Page 132 - JSOM Summer 2019

TABLE 2 Steps and Principles of Improvised Inguinal Junctional
Tourniquets
1. Apply manual pressure with a hemostatic.
2. Sole rescuers take a knee.
FIGURE 2 Lone
3. Select a pressure delivery device (PDD). rescuer with two free
4. Position the tourniquet or strap over the apex of the gluteal hands after taking a
muscle. knee in the inguinal
gutter.
5. Like improvised TQs, the most reliable IJTs have a windlass.
6. Position the windlass medial of the apex of the PDD.
7. Remove all the slack before tightening the windlass.
8. Take up tourniquet slack in a pushing motion across the patient’s
body.
FIGURE 3 Potential PDDs.
9. Junctional tourniquets move during transport.

followed by either a knee or a fist placed squarely in the
inguinal gutter on the injured side. Pack the wound with
an approved hemostatic followed by direct pressure. This
step is crucial and can afford the casualty precious time
while tourniquet preparations are made. Faltering on this inferiorly. From our experience, this step focuses the PDD
principle may result in the exsanguination of the casualty at the point most likely to cut off blood flow as measured
prior to application of the tourniquet. Manual pressure by Doppler (Figure 4).
during casualty movement may be difficult or impossible 5. Like improvised TQs, the most reliable IJTs have a wind-
to maintain, therefore it is of the utmost importance to ap- lass. Attempts with everything from pelvic binders to
5
ply a junctional tourniquet at the earliest opportunity. The tactical compression (Murphy) wrap in our training have
inguinal gutter is the linear crease between the top of the all led to the same conclusion: there always needs to be a
thigh and the lower abdomen with the vascular structures windlass in order to succeed at IJT application. Ratcheting
located midway between the pubic symphysis and anterior tourniquet mechanisms have shown promise but have been
superior iliac spine (Figure 1). insufficiently evaluated at SOCMSSC to provide comment.
FIGURE 4 Placement of tourniquet over the apex of the gluteal
muscle.

FIGURE 1 Manual
pressure in the
inguinal gutter.

2. Sole rescuers take a knee. If the rescuer is alone, prefera-
bly use a knee in the inguinal gutter in order to have two 6. Position the windlass (depicted by red line) slightly medial
hands free to prepare the IJT. Palpating distal pulses or of the apex of the PDD. This discovery was made during
with the use of a Doppler as described later can refine the the many thousands of repetitions at IJT training during
best pressure location of this technique. If pelvic fracture is SOCMSSC, especially with cylindrical or curved PDDs.
suspected, the rescuer must weigh the importance of hem- These observations were made purely by trial and error
orrhage control over the potential for further harm through and not through any structured research processes. This
manipulation of a fractured pelvis (Figure 2). step most consistently directs the PDD toward the femoral
3. Select a PDD. An object that fits into the inguinal gutter artery and prevents it moving more posteriorly compared
and can remain stable is half of the solution. The object to pressure directly over or lateral to the apex (Figure 5).
will usually be something either cylindrical or spherical. 7. Remove all the slack before tightening the windlass. Failure
Munitions or pyrotechnic devices should never be used as to take up all the slack is the number one reason for tour-
the PDD (Figure 3). niquet failure.
4. Position the tourniquet or strap over the apex of the gluteal 8. Take up tourniquet slack in a pushing motion across the
muscle. The apex of the gluteal muscle is the top part of patient’s body. Tourniquet slack can be difficult to take up
the buttocks and this prevents the strap from sliding off when pushing a small amount of strap into the ground or a

130 | JSOM Volume 19, Edition 2 / Summer 2019