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the ground by all Services in the Afghanistan Theater. TCCC TABLE 2 Concomitant Interventions Performed
cards, Department of Defense 1380 forms, and TCCC AAR QuickClot
provide the registry data. Pressure Combat Limb
Case No. IV Fluids Dressing Gauze a Tourniquet
DoDTR 1 N Y N Y
The DoDTR, formerly known as the Joint Theater Trauma Reg- 2 N Y N Y
istry, is the data repository for DoD trauma-related injuries. The 3 Y Y Y Y
DoDTR includes documentation regarding demographics, in- 4 Y Y Y Y
jury-producing incidents, diagnoses, treatments, and outcomes 5 N Y N N
of injuries sustained by US and non-US military and US and 6 Y Y Y Y
non-US civilian personnel in wartime and peacetime from the
point of injury to final disposition. 7 N N N Y
8 N N N Y
9 N Y N Y
Results 10 N Y Y Y
From January 2013 through September 2014, there were 737 11 N Y N Y
casualties in Afghanistan entered in the PHTR. Of these, 29 12 N Y N N
were killed in action, five were dead on arrival, and three were IV, intravenous; N, no; Y, yes.
enemy prisoners of war. We excluded these casualties from a Z-Medica (www.z-medica.com/healthcare).
the case series. There were 190 cases that could be linked to
the DoDTR records. We identified 13 (11 via PHTR, two via we note three documented failures. The successes in the previ-
DODTR) of documented use of a JTQ in the prehospital set- ous reports may have been due to highly selective application
ting between the two databases. We excluded one case because of the device by specifically trained individuals or case report
the prehospital providers noted using the JTQ as an impro- bias whereby only unique or successful novel treatments were
vised pelvic binder. This left 12 cases available for inclusion in published. 12,13
this case series. Table 1 lists unit affiliations, highest provider
level, injury etiology, injury severity score (ISS), and survival JTQ were added to the TCCC guidelines in 2013 after the US
status (when available). All patients were military-aged men. Food and Drug Administration (FDA) approved the use of sev-
Table 2 lists concomitant procedures performed. Table 3 gives eral commercially available JTQs, each of which has pros and
select comments related to JTQ attempt failures. No patients cons. Users noted challenges with each device. For instance,
14
received prehospital tranexamic acid. the Combat Ready Clamp (CRoC ; Combat Medical Sys-
™
tems; http://www.combatmedicalsystems.com; Figure 1) takes
Of the 10 cases of device use with documented hemorrhage significant time to assemble; the SAM Junctional Tourniquet
®
control status, seven (70%) were successful and three (30%) (SJT; SAM Medical Products; http://www.sammedical.com
were unsuccessful in controlling the hemorrhage. For the re- /products; Figure 2) continues to have belt and buckle issues;
maining two instances, it was unclear whether placement was and the discs of the Junctional Emergency Treatment Tool
successful. (JETT ; North American Rescue; http://www.narescue.com;
™
Figure 3) can fail. Furthermore, neither the CRoC, JETT, nor
14
Discussion SJT can control hemorrhage from the more proximal vessels.
Moreover, only the Abdominal Aortic and Junctional Tourni-
We present 12 cases of JTQ use in the combat setting. In con- quet (AAJT; Compression Works; http://compressionworks
™
trast to previous case reports, which noted only successes, 8–11 .com) controls abdominal hemorrhage. 14,15
TABLE 1 Case Report Data From the Prehospital Trauma Registry and the Department of Defense Trauma Registry (When Available)
Survival to Survival to Prehospital Injury
Injury JTQ Hospital Hospital Hemorrhage Severity
Case No. Unit Provider a Etiology JTQ Type Location Arrival Discharge Control Score
1 SOC M Blast JETT L thigh Y UNK Y UNK
2 SOC UNK Blast UNK Bilateral thighs Unk N UNK 75
3 AFG M Blast UNK R thigh Y UNK Y UNK
4 AFG M Blast JETT R thigh/hip Y UNK Y UNK
5 CON MO GSW JETT R pelvis Y Y Y 10
6 AFG MO GSW SAM L groin Y UNK Y UNK
7 SOC M Blast JETT R groin N N N 75
8 AFG MO Blast UNK R leg Unk UNK UNK UNK
9 AFG MO Blast UNK R groin Y UNK N UNK
10 CON M GSW UNK R thigh Y Y Y 9
11 SOC M Blast UNK L leg Y Y Y 1
12 AFG MO GSW UNK L axilla UNK UNK N UNK
AFG, Afghani (military or police); CON, conventional forces; GSW, gunshot wound; JETT, Junctional Emergency Treatment Tool; JTQ, junc-
tional tourniquet; L, left; M, Medic; MO, medical officer; N, no; R, right; SAM, SAM Junctional Tourniquet; SOC, Special Operations Com-
mand; UNK, unknown; Y, yes.
a Based on the highest-level provider involved in prehospital patient care continuum.

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