Page 104 - Journal of Special Operations Medicine - Summer 2015

“Testing of Junctional Tourniquets by Military Medics

to Control Simulated Groin Hemorrhage”

Richard Schwartz, MD; Bradford Z. Reynolds, MD; Richard D. Gordon Jr, MD;
Stephen A. Shiver, MD; Matthew Lyon, MD; Steven B. Holsten, MD

e read the article in the Fall 2014 issue titled measurements were made in the common femoral artery
W“Testing of Junctional Tourniquets by Military (CFA). The device was placed in the abdominal region
1
Medics to Control Simulated Groin Hemorrhage” with over the umbilicus; 100% of the volunteers were able to
great interest. The study attempted to compare the suc- tolerate application of the device, 100% showed reduc-
cess rates of four junctional tourniquets in treating a tion of flow, and 77% showed complete elimination of
potential vascular injury at the level of the inguinal liga- flow. 2
ment. We believe that the study has a number of meth-
odological problems that likely altered the conclusions In a second study, published in Military Medicine, we
of the article. used 16 British active duty Soldiers and also applied pulse
wave Doppler in the CFA. The device was also placed
3
One major problem is that the protocol described in the in the abdominal region over the umbilicus. Again, in
Methods section appears to have not been followed. this study, the device was tolerated by 100% of the study
The protocol indicates that the inguinal area was stud- participants. The device eliminated flow in the CFA in
ied. It states that “the right groin was assessed first; the 93.75% of the subjects. In the current article, only two
3
left groin was assessed second. Unilateral groin hemor- subjects (11%) tolerated application of the device. Prior
rhage was simulated. Each tester used each of the four evidence from two separate investigators demonstrated
models of tourniquet two times (once on the left and that the device was tolerated in 100% of 25 subjects.
once on the right side of the groin).” This is true for The authors of the current article did not cite either of
three of the devices; however, the Abdominal Aortic and these previously published articles. The cause of this dis-
™
Junctional Tourniquet (AAJT) was not studied in the crepancy is unclear. It is unlikely that the pain tolerance
inguinal area but rather in the abdominal or umbili- of this group of Soldiers differs from that of emergency
cal area. It is unclear why the authors did not test all medicine physicians or British soldiers.
four devices in the groin area according to their written
protocol. The AAJT has always had US Food and Drug One potential confounder is that in both previous stud-
Administration (FDA) approval for inguinal (groin) ap- ies the subjects had a single application of the device. In
plication. Despite this, the investigators chose to apply the current article, the subjects had the various devices
the AAJT in its abdominal aortic placement rather than placed eight times (three times on the right, three times
in the groin placement. This is simply not a reasonable on the left, and twice over the umbilicus) over a 3-hour
comparison. It is well established that placement of the time frame. The repetitive application of the device may
AAJT in the abdominal configuration causes more dis- cause anxiety or a bias with subsequent applications.
2
comfort than does groin placement. The authors state However, the discomfort of the device is far less than
that the AAJT was not FDA approved for groin place- what would be expected from a wound such as trau-
ment at the time of the study; however, a review of FDA matic bilateral amputations from a blast injury that
filings shows the AAJT’s initial approval was for both would require the use of an abdominal tourniquet.
abdominal and inguinal application.
Despite the discomfort associated with the abdominal
The validity of this study also comes into question be- placement, the AAJT is the only device that appears to
cause its findings are dramatically different than those be capable of safely stopping all hemorrhage distal to
4,5
of two published studies looking at the abdominal place- the aortic bifurcation. This becomes very important
™
ment of the Abdominal Aortic Tourniquet (AAT). We when one looks at the injury patterns of potential sur-
previously published data based on use in nine healthy vivors on the battlefield. Prospectively collected data
emergency medicine physicians. Pulse wave Doppler on UK military personnel in Afghanistan identified 32

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