Page 73 - JSOM Summer 2018

Junctional Tourniquet Use During
US Combat Operations in Afghanistan

The Prehospital Trauma Registry Experience

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Steven G. Schauer, DO, MS *; Michael D. April, MD, PhD ; Andrew D. Fisher, MPAS, PA-C, LP ;
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Cord W. Cunningham, MD ; Jennifer M. Gurney, MD, FACS 5

ABSTRACT
Background: Hemorrhage is the leading cause of potentially a mechanism to control bleeding in these junctional regions
preventable death on the battlefield. Although the resurgence where hemorrhage can be treacherous and rapidly lethal. 5–7
of limb tourniquets revolutionized hemorrhage control in
combat casualties in the recent conflicts, the mortality rate for Goals of This Case Series
patients with junctional hemorrhage is still high. Junctional Previous case reports have documented successful junctional
tourniquets (JTQs) offer a mechanism to address the high tourniquet (JTQ) application in the combat environment. 8–11
mortality rate. The success of these devices in the combat set- Nevertheless, knowledge gaps exist regarding the feasibility
ting is unclear given a dearth of existing data. Methods: From and practicality of the current device technology. Using pre-
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the Prehospital Trauma Registry (PHTR) and the Department hospital data collected in Afghanistan, we report the largest
of Defense Trauma Registry, we extracted cases of JTQ use case series to date, to our knowledge, of JTQ application in
in Afghanistan. Results: We identified 13 uses of a JTQ. We the combat setting.
excluded one case in which an improvised pelvic binder was
used. Of the remaining 12 cases of JTQ use, seven had docu- Methods
mented success of hemorrhage control, three failed to control
hemorrhage, and two were missing documentation regarding Case Acquisition
success or failure. Conclusion: We report 12 cases of prehos- We extracted the cases from registry data. Cases were casual-
pital use of JTQ in Afghanistan. The findings from this case ties in Afghanistan during Operation Enduring Freedom from
series suggest these devices may have some utility in achieving 2013 to 2014. We obtained prehospital data from the PHTR,
hemorrhage control strictly at junctional sites (e.g., inguinal which is a module of the Department of Defense Trauma Reg-
creases). However, they also highlight device limitations. This istry (DoDTR); the Joint Trauma System (JTS) compiles and
analysis demonstrates the need for continued improvements maintains both databases at the US Army Institute of Surgical
in technologies for junctional hemorrhage control, prehospital Research. JTS personnel then linked subjects from the PHTR
documentation, data fidelity and collection, as well as training to the DODTR to obtain fixed-facility outcome data, when
and sustainment of the training for utilization of prehospital available. The US Army Institute of Surgical Research regula-
hemorrhage control techniques. tory office reviewed protocol H-16-003 and determined it was
exempt from Institutional Review Board review. We obtained
Keywords: junctional tourniquet; junctional hemorrhage; only deidentified data. After-action review (AAR) and Tacti-
trauma; combat cal Combat Casualty Care (TCCC) data contained within the
PHTR were reviewed to determine hemorrhage control, when
documented.
Introduction
PHTR
The most common cause of death on the battlefield is hem- The JTS analyzes the clinical data collected on the battlefield
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orrhage. Hemorrhage is the leading cause of preventable and provides near–real-time feedback to commanders when
death in the recent Iraq and Afghanistan wars. Of the combat possible. The primary purpose of this system is to improve
mortalities, junctional hemorrhage was the primary etiology casualty visibility, augment command decision-making pro-
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in 19.2% to 21% of deaths. The resurgence of limb tour- cesses, and direct procurement of medical assets. In addition,
niquets revolutionized hemorrhage control on the battlefield this system seeks to improve morbidity and mortality rates
in the recent conflicts. However, limb tourniquets lack the through performance improvement in the areas of primary
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ability to control hemorrhage in the junctional regions (i.e., prevention (e.g., tactics, techniques, procedures), secondary
truncal-extremity junctions like the groin, axilla and neck) prevention (e.g., personal protective equipment), and tertiary
where providers cannot place tourniquets and pressure dress- prevention (e.g., casualty response system, TCCC). The JTS
ings are often insufficient. Various compression devices offer captures all documented prehospital trauma care provided on
*Correspondence to 3698 Chambers Pass Road, Fort Sam Houston, TX 78234; or steven.g.schauer.mil@mail.mil.
1 MAJ Schauer is with the US Army Institute for Surgical Research and San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam
Houston, TX. MAJ April is with the San Antonio Military Medical Center. MAJ Fisher is with the 197th Special Troops Support Company
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(SO) (A), Camp Bullis, TX. LTC Cunningham is with the 1st Air Cavalry Brigade, Fort Hood, TX. COL Gurney is with the US Army Institute
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of Surgical Research and the Joint Trauma System, San Antonio, TX.
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