Page 42 - JSOM Winter 2024

An Analysis of Junctional Tourniquet Use
Within the Department of Defense Trauma Registry

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Hailey B. Reneau, MD *; Brit J. Long, MD ; Julie A. Rizzo, MD ;
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Andrew D. Fisher, MD, MPAS ; Michael D. April, MD, DPhil, MS ; Steven G. Schauer, DO, MS 6
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ABSTRACT
Background: Junctional hemorrhage is a leading cause of bat- Junctional injury patterns are unique because they lie within
tlefield death. Multiple FDA-approved junctional tourniquet hard-to-compress regions with a robust vascular system, lead-
(JTQ) models demonstrate effective hemorrhage control in ing to rapid exsanguination.
laboratory settings. However, there are few real-world use
cases within the literature. Methods: We analyzed the De- Types of Junctional Tourniquets (JTQs)
partment of Defense Trauma Registry (DoDTR) for casualties In their earliest iteration, attempts to control hemorrhage in
with documented JTQ application (2007–2023). Results: Of junctional regions included an external hardware device called
48,301 encounters, 39 included JTQ placement. The most the Combat Ready Clamp (CRoC, Combat Medical Systems,
common injury mechanisms were explosives (23), followed by Harrisburg, NC). The CRoC could apply pressure to a sin-
firearms (15). The most common (AIS >3) serious injury sites gle wound in the axilla or inguinal region to stop hemorrhage
were the extremities (21), followed by the abdomen (4) and with the disadvantages of being limited to only one injury site,
skin (4). Only one patient died. Of nine prehospital interven- heavy, slow to assemble, and unable to stabilize the pelvis. 7,8
tions, the most common were warming (21), limb tourniquet
application (16), and intravenous fluid administration (11). The CRoC was expanded upon with the Junctional Emergency
The most common associated diagnoses were lower- extremity Treatment Tool (JETT, North American Rescue LLC, Greer,
amputation (24), testis avulsion or amputation (11), pelvic SC) and the SAM Junctional Tourniquet (SJT, Sam Medical,
fracture (9), and tympanic membrane rupture (9). The most Tualatin, OR). The JETT is a pelvic binder with built-in bilat-
common hospital procedures were a focused assessment with eral compression devices for use on inguinal injuries. The SJT
sonography in trauma (32), laparotomy (20), chest tube place- similarly applies pneumatic compression but with a mobile,
ment (13), fasciotomy (13), and arterial line placement (13). inflatable compression disc to allow application to both in-
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Conclusion: JTQ application in the combat setting was rare. guinal and axillary injuries. These devices have the advan-
When it was performed, it was frequently in the polytrauma tage of doubling as a pelvic binder and do not require external
setting. Survival was high but DoDTR enrollment survival bi- hardware, making them lighter and more portable. The SJT is
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ases likely confounded this. also less likely to be disrupted during patient transport versus
CRoC and JETT. 10
Keywords: junctional; hemorrhage; tourniquet; combat; military;
trauma; Department of Defense Trauma Registry; prehospital The Abdominal Aortic and Junctional Tourniquet (AAJT,
care; battle injuries; operational medicine Compression Works Inc., Birmingham, AL) is the latest deriva-
tion of the model (approved by the FDA in 2023). The AAJT
not only compresses junctional hemorrhage and acts as a pel-
vic binder but can also be placed on the abdomen itself to
Introduction
occlude the descending aorta directly. 11,12
Massive hemorrhage is the leading cause of preventable death
1,2
on the modern battlefield. As such, hemorrhage control is the Junctional tourniquets (JTQs) like these are not limited to
foundation of both Tactical Combat Casualty Care (TCCC) commercially available products. Recent data demonstrates
and damage control resuscitation (DCR). While point-of- improvised JTQs can be an effective method of hemorrhage
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injury tourniquet use has greatly improved survivability of control for injuries in the pelvic region. 13
extremity trauma, junctional injuries in the groin and axilla
4,5
remain a challenge; they accounted for 19.2% of lethal hemor- Efficacy of JTQs
rhages in combat fatalities in Afghanistan and Iraq from 2001 A growing body of evidence in animal models, 11,14–16 cadaver
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to 2011, 17.5% of which were deemed potentially survivable. models, and trials of healthy human subjects 10,18 have shown
*Correspondence to hailey.b.reneau.mil@health.mil
1 Capt Hailey B Reneau is currently an Emergency Medicine resident at Brooke Army Medical Center, JBSA Fort Sam Houston, TX. Maj Brit J.
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Long is an Associate Professor in the Department of Military and Emergency Medicine at the Uniformed Services University of the Health Sci-
ences, Bethesda, MD, and an associate professor at Brooke Army Medical Center, JBSA Fort Sam Houston, TX. LTC Julie Rizzo is an Associate
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Professor in the Department of Surgery at the Uniformed Services University of the Health Sciences in Bethesda, MD and a burn/trauma surgeon
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at Brooke Army Medical Center, JBSA Fort Sam Houston, TX. MAJ Andrew D. Fisher is currently a general surgery resident affiliated with the
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University of New Mexico School of Medicine, Albuquerque, NM and serving in the Texas Army National Guard. LTC Michael D. April is an
emergency physician affiliated with the 14th Field Hospital, Fort Stewart, GA. LTC Steven Schauer is an Associate Professor with the Depart-
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ment of Emergency Medicine at the University of Colorado School of Medicine, a Fellow in the Department of Anesthesia at the University of
Colorado School of Medicine, and a Fellow with the Center for Combat and Battlefield (COMBAT) Research at the University of Colorado
School of Medicine, Aurora, CO.
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