Tourniquet (junctional)

Background

• Junctional Tourniquets (JTQ) were initially cleared by FDA in 2010 for use in pre-hospital medicine
• JTQs were developed because of limitations of traditional extremity tourniquets in controlling hemorrhage between the trunk and limbs. These difficult to access locations were responsible for 20% of preventable deaths by bleeding on the battlefield.
• JTQs are devices that allow for proximal compression of arterial bleeding and thus control of junctional hemorrhage.
• Lethality of junctional hemorrhage is greater because of the large lumen size of injured vessels

Desirable Traits of a JTQ

• Stop bleeding effectively from junction areas such as groin, pelvis, buttock, shoulder, or neck
• Compress bleeding from sites where regular TQ cannot be applied
• Safe to use
• Effective for prehospital use
• Small with low profile
• Lightweight
• Low-cost
• Easy to use requiring minimal training
• Applied quickly
• Does not slip on tightening when in use
• Provides easy release of compression
• Easy to reapply
• Long shelf life

Indications

• Junctional hemorrhage not controlled by pressure dressing
• Some JTQ can also be used to stabilize suspected pelvic fractures
• Testing has shown JTQ to be 75-100% effect in controlling hemorrhage

Contraindications

• Not applicable

N.B. there is on the market a truncal tourniquet which has been cleared by the FDA for junctional hemorrhage. This device is contraindicated in pregnancy, abdominal aortic aneurysm, and penetrating abdominal trauma.

Application of Tourniquet

• As per manufacturer's guidance
• Committee on Tactical Combat Casualty Care lists three possible devices

Precautions

• Do not remove JTQ which has been in place more than 6 hours
• Expose and clearly mark all tourniquets with time of application

Proper Removal

• ASAP convert junctional tourniquet to hemostatic pressure dressing if:
  • Patient not in shock
  • It is possible to monitor the wound closely for bleeding
  • JTQ is not being used to control bleeding form an amputated extremity or to stabilize a suspected pelvic fracture
• If bleeding recurs after removal in hospital consider non-surgical interventions such as direct pelvic packing, vessel ligation, Foley or extravascular balloon tamponade although specific technique will depend on resources and skills available

References

1. Kragh, J.F., Jr., et al., Testing of junctional tourniquets by military medics to control simulated groin hemorrhage. J Spec Oper Med, 2014. 14(3): p. 58-63.
2. Klotz, J.K., et al., First case report of SAM(r) Junctional tourniquet use in Afghanistan to control inguinal hemorrhage on the battlefield. J Spec Oper Med, 2014. 14(2): p. 1-5.
3. Kragh, J.F., et al., Assessment of Groin Application of Junctional Tourniquets in a Manikin Model. Prehosp Disaster Med, 2016. 31(4): p. 358-63.
4. Kotwal, R.S., et al. Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines-Proposed Change 13-03. J Spec Oper Med, 2013. 13(4): 85-93.