Page 40 - JSOM Fall 2019

FIGURE 13 McKee JL, et al. The iTClamp in the treatment of After the tourniquet was applied, continued hemorrhage was
prehospital cranio-maxillofacial injury: a case series study. J Inj noted. Further examination showed an exit wound near the
Violence Res. 2019;11(1):29–34. Used with permission under groin with a likely femoral fracture. As the first officer and his
the terms of the Creative Commons Attribution 3.0 License
(http://creativecommons.org/licenses/by/3.0/) partner readied to apply another, more proximal tourniquet, a
third police officer arrived with an iTClamp that he had recently
been trained to use. The third officer instructed the second offi-
cer on how to apply the iTClamp to the exit wound. iTClamp
application achieved rapid hemorrhage control prior to the
successful application of the second tourniquet, and the patient
regained consciousness. The patient was found to have injuries
to both the femoral artery and vein and survived surgical repair.

Two additional case reports of iTClamp use were reported in
JSOM. In the first, a 26-year-old man suffered a 7.62mm
42
(AK-47) gunshot wound to the right medial thigh. Hematoma
formation in the wound tract and noticeable tissue deforma-
the iTClamp where eight of the cases involved CMFI or PNI. tion without external hemorrhage was observed, although no
Hemorrhage was described as adequately controlled in nine hemorrhage control intervention was in place. After examina-
of the cases. Another case series of 24 patients, including 14 tion and patient movement, arterial bleeding was observed
with head and neck injuries, was reported by the Northeast from the wound. The medic chose to use the iTClamp as the
Ambulance Service in the United Kingdom, where paramedics initial intervention. After application, the bleeding stopped,
also carried tourniquets and hemostatic dressings. Paramedics there was no further hematoma expansion, there was no
3
described the iTClamp as effective, quick, and easy to apply; complaint of discomfort, and surgical repair was described
as causing minimal pain; as being easy to learn; and as having as greatly eased. In the second case, a 28-year-old man suf-
high user satisfaction. Overall, paramedics in the field found fered a fragmentation wound to the lower left medial thigh.
that the iTClamp “enhanced their ability to quickly control Combined arterial and venous bleeding was described. Before
external hemorrhage in difficult anatomical areas and could the iTClamp application, the patient was applying self-aid
be used as part of a major hemorrhage control strategy.” 3 with ineffective intermittent manual pressure. Hemorrhage
was controlled after iTClamp application, and there was no
Clinical use of the iTClamp specifically for scalp and face lac- complaint of pain during or after application. It is important
erations was reported in the Journal of Injury and Violence to note that these two cases describe treatment that is not in
Research in 2019. Of 216 cases reviewed, 37% (n = 80) were accordance with current TCCC guideline recommendations.
9
for control of hemorrhage from CMFI (94% scalp and 6% Limb tourniquet application is the primary method to con-
face. Adequate hemorrhage control was reported in 87.5% trol life-threatening external hemorrhage that is anatomically
(n = 70) of cases. Direct pressure with packing was abandoned amenable to tourniquet use.
in favor of the iTClamp in 27.5% (n = 22) of cases.
4. What are the indications, contraindications, and warnings
Effective use of the iTClamp has been reported in several for the iTClamp?
other published cases, including successful control of PNI We recommend the iTClamp as a primary treatment modality
4,5
and CMFI hemorrhage with arterial involvement. In one for external hemorrhage from wounds in the head and neck
41
4,6
case, a paramedic used the iTClamp to treat a knife wound to region. The iTClamp should be combined with XStat or a
the posterior mandible and found it quick, easy, painless, and CoTCCC-recommended hemostatic dressing to facilitate hemo-
effective in an otherwise awkward area to treat. In a case re- stasis and reduce total blood loss in large penetrating neck
6
port describing a hypotensive patient (no palpable radial pulse) wounds with external hemorrhage. If the wound is longer than
with a left shoulder stab wound not amenable to tourniquet 5cm (2 inches), additional iTClamps should be placed end to
application, the bleeding was successfully controlled with the end in series. Although it is advisable to hold direct pressure at
iTClamp. Initial attempts at hemorrhage control with direct the bleeding site until the iTClamp is applied, there is no need
59
pressure or pressure dressing were unsuccessful due to pa- for additional direct pressure once the iTClamp has been placed.
tient agitation and noncompliance. An iTClamp was quickly
applied without patient complaint and provided immediate The manufacturer’s contraindication for iTClamp are included
hemorrhage control. Bleeding from the circumflex scapular ar- with the product’s “Directions for Use”:
tery was subsequently found on CT scan (performed with the
iTClamp in place) and was controlled with embolization by in- Do not use where wound edge approximation can-
terventional radiology. No operative repair of the injured ves- not be obtained (for example, large skin defects un-
sel was required, and the patient made an uneventful recovery. der high tension).

There have been several case reports of the iTClamp use in tac- Additionally, the manufacturer provides these relevant warn-
tical scenarios. In one case, police officers used a combination ings and precautions:
of tourniquets and the iTClamp to control a life-threatening
femoral artery injury from a 7.62mm (AK-47) gunshot wound 1. Do not use where delicate structures are near the skin sur-
in an unconscious patient. An entrance wound was observed face, within 10mm of the application site, such as the orbits
60
on the medial left thigh, just proximal to the knee. The first of the eye;
police officer was a combat veteran with prior training on tour- 2. This device is intended for temporary use only; use beyond
niquet use and applied a SOF-T tourniquet above the wound. 6 hours has not been studied;

38 | JSOM Volume 19, Edition 3 / Fall 2019