It’s two o’clock in the afternoon on a busy Monday. As the radio alerts you, your stomach sinks to your feet: You’ve just been dispatched to a school shooting. The estimated casualty count: 28 persons; ages 5–46 years.

As your adrenaline surges, a flurry of thoughts race through your mind: “Sarah is 4-years-old, we were planning to enroll her in that school this fall.” “Are my friends’ children safe?” “Do I have enough pressure dressings and tourniquets?”

“Will my commercial tourniquets even work on small children?”

The Gun Violence Archive reports that, in 2017, 346 active shooter incidents resulted in the deaths of 437 individuals—the deadliest year in American history.1 A Federal Bureau of Investigation meta-analysis of active shooter incidents (160 incidents, 2000–2013), has shown an average initial incident time frame of less than or equal to 5 minutes.2 These findings demonstrate the extreme importance of an immediate, well-prepared mass casualty response on behalf first responders, law enforcement and emergency services personnel.

From Jan. 1 to March 20, 2018, 10 shootings have taken place on school grounds.1 Although shooters are often indiscriminate in their choice of targets, these facts and pervasive discussion make it necessary to revisit published evidence regarding the use of commercial tourniquets for the control of pediatric extremity hemorrhage. In addition to detailing tourniquet specifications, this article further offers healthcare providers a practical approach to addressing tourniquet selection, application, modification and alternatives.

Pediatric Extremity Hemorrhage: The Facts

Although nearly 680 children die annually as a result of gun violence (e.g. homicide; National Vital Statistics System), unintentional injury remains the leading cause of death for pediatric persons ages 0–19 years.3,4 A recent report from the American College of Surgeons’ National Trauma Data Bank indicates that in 2016 alone, 1,065 children succumbed to injuries sustained in motor vehicle collisions, 187 died after having been struck by a vehicle, and 71 perished due to lacerations.5

Unfortunately, information regarding deaths directly resulting from uncontrolled hemorrhage is lacking. However, all of the aforementioned cases present situations in which the application of a tourniquet may well have been lifesaving.

Although data is sparse, much of what we can prove about pediatric tourniquet application comes from the battlefield. In 2009, one study identified extremity injury as the most common diagnosis resulting in combat support hospital admission during Operations Iraqi Freedom and Enduring Freedom.6 In order to characterize this cohort, investigators utilized the Department of Defense Trauma Registry (DoDTR) to assess emergency tourniquet application in pediatric casualties. Of 88 casualties who received tourniquets, 57 had documented extremity injuries and seven dead casualties were identified (mean injury severity score = 27; range 8–75):

One casualty had an extremity as the highest abbreviated injury scale score;

Two casualties had an extremity injured as severely as documented external injuries (burns, abrasions, etc.); and

Four casualties had non-extremity areas as the most severe injuries.7

Abbreviated Injury Scale (AIS) scores and Injury Severity Scores (ISS) were recorded for all pediatric patients. We include the discussion of AIS and ISS scores to portray the patient’s injury patterns accurately and to address potential confounders. With this in mind, four of seven pediatric casualties had non-extremity areas as the most severe component of their presentation.7

As detailed above, two of the pediatric patients who died had extremity injuries that were as severe as their documented external injuries (i.e., abrasions, lacerations or burns). In a 2012 review of the data, death secondary to injury (even extremity injury) was not synonymous with a lack of hemorrhage control and/or tourniquet failure.8

(Note: A summary of AIS and ISS is available in the appendix tables that follow the article’s references.9,10)

A 2014 retrospective review looked at DoDTR patients (2000–2011), ages 1–17 years old, who had been treated at United States military hospitals in Iraq and Afghanistan for vascular injury.According to the authors, 45 patients sustained upper extremity injuries, and 59 presented with lower extremity vascular injuries. In total, six tourniquets were placed; three in the field and three in the emergency department.All individuals who received tourniquets in the field lived, while two of the three who had tourniquets placed in the emergency department survived to hospital discharge (one patient with a concomitant brain injury subsequently died).11

