Combat lifesaver-trained, first-responder application of junctional tourniquets: A prospective, randomized, crossover trial

Abstract

Background: Junctional hemorrhage surpassed extremity hemorrhage as the leading cause of preventable death after the resurgence of limb tourniquets during the recent conflicts in Afghanistan and Iraq. Junctional tourniquets (JTQs) were developed in response to this injury pattern. Published data for JTQ efficacy are limited and do not incorporate nonmedical, military first responders. We compared the time for effective placement and scores for device satisfaction between two different JTQs, stratified by combat lifesaver (CLS) and combat medics. Methods: We performed a prospective, randomized, crossover trial utilizing the SAM® Medical Junctional Tourniquet (SJT) and Junctional Emergency Treatment Tool (JETT™). Investigators simple randomized CLS and combat medics to SJT or JETT for their first JTQ application on mannequins with penetrating inguinal injuries. Then, participants immediately placed the other JTQ on another casualty with the same injury. The primary outcome measured was time of successful application. Success was defined as proper JTQ placement and a pressure reading of at least 180 mmHg. We compared outcomes between CLS and combat medics. Unsuccessful JTQ applications were excluded from the comparative analysis. Results: From June 2015 to August 2015, a total of 227 personnel (133 CLS and 94 combat medics) at Fort Hood, Texas, USA volunteered to participate in the study. Twenty-eight percent (38 of 133) of CLS and 40% (38 of 94) of combat medics placed both JTQs successfully, for a total of 152 applications (76 SJTs and 76 JETTs). We found a significant difference between applications of the JETT between the CLS and combat medics (92.0 ± 37.7 s versus 70.5 ± 20.5 s, P = 0.004). No other subgroup analyses, whether by device or user, demonstrated a significant difference in application time. Both groups preferred the SJT over the JETT. CLS disagreed with combat medics that the JETT could be easily applied by one person (median 3.0 [2.0, 4.0] versus median 4.0 [3.0, 5.0]; P = 0.006). Conclusion: Overall, success rates for both the SJT and JETT were low. Improved training is needed to increase successful application of junctional tourniquets before widespread implementation. Combat lifesavers and combat medics prefer the SJT over the JETT.