Page 76 - JSOM Winter 2019

The Potential Use of the Abdominal Aortic Junctional Tourniquet
®
in a Military Population

A Review of Requirement, Effectiveness, and Usability

1
Charles Handford, MBChB (hons), MRCS, DMCC, PGCME, RAMC *;
Paul Parker, FIMC, FRCSEd (Orth), RAMC 2

ABSTRACT
Uncontrolled hemorrhage is the leading cause of preventable personnel in combat situations could use the device. This re-
prehospital death on the battlefield; 20% is junctional. This is port examines the potential uses of the AAJT and its potential
a challenge to manage in the forward and prehospital military place within the current operating environment.
environment. With the widespread use of body armor, periph-
eral tourniquets and continued asymmetric warfare this con- The AAJT
sistent figure is unlikely to reduce. Resuscitative endovascular
balloon occlusion of the aorta (REBOA) is an often-quoted The AAJT is an external compression device developed and
potential solution; however, this invasive strategy requires a manufactured by Compression Works and can be used for
high skill level alongside a significant failure and complication junctional bleeding in the groin or axilla. Due to its ability to
rate. The Abdominal Aortic Junctional Tourniquet (AAJT) is provide compression at the aortic bifurcation, it can be used
®
a noninvasive potential adjunct for the management of hem- for pelvic bleeding. Eighty-five percent of all pelvic bleeding is
orrhage below the level of the aortic bifurcation with pub- venous, and REBOA does not affect the valveless inferior vena
lished case reports of successful use in prehospital blast and cava (IVC), the additional IVC compression provided by the
gunshot wounds. When placed at the level of the aortic bi- AAJT is likely to be beneficial.
furcation, alongside a pelvic binder, it can be used to control
pelvic hemorrhage, buying time until definitive management. The AAJT is applied and buckled around the waist with the
Importantly it has a low training burden and is easy to use. inflatable bladder over the region of the umbilicus, the belt is
The AAJT has potential use as a prehospital device in the ex- tightened, and the windlass is turned (Figure 1). The bladder
sanguinating patient, those in traumatic cardiac arrest, as a is then inflated using a hand pump until the pressure indica-
bridging device, and as fluid conserving device in resource-lim- tor shows green, indicating a pressure of between 250 and
ited environments. The evidence surrounding the AAJT is re- 300mmHg. Overinflation is prevented by a “bleed-off” valve
viewed, and potential uses in the military setting are suggested. that occurs above pressures of 300mmHg. 3
FIGURE 1 Combined pelvic binder and AAJT application.
Keywords: tourniquet; trauma; military; junctional; hemor-
rhage; combat; mortality; pelvic injury; prehospital

Introduction
Uncontrolled hemorrhage is the leading cause of preventable
prehospital death. Limb tourniquets, such as the Combat Ap-
®
plied Tourniquet (C-A-T), are now commonly used in both
civilian and military trauma for peripheral bleeding. Uncon-
trollable hemorrhage is more likely to be in junctional regions
or truncal (pelvic, abdominal, and thoracic). For pelvic, lower
limb junctional or proximal lower limb trauma too high for
a classic tourniquet, multiple adjuncts have been suggested,
although the definitive answer is surgery. Suggestions include
abdominal foams, selective aortic perfusion strategies, and
REBOA. However REBOA is a complex and invasive inter- Epidemiological Requirement
vention, with significant associated morbidity, and requires a
1,2
trained and competent user. The AAJT is a noninvasive alter- A large review of US casualties in Iraq and Afghanistan re-
native approach to pelvic or lower limb trauma not amenable vealed that the majority of deaths occurred in the prehospital
to standard tourniquet use. It is a rapidly applied, easy-to-use arena and that a quarter (24.3%) were potentially surviv-
device with a low training burden. This means that less-trained able. Of these potentially survivable cases, 90.9% died of
4
*Correspondence to charles.handford@nhs.net
1 Maj Handford is a core surgical trainee at Queen Elizabeth Hospital Birmingham, UK. Col Parker is from the Royal Centre for Defence Medi-
2
cine, Queen Elizabeth Hospital, Birmingham, W. Midlands, UK; and senior lecturer in SOF medicine at University College Cork.
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