Sweating the Little Things: Tourniquet Application Efficacy in Two Models of Pediatric Limb Circumference

Abstract

Background Current military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models. Methods Five different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet – Wide), SWAT-T (Stretch Wrap and Tuck – Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25” to 16.5”. Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable). Results In both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75” circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25” and 15.5” circumference PVC pipes (age 7–12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes. Discussion The current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

“…Previous reviews of adult and pediatric literature identified experimental studies of tourniquet use in pediatric models such as polyvinyl chloride pipes that demonstrated failure of adult tourniquets on smaller pipes. 397…”

“…Previous reviews of adult and pediatric literature identified experimental studies of tourniquet use in pediatric models such as polyvinyl chloride pipes that demonstrated failure of adult tourniquets on smaller pipes. 397 In making this recommendation, the First Aid Task Force weighed the lack of direct evidence to show that tourniquets are a lifesaving intervention for lifethreatening extremity bleeding in children against the previously established role of a manufactured windlass tourniquet in reducing mortality in adults with life-threatening extremity bleeding. 391 The Combat Application Tourniquet Generation 7 was the specific brand of windlass rod tourniquet used in both included studies, and the minimum limb circumference of the children included was 13 cm.…”

2020 International Consensus on First Aid Science With Treatment Recommendations

“…A second study 213 enrolled children 2 to 7 years of age undergoing elective orthopedic surgery, reporting successful application of the C-A-T GEN 7 in all 24 children (11 upper extremities and 13 lower extremities) with a 100% success rate in occluding distal pulses down to a minimal limb circumference of 13 cm. Two studies using models or manikins 210,211 reported that elastic type tourniquets (SWAT-T [H&H Medical Corporation, Williamsburg, Virginia] and R.A. T.S. [RATS Medical, Salt Lake City, Utah]) and pediatric-specific ratcheting tourniquets were the designs capable of tightening on the smallest models (to a circumference of 11.9 cm for the CRMT [M2 Inc, Colchester, Vermont] and R.A.T.S.…”

Appropriate Tourniquet Types in the Pediatric Population: A Systematic Review

“…Use of other tightening mechanisms, such as ratcheting tourniquets, has been suggested for use in children, but the evidence is lacking. No evidence from human studies was available for other tourniquet mechanisms, however, indirect evidence is available from three experimental studies that evaluate tourniquets in models representing a small limb diameter [16][17][18]. While these studies evaluate a broader range of tourniquet mechanisms, including ratcheting and elastic wrap, the experiments were conducted on manikins and in models using PVC pipe and stair rails and were excluded by our initial search strategy.…”