrhage blood was noted in the patient’s pants. The proximal left
control as an important capability gap in military medi- thigh wound was bleeding profusely when exposed. The
cine. One recent review of battle casualties found that patient was lethargic. He was brought to a resuscitation
1
21% of casualties who died of wounds had junctional room, and direct manual pressure was applied to the left
bleeding, possibly amenable to a truncal tourniquet. groin wound to control the hemorrhage.
2
The Abdominal Aortic Tourniquet (AAT) was applied
™
to a Soldier with multiple life-threatening injuries in The diaphoretic patient was arousable but confused.
Afghanistan in 2013. The AAT rapidly stopped the The primary emergency physician focused on hemor-
3,4
bleeding and freed the hands of medical providers to rhage control, and a partner focused on assessing the
perform other lifesaving prehospital interventions on the airway. Monitoring at that time showed a heart rate of
wounded patient. The AAT was applied to an axillary 150 beats/min (bpm); however, blood pressure was too
wound in the patient who had lost 6 cm of his axillary low to be detected when measurement was attempted.
artery. It successfully stopped the hemorrhage and al- A thready carotid pulse was noted. With tachycardia,
lowed the patient to be resuscitated and to undergo unobtainable blood pressure, and lethargic state, the

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