Page 60 - Journal of Special Operations Medicine - Spring 2016

Evaluation and Testing of Junctional Tourniquets
by Special Operation Forces Personnel

A Comparison of the Combat Ready Clamp and the
Junctional Emergency Treatment Tool

Charalampos A. Theodoridis, MD; Kelly E. Kafka, MD; Alejandro M. Perez;
Jeremy B. Curlee; Paul C.J. Yperman; Nico Oppermann; Eirik Holmstroem;
Derek D. Niegsch; Antonino Mannino, MD; Nicola Ramundo, MD

ABSTRACT
Background: Previous research has shown that external pelvic binder is not sufficiently tightened prior to thread-
hemorrhage from proximal leg amputations and junc- ing the T-handled pad. The CRoC’s application time can
tional sites represents 19.2% of potentially survivable be drastically reduced if the device is kept assembled and
lethal hemorrhage. A recent effort to address this prob- firm pressure is immediately asserted upon placement
lem has resulted in the development of various junctional on the intended location through the vertical arm, then
tourniquets. This study assessed and compared two Tac- threading the device. Both devices were applied safely;
tical Combat Casualty Care Committee–approved junc- no adverse effects were reported during or after applica-
tional tourniquets, the Combat Ready Clamp (CRoC) tion. Conclusion: Even though the JETT might be pre-
and the Junctional Emergency Treatment Tool (JETT), ferred by military medical providers, the CRoC still has
to contribute to their future development and to better merits. As both devices proved to occlude the arterial
inform on the decisions for device selection by military flow in no less than 54 seconds on average, they could
units. Aims of the study also were to provide concrete be used to supplement direct pressure and wound pack-
feedback and suggestions on how to effectively apply the ing, the latter two still being considered the immediate
devices. Methods: Via a specific questionnaire, 75 in- actions for inguinal bleeding control. Considering that
ternational attendees of the International Special Train- the CRoC and the JETT can be applied in as little as 37
ing Centre Medical Branch Special Operations Forces and 29 seconds, respectively, users should be effectively
Advanced Medical First Responder course evaluated trained and entirely proficient on either device to justify
the CRoC and the JETT on different parameters. Both their election as the primary countermeasure to hemor-
devices were tested objectively through timed applica- rhage not amenable to regular tourniquets.
tions aimed at stopping unilateral lower-extremity distal
pulse on 33 of these 75 students, verified by palpation Keywords: hemorrhage, junctional; hemorrhage control; tourni-
by Medical Branch instructors. Subjective and objective quet, junctional; Combat Ready Clamp; Junctional Emergency
data were examined for mutual correlation. Results: Us- Treatment Tool; Tactical Combat Casualty Care Committee
ers ranked the JETT higher than the CRoC on all param-
eters, including effectiveness on the battlefield (p < .001),
ease of use (p < .039), speed of application (p < .001), Introduction
and not slipping in use (p < .001), although the difference
on other parameters such as effectiveness in hemorrhage Hemorrhagic shock remains a leading cause of death
control was not statistically significant. Considering all and the first leading cause of preventable deaths in mili-
parameters together, the JETT was evaluated as a better tary trauma patients on the battlefield. In particular, ex-
device than the CRoC (p < .001). The application time ternal hemorrhage from proximal leg amputations and
measurement suggested that the JETT was applied faster junctional sites represents 19.2% of potentially surviv-
(by approximately 15 seconds on average; p < .001). The able lethal hemorrhage. For hemorrhage in body ar-
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fastest CRoC and JETT applications were 37 and 29 sec- eas too proximal for regular tourniquet use, junctional
onds, respectively. The JETT was not easier to use or tourniquets may be used. Junctional tourniquets apply
more effective than the CRoC; there was a 9% failure firm direct pressure necessary to stop bleeding from
rate of the JETT occluding a unilateral common femoral injured major vessels, including proximal amputation.
artery. The JETT’s efficacy in occluding a unilateral com- Previous research has demonstrated that a compression
mon femoral artery can be compromised if the device’s force equivalent to 54kg may be required to occlude the

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