One year later, investigators published retrospective findings on pediatric patients treated at Camp Bastion in Afghanistan from 2004-2012 (DoDTR query). Of 766 children injured ( ≤ 18 years of age), 125 sustained extremity injuries, which required pre-hospital tourniquet placement (AIS ≥ 2).Of these 125 pediatric casualties, 47 received tourniquets.12

Although tourniquet placement demonstrated no significant difference in mortality when adjusted for ISS, children with lower extremity amputations treated with tourniquets required significantly less IV fluids and blood products (reduced risk of transfusion-associated complications).12

Given these findings, the Committee on Tactical Emergency Casualty Care (C-TECC) published the recommendation for tourniquet placement as the first medical intervention in pediatric patients when care is administered under direct threat.13

The Role of Commercial Tourniquets

Commercial tourniquets were employed in the aforementioned studies. During data collection for the 2012 review, deployed military personnel were equipped with the Combat Application Tourniquet (CAT or Generation 6 CAT from North American Rescue).8

In recent years, military forces have entered combat zones with the Generation 7 CAT (equipped with a simplified buckle), and the SOF-TT (Special Operations Forces Tactical Tourniquet from Tactical Medical Solutions).

When interpreting the aforementioned military studies, keep in mind: According to Tactical Combat Casualty Care Guidelines, during Care-Under-Fire, service members place the tourniquet proximal to the bleeding site if the site is visualized, or in the absence of visualization, “high and tight.” If care is administered in a secured setting (tactical field care) the tourniquet is applied 2-3 inches above the bleeding site.7

In the civilian sector, there’s a case report of a lifesaving application of a CAT to the thigh of a 7-year-old male sustaining injury secondary to a lawn mower blade.14 No additional data, aside from the aforementioned studies and case report, regarding tourniquet application in the pediatric population could be found in a search of MEDLINE, EBSCOhost, PubMed, and ClinicalKey using the following keywords and phrases: pediatric hemorrhage, pediatric tourniquet, pediatric bleeding, and control of pediatric hemorrhage.

Pediatric Tourniquets: How Small is Small Enough?

Historically, the most extensive research into pediatric limb circumference comes from a 1975 observational study to assess the anthropometric data of U.S. children. Researchers measured the limb circumferences of 4,027 children (newborn to 12 years of age) over a period of three years. The means for specified ages are detailed in Table 1.15

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As previously mentioned, military personnel commonly carry the CAT Generation 6 or 7, or the Special Operations Forces-Tactical Tourniquet. Additionally Tactical Medical Solutions manufactures the Special Operations Forces-Tactical Tourniquet-Wide (SOFTT-W), H&H Medical Corporation offers the Stretch-Wrap-And-Tuck (SWAT) Tourniquet, and Rescue Essentials offers the CHILD/Pediatric Ratcheting Medical Tourniquet (RMT), which was developed for extremity hemorrhage control in persons weighing less than 120 pounds.

North American Rescue’s CAT Generation 6 and 7 have been evaluated for efficacy for limb circumferences between 12.7–88.9 cm (5–35 in), the CHILD/Pediatric RMT is effective for limb circumferences as small as 6.35 cm (2.5 in), and the manufacturers of the SOFTT, SOFTT-W, and the SWAT do not specify limb circumferences.16,17 (See Table 2.)

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It’s important to note that there is no current data to suggest that these devices have failed, or will fail when utilized in pediatric populations. This is an area for further research and publication.

As mentioned, data and case reports are lacking when it comes to commercial tourniquets, and this includes improvised tourniquets and adjuncts to commercial tourniquets. We can, however, consider pediatric physiology.

