Page 80 - JSOM Winter 2019

AAJT for patient on their trauma registry. Strangely, in their FIGURE 2 Three potential scenarios for AAJT use.
41
study, they found that while 90% of trauma patients could
potentially benefit from REBOA, only 9% could have bene-
fitted from AAJT. A limitation of this study is that it is based
on a civilian population with the majority of the injuries being
above the aortic bifurcation. Within the military population
with the effectiveness of body armor protecting the torso and
prevalence of blast injury, the AAJT would be of increased use-
fulness than postulated in a civilian population by Cantle et al.

Both REBOA and AAJT appear to have potential benefit in
injuries distal to the aortic bifurcation, but patient selection
is likely to be the key factor with further research required in
comparing both interventions. In the military context, those
with DCBI or gunshot wounds to the groin/pelvis are the can-
didates most likely to benefit from AAJT or Zone 3 REBOA.
The likely strength of the AAJT over REBOA is ease of use and
low training burden, meaning that relatively low-skilled medi-
cal professionals or nonmedical personnel could easily use the
device and deliver far forward potentially lifesaving benefit.
Even clinicians trained in REBOA use are likely to suffer rel- an appealing potential solution—it is currently being adopted
atively rapid skill fade unless using the device and skills regu- by both military and civilian prehospital providers, which will
larly. To mitigate this risk, there needs to be regular training add further evidence to inform ongoing adoption or use of the
or acceptance of a significant governance risk. It is likely that device.
a “good” AAJT will always be better than a “bad” REBOA.
References
1. Brenner M, Bulger EM, Perina DG, et al. Joint statement from
Cost the American College of Surgeons Committee on Trauma (ACS
COT) and the American College of Emergency Physicians (ACEP)
In an increasingly budget-constrained environment, cost is a key regarding the clinical use of resuscitative endovascular balloon
consideration. The AAJT is advertised by Compression Works occlusion of the aorta (REBOA). Trauma Surg Acute Care Open.
2018;3(1):e000154. doi:10.1136/tsaco-2017-000154
(http://compressionworks.com/products-aajt/) at a retail value 2. Ribeiro Junior MAF, Feng CYD, Nguyen ATM, et al. The com-
of $525 (£415). The REBOA Kit is sold by SP Services (https:// plications associated with resuscitative endovascular balloon oc-
3
www.spservices.co.uk/item/Brand_REBOAKit_1_0_5519_1. clusion of the aorta (REBOA). World J Emerg Surg. 2018;13:20.
html) for $1507 (£1194). The increased cost of REBOA is doi:10.1186/s13017-018-0181-6
42
noteworthy compared with the AAJT, additionally as the 3. Fenton Pharmaceuticals. Abdominal Aortic Junctional Tourni-
quet Instructions for Use.
REBOA is an internal device that will need to remain sterile, 4. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
which will increase wastage due to shelf life and the inevita- (2001-2011): implications for the future of combat casualty
bility of tears to packaging when stored in a prehospital ber- care. J Trauma Acute Care Surg. 2012;73(6 suppl 5):S431–S437.
gan. Financial training cost is also likely to be increased for the doi:0.1097/TA.0b013e3182755dcc
REBOA compared with for the AAJT. 5. Kragh JF Jr, Murphy C, Dubick MA, et al. New tourniquet device
concepts for battlefield hemorrhage control. US Army Med Dep
J. 2011:38–48.
6. Walker NM, Eardley W, Clasper JC. UK combat-related pelvic
Study Limitations junctional vascular injuries 2008-2011: implications for future in-
In our review, the focus has been on the AAJT however there tervention. Injury. 2014;45(10):1585–1589. doi:10.1016/j.injury.
2014.07.004
are other external hemorrhage devices available which we 7. Morrison JJ, Ross JD, Rasmussen TE, et al. Resuscitative en-
have not explored in this paper. All of these devices, including dovascular balloon occlusion of the aorta: a gap analysis of
the AAJT, have limited evidence, with much of it being animal severely injured UK combat casualties. Shock. 2014;41(5):388–
study based. As the AAJT is used for real-life casualties, evi- 393. doi:10.1097/SHK.0000000000000136
dence for or against its use will start to build. 8. Barnard EB, Morrison JJ, Madureira RM, et al. Resuscita-
tive endovascular balloon occlusion of the aorta (REBOA): a
popu lation based gap analysis of trauma patients in England
and Wales. Emerg Med J. 2015;32(12):926–932. doi:10.1136/
Summary emermed-2015-205217
In 2013, the American Committee on TCCC added junctional 9. Smith S, White J, Wanis KN, et al. The effectiveness of junctional
tourniquet use to its recommendation for junctional hemor- tourniquets: a systematic review and meta-analysis. J Trauma
Acute Care Surg. 2018. doi:10.1097/TA.0000000000002159
rhage; however, currently, there is no equivalent in UK military 10. Kragh JF, Kotwal RS, Cap AP, et al. Performance of junctional
doctrine standard operating procedures. tourniquets in normal human volunteers. Prehosp Emerg Care.
2015;19(3):391–398. doi:10.3109/10903127.2014.980478
11. Taylor DM, Coleman M, Parker PJ. The evaluation of an abdom-
The AAJT likely offers an effective, low–training-burden inter- inal aortic tourniquet for the control of pelvic and lower limb
vention to be applied in the prehospital environment to poten- hemorrhage. Mil Med. 2013;178(11):1196-201 doi:10.7205/
tially salvage “potential survivors” with injuries distal to the MILMED-D-13-00223 [published Online First: Epub Date].
aortic bifurcation, and the authors envision three scenarios 12. Lyon M, Shiver SA, Greenfield EM, et al. Use of a novel ab-
in which AAJT could be beneficial (Figure 2). However, fur- dominal aortic tourniquet to reduce or eliminate flow in the
ther research is required with a scarcity of human data, and common femoral artery in human subjects. J Trauma Acute
Care Surg. 2012;73(2 suppl 1):S103–S105. doi:10.1097/TA.
other external devices are available. The AAJT appears to be 0b013e3182606219

78 | JSOM Volume 19, Edition 4 / Winter 2019