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It should be noted that we did not evaluate for clot stabili- 2. Keene DD, Penn-Barwell JG, Wood PR, et al. Died of wounds: a
zation in this study. However, studies on intra-abdominal in- mortality review. J R Army Med Corps. 2016;162(5):355–360.
sufflation with gas, self-expanding polyurethane foam, and doi:10.1136/jramc-2015-000490
hyper- pressure intra-abdominal fluid using sharp trocars have 3. Walker NM, Eardley W, Clasper JC. UK combat-related pelvic
junctional vascular injuries 2008–2011: implications for future in-
all been shown to improve survival by significantly reducing tervention. Injury. 2014;45(10):1585–1589. doi:10.1016/j.injury.
12
11
blood loss and stabilizing clots in splenic, portal, hepatic, 2014.07.004
13
and mesenteric injuries, as well as in iliac and pelvic injuries. 14 4. Barnard EBG, Smith JE. Non-compressible torso haemorrhage: the
new holy grail for further improvement in trauma survival. J R Nav
IAPs of just 15–20mmHg have been demonstrated to equate to Med Serv. 2018;104(2):107–114. doi:10.1136/jrnms-104-107
a highly significant reduction in arterial blood flow to splenic 5. Morrison JJ. Noncompressible torso hemorrhage. Crit Care Clin.
2017;33(1):37–54. doi:10.1016/j.ccc.2016.09.001
45
(>44%), portal (63%), hepatic (>39%), left gastric (40%– 6. Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage:
44
11
54%) and mesenteric (54%) 11,46 arteries. IAPs up to 40mmHg a review with contemporary definitions and management strate-
through fluid administration have been demonstrated to have gies. Surg Clin North Am. 2012;92(4):843–858. doi:10.1016/j.suc.
titratable effects on superior mesenteric artery flow, especially 2012.05.002
47
in the presence of hemorrhage. Titratable temporizing of 7. Morrison JJ, Stannard A, Rasmussen TE, Jansen JO, Tai NR,
hemorrhage has been demonstrated in high-grade hepato- Midwinter MJ. Injury pattern and mortality of noncompress-
portal injury porcine models when intra-abdominal foams are ible torso hemorrhage in UK combat casualties. J Trauma Acute
Care Surg. 2013;75(2 Suppl 2):S263–S268. doi:10.1097/TA.
applied. Prolonged increases in IAP are detrimental, but we 0b013e318299da0a
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49
must strike a balance between hemorrhage control, prevent- 8. Stannard A, Brown K, Benson C, Clasper J, Midwinter M, Tai NR.
able battlefield death, and potential organ damage. Outcome after vascular trauma in a deployed military trauma sys-
tem. Br J Surg. 2011;98(2):228–234. doi:10.1002/bjs.7359
It has already been demonstrated that after 1 hour of training, 9. Theodorou CM, Salcedo ES, DuBose JJ, Galante JM. Hate to
Combat Medics can apply AAJT-S in less than a minute at burst your balloon: successful REBOA use takes more than a
course. J Endovasc Resusc Trauma Manag. 2020;4(1):21–29. doi:
the point of injury, with further training reducing this to just 10.26676/jevtm.v4i1.106
26
over 30 seconds, including body armor and belt kit removal. 10. Douma MJ, Picard C, O’Dochartaigh D, Brindley PG. Proximal
Prehospital randomized control trials are ongoing comparing external aortic compression for life-threatening abdominal-pelvic
AAJT-S to standard care. and junctional hemorrhage: An ultrasonographic study in adult
volunteers. Prehosp Emerg Care. 2019;23(4):538–542. doi:10.10
80/10903127.2018.1532477
Conclusion 11. Perova-Sharonova VM, Albokrinov AA, Fesenko UA, Gutor TG.
Effect of intraabdominal hypertension on splanchnic blood flow
An applied AAJT-S at 250mmHg inflation generates a prox- in children with appendicular peritonitis. J Anaesthesiol Clin Phar-
imal epigastric compartment pressure sufficient to temporize macol. 2021;37(3):360–365. doi:10.4103/joacp.JOACP_293_19
any hemorrhage from injury to branches of the celiac trunk 12. Duggan M, Rago A, Sharma U, et al. Self-expanding polyure-
and solid organs. This effect is not compromised by 500mL thane polymer improves survival in a model of noncompress-
of blood in the abdomen. AAJT-S is a forward combat medic– ible massive abdominal hemorrhage. J Trauma Acute Care Surg.
2013;74(6):1462–1467. doi:10.1097/TA.0b013e31828da937
delivered, titratable, point-of-injury intervention that provides 13. Rago A, Duggan MJ, Marini J, et al. Self-expanding foam im-
non-surgical hemorrhage control and likely clot stabilization proves survival following a lethal, exsanguinating iliac artery in-
for zone 1 NCTH injuries. jury. J Trauma Acute Care Surg. 2014;77(1):73–77. doi:10.1097/
TA.0000000000000263
Acknowledgments 14. King DR, Hwabejire JO, Pham QP, et al. Self-expanding foam ver-
The authors would like to acknowledge the Brighton and Sus- sus preperitoneal packing for exsanguinating pelvic hemorrhage.
sex Medical School Anatomy Department and the cadaver do- J Trauma Acute Care Surg. 2024;96(5):727–734. doi:10.1097/TA.
0000000000004138
nors for providing their bodies for science and consenting to 15. Barnard EB, Morrison JJ, Madureira RM, et al. Resuscita-
image release. tive endovascular balloon occlusion of the aorta (REBOA): a
population-based gap analysis of trauma patients in England
Author Contributions and Wales. Emerg Med J. 2015;32(12):926–932. doi:10.1136/
PJP conceived the original concept and designed the study emermed-2015-205217
with IP. TNS, IP and PJP performed data collection. TNS pre- 16. Brenner M, Bulger EM, Perina DG, et al. Joint statement from
pared the manuscript, with PJP providing guidance and edi- the American College of Surgeons Committee on Trauma (ACS
torialization. All authors approved the final draft. PJP acts as COT) and the American College of Emergency Physicians (ACEP)
regarding the clinical use of resuscitative endovascular balloon
guarantor. occlusion of the aorta (REBOA). Trauma Surg Acute Care Open.
2018;3(1):e000154. doi:10.1136/tsaco-2017-000154
Disclosures 17. Jansen JO, Hudson J, Cochran C, et al. UK-REBOA Study Group.
The authors have nothing to disclose. Emergency department resuscitative endovascular balloon oc-
clusion of the aorta in trauma patients with exsanguinating
Funding hemorrhage: the UK-REBOA randomized clinical trial. JAMA.
The authors have not declared a specific grant for this research 2023;330(19):1862–1871. doi:10.1001/jama.2023.20850
from any funding agency in the public, commercial or not-for- 18. Chien C-Y, Lewis MR, Dilday J, Biswas S, Luo Y, Demetriades D.
Worse outcomes with resuscitative endovascular balloon occlu-
profit sectors. sion of the aorta in severe pelvic fracture: a matched cohort study.
Am J Surg. 2023;225(2):414–419. doi:10.1016/j.amjsurg.2022.
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Abdominal Aortic Tourniquets for Epigastric Non-Compressible Torso Hemorrhage | 21