Page 33 - JSOM Fall 2019

Management of Hemorrhage From Craniomaxillofacial Injuries and
Penetrating Neck Injury in Tactical Combat Casualty Care

iTClamp Mechanical Wound Closure Device
TCCC Guidelines Proposed Change 19-04
06 June 2019

Dana Onifer, MD *; Jessica McKee, BA, MSc ; Lindsey (Kyle) Faudree, PA-C ; Brad Bennett, PhD ;
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Ethan Miles, MD ; Toran Jacobsen, SO-ATP ; John “Kip” Morey, SO-ATP ; Frank Butler, MD 8
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ABSTRACT
The 2012 study Death on the battlefield (2001–2011) by Eas- by any level of first responder with minimal training, and fa-
tridge et al. demonstrated that 7.5% of the prehospital deaths cilitates excellent skills retention. The iTClamp reapproximates
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caused by potentially survivable injuries were due to external wound edges with four pairs of opposing needles. This mecha-
hemorrhage from the cervical region. The increasing use of nism of action has demonstrated safe application for both the
Tactical Combat-Casualty Care (TCCC) and other medical patient and the provider, causes minimal pain, and does not
interventions have dramatically reduced the overall rate of result in tissue necrosis, even if the device is left in place for ex-
combat-related mortality in US forces; however, uncontrolled tended periods. The Committee on TCCC recommends the use
hemorrhage remains the number one cause of potentially of the iTClamp as a primary treatment modality, along with a
survivable combat trauma. Additionally, the use of personal CoTCCC- recommended hemostatic dressing and direct manual
protective equipment and adaptations in the weapons used pressure (DMP), for hemorrhage control in craniomaxillofacial
against US forces has caused changes in the wound distribu- injuries and penetrating neck injuries with external hemorrhage.
tion patterns seen in combat trauma. There has been a signif-
icant proportional increase in head and neck wounds, which Keywords: craniomaxillofacial injury; penetrating neck in-
may result in difficult to control hemorrhage. More than 50% jury; junctional hemorrhage; compressible hemorrhage;
of combat wounded personnel will receive a head or neck hemorrhage control; iTClamp; TCCC; Tactical Combat Ca-
wound. The iTClamp (Innovative Trauma Care Inc., Edmon- sualty Care
ton, Alberta, Canada) is the first and only hemorrhage control
device that uses the hydrostatic pressure of a hematoma to
tamponade bleeding from an injured vessel within a wound. Proximate Cause for This Change
The iTClamp is US Food and Drug Administration (FDA) ap-
proved for use on multiple sites and works in all compress- The physical proximity and relatively exposed location of ma-
ible areas, including on large and irregular lacerations. The jor vascular, neural, and airway structures in the head and neck
iTClamp’s unique design makes it ideal for controlling exter- make wounds in this region a challenge to treat, especially for
nal hemorrhage in the head and neck region. The iTClamp the Role 1 provider. These regions are not amenable to tour-
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has been demonstrated effective in over 245 field applications. niquet use, and the anatomy of the scalp makes compression
The device is small and lightweight, easy to apply, can be used challenging. Direct pressure of the neck can lead to airway and
*Correspondence to doctor.onifer@gmail.com
1 Dr Onifer is a Navy family physician, assistant professor of family medicine at the Uniformed Services University, and Undersea Medical Offi-
cer. He has served as both a physician and a Special Amphibious Reconnaissance Corpsman with USMC Reconnaissance units and the Marine
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Special Operations Command. Ms McKee is the project manager for the Department of Surgery, University of Calgary, Foothills Medical Cen-
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tre, Calgary, Alberta, Canada. Mr Faudree is a retired Army PA-C and prior Special Operations combat medic. He has served with the 82nd
Airborne Division and the 160th Special Operations Aviation Regiment. Dr Bennett is a physiologist who served on faculty and as the vice
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chairman of the Department of Military and Emergency Medicine at the Uniformed Services University. He served as the commanding officer of
Field Medical Service School, Camp Pendleton, CA, and the commanding officer of Naval School of the Health Sciences, Portsmouth, VA. Dr
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Miles is an Army family physician currently serving as the command surgeon for the US Army Maneuver Center of Excellence. HM1 Jacobsen,
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USN, is a Special Operations Independent Duty Corpsman (SOIDC) and advanced tactical paramedic, currently serving as the leading petty
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officer of Marine Special Operations Company (MSOC) Alpha and senior medic for Marine Special Operations Team (MSOT) 8111. HMCS
Morey, USN is an SOIDC and advanced tactical paramedic, currently serving as the medical leading chief petty officer for Tactical Development
Squadron 2, Naval Special Warfare Development Group. CAPT (Ret) Butler, USN, was a Navy SEAL platoon commander before becoming a
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physician. He is an ophthalmologist and a Navy Undersea Medical Officer with more than 20 years of experience providing medical support to
Special Operations Forces. Dr Butler has served as the command surgeon for the US Special Operations Command. He is currently the chairman
of the Department of Defense’s Committee on TCCC and chief of prehospital trauma care at the Joint Trauma System.
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