Page 139 - JSOM Fall 2019

Dr Schreiber presented a study he conducted at Oregon Health Some tourniquet evaluation studies have been performed in
and Science University comparing Zone 1 partial REBOA* in recent years, but these studies have not been comprehensive
swine using two different catheters. Prytime, the manufacturer or standardized, making comparative quality assessments of
of the REBOA catheters used funded the study. the available tourniquet options more difficult. The criteria
selected and weighted scoring system standardizes a method
™
The Prytime pREBOA-PRO catheter has two balloons. The for comparable future assessments. No change in the word-
second smaller balloon pushes the first away from the aortic ing of the TCCC Guidelines is necessary, but should the
wall to create blood flow bypass channels. In this way, partial proposed change be approved, an updated list of CoTCCC-
occlusion is achieved without deflation of the main balloon.
recommended tourniquets will be published. Both the pub-
The study examined physiologic responses in subjects receiv- lished medical literature and unpublished military laboratory
ing partial REBOA with Prytime ER-REBOA catheters, par- reports were searched for evaluations of tourniquet perfor-
tial REBOA with pREBOA-PRO catheters, and no REBOA mance published since the original CoTCCC recommenda-
(controls). After a 4mm punch biopsy of the supraceliac aorta, tions in 2004.
uncontrolled hemorrhage was allowed for 30 seconds in the †
partial REBOA arms. This was followed by full inflation for The Criteria for Tourniquet Assessment were :
10 minutes to allow for stable clot formation. Thereafter par- 1. Arterial Occlusion
tial occlusion was maintained for 4 hours, maintaining mean 2. Time of Application
arterial pressure at 40 ± 5mmHg. a. Time to Occlusion <60 seconds
b. Time to Complete <90 seconds
The control group experienced 100% mortality within 20 3. Simplicity of Application
minutes after the onset of bleeding. There were no significant a. “Usability” / Ease of Use
differences in mortality, blood loss, blood pressure or other phys- b. Steps to Complete
iologic parameters between the ER-REBOA and pREBOA-PRO 4. Pressure
catheter groups. The pREBOA-PRO catheter required 70% a. To Achieve Initial Occlusion
fewer adjustments and this could allow for automation.
b. Evaluation for Potential Harm
5. Specifications
8. Comprehensive Tourniquet Review: a. Width
Mr Harold Montgomery – CoTCCC
b. Length
The first 2 tourniquets recommended for use on the battle- c. Locking Mechanism
field were the Combat Application Tourniquet (C-A-T) and d. Time Recording
the Special Operations Forces Tourniquet – Tactical (SOFT-T). e. Weight
These two tourniquets have performed well in combat casu- 6. Complications & Safety
alty care and there have been no updated TCCC tourniquet a. Reported Failures/Problems
recommendations made since 2004. b. Safety Issues
7. Usage Reports
The CoTCCC has recommended in the past that periodic, a. Combat Usage Reports
comprehensive, and standardized testing of the various com- b. Civilian Usage Reports
mercially tourniquets be conducted by the DoD. This would c. User Preferences
be helpful both to study new tourniquets and to evaluate the 8. Logistics
impact of changes that have been made to previously recom- a. NSN Authorized
mended tourniquets. (Both the CAT and the SOFT-T tourni- b. GSA Cost per Unit
quets have been modified from the versions tested in 2004.)
c. Commercial Cost per Unit
Other factors also make it important to review TCCC tourni-
quet recommendations at the present time: Weighted Scoring:

1. Although the C-A-T and the SOFT-T have performed well • Each component of the assessment criteria was scored with
in combat, there may be newer tourniquet technology that a weighted scale approach with each criterion having a 0-5
offers advantages in speed of application, simplicity of ap- score range.
plication, occlusion pressures achieved, safety, durability, • Data points resulting from studies with n greater than or equal
user preference, or other aspects of tourniquet performance. to 20 were weighted higher than those with less than 20.
2. Some tourniquets that have become commercially available The tabulated scoring results from the currently available lit-
have performed poorly – either in laboratory testing or in erature (in draft format) is shown at the top of the left-hand
actual use. Agencies making tourniquet purchase decisions column on page 138.
should be aware of these issues.
3. The newer versions of the C-A-T and the SOFT-T need to The CoTCCC will vote on changing the CoTCCC recommen-
be evaluated in comparison to other tourniquets to identify dations for tourniquets in the near future.
and characterize the effects of post-2004 design changes on
their performance. 9. Management of Hemorrhage From Craniomaxillofacial
4. Tourniquet use is increasing in the U.S. civilian sector as Injuries and Penetrating Neck Injury in TCCC:
®
a result of the American College of Surgeons “Stop the The iTClamp Mechanical Wound Closure Device:
Bleed” campaign. Many civilian agencies request guidance CDR Dana Onifer – Naval War College
from the CoTCCC on which tourniquets to acquire.
*REBOA Zone 1 extends from the celiac axis to the subclavian artery.
† Final criteria determined by the TQ breakout working group at the Sept. 2018 CoTCCC meeting.
CoTCCC Meeting Minutes | 137