Page 67 - JSOM Spring 2025

Successful Management of
Battlefield Traumatic Cardiac Arrest Using the
Abdominal Aortic and Junctional Tourniquet (AAJT)

A Case Series

Dmytro Androshchuk *; Andriy Verba, PhD 2
1

ABSTRACT
The Russo-Ukrainian war’s prolonged warfare, resource con- constant threat of bombardment, artillery fire, and drone use
straints, and extended evacuation times have forced significant have extended evacuation times from the front lines to higher
adaptations in Ukraine’s medical system – including techno- levels of emergency care at Role 1 and Role 2.
logical advancements and strategic resource placement. This
study examined if the Abdominal Aortic and Junctional Tour- The extended evacuation timelines have been mitigated to
niquet – Stabilized (AAJT-S) could manage traumatic cardiac some degree by technological advancements in medical care
arrest (TCA) at forward surgical stabilization sites (FSSS) as and the placement of surgical resources closer to the front lines
an adjunct to damage control surgery. Six patients in severe and the forward edge of the battle area. The ability to control
hypovolemic shock presented at an FSSS during fighting in massive hemorrhage is now required everywhere on the battle-
Bakhmut (July 2022) and Slovyansk (May 2023). Following field. Control of massive hemorrhage is now required at every
TCA due to exsanguination, the AAJT-S was applied 2cm be- stage, from point of wounding to forward surgical stabiliza-
low the umbilicus. Cardiopulmonary resuscitation (CPR) and tion sites. Early observations of the war suggest these changes
transfusion (blood and/or plasma) were initiated. All six pa- may have reduced the immediate mortality of battlefield in-
tients were resuscitated. None required vasopressor support juries by up to 30% (unpublished observations by our team).
post-resuscitation. Five survived to the next level of care.
One died awaiting evacuation, and another of wounds after Hemorrhage risks traumatic cardiac arrest (TCA), but even
10 days. Four survived to discharge. Three were followed in-hospital civilian TCA demonstrates very poor outcomes.
and neurologically intact, and no death records matched the Traditional management techniques include emergency tho-
fourth’s name and date of birth at 18 months. Follow-up was racotomy with aortic clamping, resuscitative endovascular
limited, but one patient was neurologically intact at one year. balloon occlusion of the aorta (REBOA), and massive transfu-
The AAJT-S effectively resuscitated TCA patients. It increased sion protocols, all labor- and equipment-intensive. Emergency
mean arterial pressure, focused resuscitative efforts on the up- thoracotomy also increases patient risk, even when a return of
per torso, simplified care, and preserved crucial field resources. spontaneous circulation (ROSC) is achieved.
An alternative to traditional emergency thoracotomy, AAJT-S
could replace or complement resuscitative endovascular bal- In contrast, the Abdominal Aortic and Junctional Tourniquet –
loon occlusion of the aorta in pre-hospital settings, given Stabilized (AAJT-S) has been shown to control bleeding in the
its ease of application by combat medics. AAJT-S, alongside pelvis and the junctional regions of the groin and axilla by
blood transfusion and CPR, achieved 100% success in return stopping blood flow. 1,2,3 It had been incorporated as an ad-
of spontaneous circulation and effectively managed TCA in a junct hemorrhage control measure at the 59th MMH forward
wartime FSSS. stabilization sites when damage control surgery (DCS) was ini-
tiated. Research from U.S. and Australian researchers suggest
Keywords: traumatic cardiac arrest; hemorrhagic shock; damage AAJT-S could now play a role in the management of TCA.
4,5
control surgery; damage control resuscitation; abdominal aortic The use of tourniquets to increase vascular resistance has been
and junctional tourniquet – stabilized; AAJT-S; resuscitative shown to generate significantly greater coronary perfusion
endovascular balloon occlusion of the aorta; trauma pressure, end-tidal carbon dioxide, and carotid blood flow. 6
management; emergency thoracotomy
Surgeons at a surgical stabilization site (Role 2) in Ukraine
during fighting in Bakhmut (July 2022) and Slovyansk (May
2023) explored the use of the AAJT-S as an alternative to tra-
Introduction
ditional thoracotomy for the management of TCA. AAJT-S use
Prolonged warfare during the Russo-Ukrainian war beginning was hypothesized to avoid emergency thoracotomy, simplify
in 2014, including the armed occupation of Ukrainian terri- care, and preserve the already limited resources that these sites
tories, has forced significant changes to the Ukrainian medi- use to treat casualties. Thus, this article examines the use of
cal system. Limited resources, a lack of clear air superiority, a the AAJT-S (Compression Works, Inc., Birmingham, AL) in
*Correspondence to croushorn@gmail.com
1 Dmytro Androshchuk is a Senior Lieutenant affiliated with the Medical Service of the Ukrainian Armed Forces, a vascular surgeon, and a Senior
Officer of the Frontline Surgical Group. Dr. Andriy Verba is a Professor General Surgeon and Major General in the Ukrainian Military Medical
2
Service.
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