Page 33 - Journal of Special Operations Medicine - Summer 2016

Discussion Funding
The C-A-T was effective at eliminating distal pulses This study was supported by the Massachusetts General
and plethysmographic waveforms when applied over Hospital’s Division of Trauma, Emergency Surgery, and
the JSLIST. SOF operating in the nonpermissive CBRN Surgical Critical Care.
environment wearing the JSLIST can effectively control
extremity bleeding with the standard C-A-T applied over Disclosures
the top of the protective suit. The C-A-T performed as
well as our chosen gold standard device, a standard op- The authors declare no conflicts of interest.
erating-room pneumatic tourniquet. This represents the
first scientific description of the successful application of References
a tourniquet over the JSLIST to occlude arterial flow.
1. Holocomb JB, McMullin NR, Pearse L, et al. Causes of death
Military doctrine appropriately emphasizes the impor- in US Special Operations Forces in the global war on terror-
ism: 2001-2004. Ann Surg. 2007;245: 986–991.
tance of early and aggressive tourniquet application to 2. Eastridge BJ, Mabry RL, Sequin P, et al. Death on the battle-
6
control limb exsanguination. The most common tour- field (2001-2011): implications for the future of combat ca-
niquet carried on the battlefield to achieve this goal, by sualty care. J Trauma Acute Care Surg. 2012;73(6, suppl 5):
conventional military and SOF alike, is the C-A-T. It has S431–S437.
been shown to be largely effective in occluding arterial 3. Kragh JF Jr, Dubick MA, Aden JK, et al. U.S. Military use of
7,8
flow in the laboratory as well as the battlefield. 3–5 tourniquets from 2001 to 2010. Prehosp Emerg Care. 2015;
19:184–190.
4. Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with emer-
Not all studies, however, are in agreement on the overall gency tourniquet use to stop bleeding in a major limb trauma.
effectiveness of the C-A-T, with some authors reporting Ann Surg. 2009;249:1–7.
varied effectiveness. 9,10 This could have been a result of 5. Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital
BMI, interuser variability, self-application, or incorrect tourniquet use in Operation Iraqi Freedom: effect on hem-
orrhage control and outcomes. J Trauma. 2008;64(2 suppl):
application. As a consequence, we postulated that ap- S28–S37.
11
plication of the C-A-T over the bulky JSLIST protective 6. Walters TJ, Mabry RL. Issues related to the use of tourniquets
suit may be ineffective. This investigation demonstrates on the battlefield. Mil Med. 2005;170:770–775.
that, in the idealized laboratory environment, the C-A-T 7. Swan KG Jr, Wright DS, Barbagiovanni SS, et al. Tourniquets
revisited. J Trauma. 2009;66:672–675.
is effective when placed over the JSLIST. SOF operating 8. Walters TJ, Wenke JC, Kauvar DS, et al. Effectiveness of self-
in this environment should not expose lower extremity applied tourniquets in human volunteers. Prehosp Emerg
wounds before application of the C-A-T. Care. 2005;9:416–422.
9. Taylor DM, Vater GM, Parker PJ. An evaluation of two tour-
The study carries some limitations. Most importantly, it niquet systems for the control of prehospital lower limb hem-
orrhage. J Trauma. 2011;71:591–595.
was conducted in an idealized laboratory environment. 10. Wenke JC, Walters TJ, Greydanus DJ, et al. Physiological
Real-world results in a nonpermissive CBRN environment evaluation of the U.S. Army one-handed tourniquet. Mil Med.
are expected to be more variable. Furthermore, all tourni- 2005;170:776–781.
quets were placed by a single, experienced military trauma 11. King DR, van der Wilden G, Kragh JF Jr, et al. Forward as-
surgeon to eliminate interuser variability. The results may sessment of 79 prehospital battlefield tourniquets used in the
have differed if the tourniquets were self-applied or if they current war. J Spec Oper Med. 2012;12:33–38.
were applied by one volunteer to another. Although pulse
examinations were performed by an unblinded investiga- Dr Peponis is a trauma surgery research fellow at the Mas-
tor, plethysmographic amplitude was consistently below sachusetts General Hospital, Boston, Massachusetts.
the threshold for palpation in all cases where a pulse was
not appreciated. Finally, a sample size of 20 is standard in Dr Ramly is a trauma surgery research fellow at the Massa-
the literature for this type of investigation; however, as the chusetts General Hospital, Boston, Massachusetts.
patient population expands to include more variable BMI
and comorbid conditions, effectiveness may vary. Ms Roth is a trauma and acute care advanced nurse prac-
titioner at the Massachusetts General Hospital, Boston,
Massachusetts.
Conclusions
LTC King, US Army, is a surgeon at the Massachusetts Gen-
This study demonstrates that the C-A-T can be expected eral Hospital in Boston, Massachusetts, with a practice limited
to provide hemostasis for exsanguinating lower extrem- to trauma and acute care surgery, as well as surgical critical
ity wounds when placed over the JSLIST. SOF should care. He is an assistant professor of Surgery at the Harvard
maintain the same, aggressive, lower extremity hemor- Medical School, Boston, Massachusetts. Operationally, Dr
rhage-control posture in the CBRN environment that King is attached to the Joint Special Operations Command.
they maintain on the conventional battlefield. E-mail: dking3@mgh.harvard.edu.

Tourniquet Effectiveness When Placed Over JSLIST 19