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internal technique. However, REBOA and other noninvasive 2. Smith S, White J, Wanis KN, et al. The effectiveness of junctional
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techniques require special equipment, expertise, and, most im- tourniquets. J Trauma Acute Care Surg. 2018;86(3):532–539.
portantly, time. 3. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
(2001–2011). J Trauma Acute Care Surg. 2012;73:S431–S437.
4. Markov NP, DuBose JJ, Scott D, et al. Anatomic distribution and
As outlined, manual or knee-PEAC can be applied immediately mortality of arterial injury in the wars in Afghanistan and Iraq
by any minimally trained lay rescuer and requires no equipment with comparison to a civilian benchmark. J Vasc Surg. 2012;56
to be retrieved or applied. Even if not trained, it should be easy (3):728–736.
for 911 call-takers to provide bystander instruction, in the same 5. Smith ER, Shapiro G, Sarani B. Fatal wounding pattern and causes
manner as occurs with chest compressions after cardiac arrest. of potentially preventable death following the pulse night club
43
Accordingly, we believe PEAC is a maneuver that should be shooting event. Prehospital Emerg Care. 2018;22(6):662–668.
used as a rapid bystander intervention or buddy rescue tech- 6. Winstanley M, Smith JE, Wright C. Catastrophic haemorrhage
in military major trauma patients: a retrospective database anal-
nique and alongside traditional hemorrhage control measures. ysis of haemostatic agents used on the battlefield. J R Army Med
It can fit seamlessly into broader public health measures geared Corps. 2019;165(6):405–409.
toward engaging the public and first responders. 5,17 7. Chen J, Benov A, Nadler R, et al. Testing of junctional tourni-
quets by medics of the Israeli Defense Force in control of simu-
Though PEAC (whether by device, hands, or knee) is intui- lated groin hemorrhage. J Spec Oper Med. 2016;16(1):36–42.
tive and has likely been attempted many times, we believe it 8. Kragh JF, Kotwal RS, Cap AP, et al. Performance of junctional
tourniquets in normal human volunteers. Prehosp Emerg Care.
has still been insufficiently reported, studied, optimized, and 2015;19(3):391–398.
disseminated. The available literature suggests we need to do 9. Theodoridis CA, Kafka KE, Perez AM, et al. Evaluation and test-
better. For example, according to one report, a substantial ing of junctional tourniquets by Special Operation Forces person-
percentage (25%–72%) of junctional devices were not placed nel: a comparison of the Combat Ready Clamp and the Junctional
correctly or did not achieve hemostasis. We are not criticiz- Emergency Treatment Tool. J Spec Oper Med. 2016;16(1):44–50.
44
ing these devices nor denigrating their potential. Rather, we 10. Sadek S, Lockey DJ, Lendrum RA, et al. Resuscitative endovas-
believe manual or genicular PEAC offers an important adjunct cular balloon occlusion of the aorta (REBOA) in the pre-hospital
setting: an additional resuscitation option for uncontrolled cata-
role, especially while troubleshooting a device and as the pa- strophic haemorrhage. Resuscitation. 2016;107:135–138.
tient rushed to definitive rescue. 11. Sokol KK, Black GE, Willey SB, et al. Preperitoneal balloon
tamponade for lethal closed retroperitoneal pelvic hemorrhage
in a swine model. J Trauma Acute Care Surg. 2016;81(6):1046–
Conclusion 1055.
12. Sims K, Montgomery HR, Dituro P, et al. Management of EXTER-
As with much prehospital resuscitation research, evidence ex- NAL HEMORRHAGE in Tactical Combat Casualty Care: the
ists for PEAC but it is of low quality and frequently from col- adjunctive use of XStat compressed hemostatic sponges: TCCC
™
lateral populations, requiring inference. Accordingly, clinical Guidelines Change 15-03. J Spec Oper Med. 2016;16(1):19–28.
recommendations such as ours are at the level of expert opin- 13. Cantle PM, Hurley MJ, Swartz MD, et al. Methods for early con-
ion only. We believe the available indirect evidence supports trol of abdominal hemorrhage: an assessment of potential benefit.
the use of PEAC when faced with massive lower abdominal or J Spec Oper Med. 2018;18(2):98–104.
pelvic hemorrhage. The available evidence and opinion sup- 14. Riley D, Burgess R. External abdominal aortic compression: a
study of a resuscitation manoeuvre for postpartum haemorrhage.
port early application of PEAC until either (1) a suitable de- Aneasth Intensive Care. 1994;5(57):1–5.
vice (or hemostatic packing) can be applied or (2) an invasive 15. Douma M, Smith KE, Brindley PG. Temporization of penetrating
procedure such as REBOA or resuscitative thoracotomy can abdominal-pelvic trauma with manual external aortic compres-
be performed by a suitably skilled clinician, and as the victim sion: a novel case report. Ann Emerg Med. 2014;64(1):79–81.
is transported to surgical rescue. 16. Douma MJ, Picard C, O’Dochartaigh D, et al. Proximal exter-
nal aortic compression for life-threatening abdominal-pelvic and
junctional hemorrhage: an ultrasonographic study in adult volun-
Acknowledgment teers. Prehosp Emerg Care. 2019:23(4):538–542.
The authors acknowledge the courageous clinicians who are 17. Jacobs LM, Burns KJ, Langer G, et al. The Hartford Consensus:
early adopters of proximal external aortic compression and a national survey of the public regarding bleeding control. J Am
share their success stories. Coll Surg. 2016;222(5):948–955.
18. World Health Organizations (WHO). WHO Recommendations
Disclaimer for the Prevention and Treatment of Postpartum Haemorrhage.
The views expressed do not necessarily represent those of our Geneva, Switzerland: World Health Organization; 2012.
respective employers. 19. The Society of Obstetricians and Gynaecologists of Canada.
Advances in Labour and Risk Management. ALARM Course
Manual. 22nd ed. The Society of Obstetricians and Gynaecolo-
Author Contributions gists of Canada. 2015. https://alarm.cfpc.ca/wp-content/uploads
All authors equally contributed to the drafting and editing of /2015/05/22nd-Ed-Manual-Printable-Version.pdf. Accessed 29
this review, and read and approved the final manuscript. September 2019.
20. Queensland Government. Clinical Practice Procedures: Obstet-
Financial Support rics/Bimanual Compression. April 2016.
Our work is unfunded and we have no relationships with in- 21. Soltan MH, Sadek RR. Experience managing postpartum hem-
dustry, medication or device manufacturers. orrhage at Minia University Maternity Hospital, Egypt: no mor-
tality using external aortic compression. J Obstet Gynaecol Res.
2011;37(11):1557–1563.
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