Page 122 - JSOM Fall 2025

However, prehospital interventions remain limited, and in Methods
cases where NCTH is the underlying cause, even rapid resus-
citation efforts may be ineffective without concurrent hemor- Search Strategy
rhage control. According to Eastridge et al., 79% of potentially Medical Subject Headings (MeSH) terms were used with the
preventable prehospital deaths among U.S. combat fatalities search string: (“Abdominal Aortic and Junctional Tourniquet”
6
were due to uncontrolled torso and junctional bleeding. This OR AAJT OR AAJT-S OR “external haemorrhage control
stark statistic highlights a fundamental gap in trauma man- devices” OR “external haemorrhage control devices” OR
agement; while extremity hemorrhage can be controlled, torso EHCD) AND (hemor* OR haemor* OR effect* OR occlusion
and internal bleeding remain overwhelming causes of death OR REBOA OR resuscitat* OR prehospital OR “chest com-
before definitive surgical care can be administered. pression*” OR application OR “intermittent hemostasis” OR
“safe duration” OR utility). A literature search was performed
on 3 September 2024 (Figure 1). Access to the biomedical da-
To address this challenge, new methods of prehospital hem-
orrhage control are being explored, including the abdominal tabases was granted by the University of Turku, Finland.
aortic and junctional tourniquet (AAJT, windlass version FDA
cleared in 2013). The AAJT is an external hemorrhage con- Inclusion and Exclusion Criteria
trol device (EHCD) that resembles a belt-like tourniquet with Results were limited to English-language publications in peer-
an air bladder that, when inflated, compresses the abdominal reviewed journals published between 2019 and 2024. Only
aorta and stops circulation below the aortic bifurcation. The medical journal articles were considered for inclusion. Publica-
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only product commercially available today is a more advanced tions in which a hemorrhage was treated with the abdominal
version, the abdominal aortic and junctional tourniquet – application of the AAJT were considered for inclusion. Pub-
stabilized (AAJT-S, FDA cleared in 2023), which features a lications regarding non-hemorrhagic injuries were excluded.
ratchet buckle tensioning mechanism instead of the traditional Healthy volunteer and animal studies were considered for in-
windlass rod; the ratchet makes it easier to apply and reduces clusion alongside human patient studies.
10
the risk of pressure loss if the operator loses grip. This review
refers to the device as AAJT regardless of more recent studies Selection Process and Quality Assessment
using the updated model. Studies on hemorrhage, TCA, and combined open-book pel-
vic fractures with major iliac vascular injuries were included.
One animal study that examined electrically induced ventric-
Most research on the AAJT has been conducted in animal
studies, demonstrating clear physiological benefits in resusci- ular fibrillation as the mechanism of injury was excluded. An
tation efforts. 11–13 However, its practical application presents imaging study of external compression of hemorrhage, which
challenges. The device exerts significant pressure over a large focused on the localization of the lower abdominal arteries,
area, raising concerns about severe organ damage and isch- was also discarded.
emic injury if applied for extended periods. 14,15 The evidence
of the effectiveness of the AAJT in human patients is limited. 16 After the titles and abstracts were independently screened and
duplicates removed, the remaining full papers were reviewed
to assess how the results matched the inclusion criteria. The
Another intervention to control abdominal hemorrhage, the
resuscitative endovascular balloon occlusion of the aorta patient outcome measures included in the analysis were mor-
(REBOA), was used to treat patients with hemorrhagic shock tality, rate of ROSC achieved, and benefit, including rate of
both in and outside the hospital until its controversial results successful application and the time of application. The sys-
in recent clinical trials. A recent randomized controlled trial tematic literature review identified nine publications from 21
of REBOA integration to hemorrhage care protocol revealed records (Figure 1). Level of evidence was evaluated with the
increased mortality when compared with standard care alone, Oxford Centre for Evidence-Based Medicine tool, and the risk
partly due to delays in intervention and prolonged time to of bias was interpreted with the Cochrane Risk of Bias Tool
17
definitive surgical management. Other similar studies have (RoB 1.0).
reported high rates of late mortality in initially surviving pa-
tients, raising concerns about the long-term complications Results
associated with REBOA’s prehospital use, even with partial
aortic occlusion. 18.19 Nine publications on the AAJT were identified for this review
(Table 1). One studied the difficulty of using the AAJT, as
tested on British combat medic technician (CMT) operators.
Given the ambiguous effects of the AAJT and the mixed out-
comes of REBOA’s prehospital use, there is an urgent need to One was a descriptive case series on the use of AAJT in an Aus-
evaluate the effectiveness of the AAJT in human trauma pa- tralian Helicopter Emergency Medical Services (HEMS) unit
tients. This review aimed to determine the effect of the AAJT for TCA. Seven publications were animal model studies. The
on survival rates among patients with hemorrhagic shock, level of evidence was IV or V for all included studies. Attrition
based on the most recent literature. The analysis was con- bias was high in all studies. Reporting bias was high in six of
ducted by reviewing studies published from 2019 to 2024. the included studies (Appendix A).
The primary parameter was the reported survival of patients
with hemorrhagic shock treated with the AAJT. The secondary The seven animal case studies focused mainly on physiological
parameter was return of spontaneous circulation (ROSC) in and hemodynamic changes associated with AAJT use and its
TCA following hemorrhagic shock, given its correlation with resuscitative effects. Three of the studies investigated hemody-
survival in both human and animal studies. In addition, stud- namic effects by comparing REBOA and AAJT. One of these
ies assessing the utility of the AAJT, specifically the successful included different resuscitative fluids in its analysis, while the
application rate and time to aortic occlusion, were included other two studies concentrated on installing REBOA in an an-
to determine AAJT’s feasibility in urgent emergency settings. imal model with the AAJT.

120 | JSOM Volume 25, Edition 3 / Fall 2025