Do commercially available tourniquets work on Children?
Jacob Hall, 6 years old, died of a femoral artery laceration after being shot by a 14-year-old while he was at recess at his school. Another student and a teacher were wounded. Would a tourniquet have worked to save him? Tragically, Jacob ultimately succumbed to his wounds. No commercially available tourniquets were available at his school, leaving the school nurse with few good haemorrhage control options.
Despite over 10,000 applications and 2,000 lives saved by tourniquet placement during the Global War on Terror, the commercially available tourniquets being used by the Department of Defense were never designed for pediatric use.
Conceptually the two most common DOD-issued tourniquets, the Combat Aplication Tourniquets and SOFT-Wide should work on children as long as they can adequately circumferentially constrict the limb they are placed on. However, those devices are specified for adult service member limbs, not smaller-sized child limbs.
With the publication of Dr Harcke’s study using 7th Generation CAT tourniquets on 60 children aged 6 to 16, we have even more data that commercially available tourniquets work just fine on children.
In the study, 7th-generation CATs were placed on both the upper arm and thigh of 60 children. The tourniquets were tightened until the distal Doppler pulse ceased or the windlass had been twisted 3 full turns (1080 degrees). This limit was chosen to decrease the pain of the tourniquet placement for the study. They acknowledged in actual application pain is irrelevant.
The CATS occluded 100% of the upper extremities and 93% of the thighs. One subject quit during thigh application secondary to pain, and another three could not be occluded despite three twists of the windlass. The three tourniquet applications that failed to occlude were in the oldest (14 to 16 years) age group and were obese.
This is the largest tourniquet study using Doppler ultrasound to verify artery occlusion we are aware of in either adults or children. It is a nice compliment to the previous study by Dr John Kragh.
Commercial tourniquets are more prone to failure on larger circumference limbs where they cannot fully occlude arterial flow. Placing adult spec devices on children’s limbs, which are generally much smaller, might actually increase their likelihood of effectiveness. Additionally, kids are generally squishier than adults who may have co-morbidities like calcified and incompressible arteries. All of which should make it easier to occlude a child’s arterial flow.
Once again, the medical literature supports that commercial tourniquets work just fine on children. Now we have one study showing the successful application of commercially available tourniquets on kids in a lab setting and another showing similar efficacy in real-world, combat applications.
According to the World Health Organization and US CDC, 50% of boys and girls have arm circumferences at least 16.5 to 17.7 cm. There is no specific data on thigh circumference, but the average 6 to 12-month-old American baby is felt to have a thigh circumference of 8 inches / 20 cm. The SOFT Wide circumference is 6.75 inches / 17 cm. The CAT 6th and 7th generation are both about 7.75 inches / 19.5 cm.
The first case report of a commercially available tourniquet being placed on a child was published recently. A 7-year-old sustained a femoral artery laceration when a piece of metal flew out of a running lawnmower. Although in shock when prehospital providers arrived, he survived after a commercial tourniquet was placed, before transport to the hospital.
What do you do for a massive haemorrhage on a child’s arm too small for a tourniquet? Good clamshell direct pressure. It’s strong enough to occlude arterial flow in an adult male’s arm; it should work easily on a child.