Our goal in hemorrhage control is to create enough pressure proximal to the injury to impede arterial blood flow. As a child’s circulating blood volume is approximately 80 mL/kg, even a small amount of blood loss may lead to hypotension.18 (See Table 3.19)

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The pressure applied with a tourniquet need only exceed the patient’s systolic blood pressure. There is no current data that suggests that the application of direct pressure, a commercial tourniquet, or an improvised tourniquet may fail to control pediatric extremity hemorrhage.

Something as simple—and time tested—as a cravat fashioned into a girth hitch, placed around a child’s extremity, can and will suffice.

If you have a non-pediatric commercial tourniquet available for use, and are concerned about the patient’s limb circumference, consider placement of a rolled gauze or pad underneath the constricting band prior to securing the tourniquet—this essentially increases the extremity’s circumference.

Figure 1: Standard wristband laying on top of a ruler.

Note the arrow and eyelet (or punch-hole) is just past the 5 1/4 inch mark. Photo courtesy Centre for Emergency Health Sciences

Figure 2: Wristband tab locked into position (slightly past the 5 1/4 inch mark at the first eyelet).

Note that the entire circumference is being held in the hand of an adult male. Photo courtesy Centre for Emergency Health Sciences

Takeaway from the Figures 1 and 2: This small circumference is actually 5 1/4 inches (the size of an infant’s leg or small child’s arm). Bleeding from something this small could likely still be controlled by a commercial tourniquet.

Takeaway from the Figures 1 and 2: This small circumference is actually 5 1/4 inches (the size of an infant’s leg or small child’s arm). Bleeding from something this small could likely still be controlled by a commercial tourniquet.

Figure 3: Right femoral junction of 2.77 kg newborn (infant) male.

In each of the below infant-related images (Figures 3 to 6), one can easily appreciate that direct digital control would likely suffice.

Dissections courtesy of Jennifer Achay Centre for Emergency Health Sciences

In each of the below infant-related images (Figures 3 to 6), one can easily appreciate that direct digital control would likely suffice.

Figure 4: Right radial-axillary junction of 2.77 kg newborn (infant) male.

Dissections courtesy of Jennifer Achay Centre for Emergency Health Sciences



Figure 5: Left arm amputation (at mid-shaft humerus) of 2.77 kg newborn (infant) male.

Note the instrument grasping the brachial artery, as well as the size of the arm in relation to the clinician’s fingers (an adult female). Dissections courtesy of Jennifer Achay Centre for Emergency Health Sciences

Figure 6: Left leg amputation (at mid-shaft femur) of 2.77 kg newborn (infant) male.

Note the instrument grasping the femoral artery, as well as the size of the leg in relation to the clinician’s fingers (an adult female). Dissections courtesy of Jennifer Achay Centre for Emergency Health Sciences

Conclusion

Current evidence suggests that direct pressure, commercial tourniquets and improvised tourniquets can adequately control pediatric extremity hemorrhage.

Being prepared for an emergency requires dedicated and recurrent training. Practice bleeding control by applying direct pressure, a commercial tourniquet, and a cravat on a simulated (yet human, i.e., standardized) small patient.

Take a moment to share the information you gained from this article, and from your own practice, with colleagues. Your knowledge, and the knowledge that you impart to others, will save lives.

Back to the Call

You take a deep breath and gather your thoughts, you remember the military studies and case report findings. You quickly grab your individual first aid kit (IFAK) and mass casualty bag, and load your pockets with additional tourniquets, gauze and cravats.

Despite knowing the next few hours will be painful, you are confident your team can and will successfully address pediatric extremity hemorrhage.

Disclaimer

The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Airforce, Department of the Navy, Department of Defense, or the U.S. Government. “I am a military Servicemember. This work was prepared as part of my official duties. Title 17, USC, § 105 provides that ‘Copyright protection under this title is not available for any work of the U.S. Government.’ Title 17, USC, §101 defines a U.S. Government work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.”

Disclosures

The authors have nothing to disclose.

References

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2. Blair J, Schweit K. (2014.) A study of active shooter incidents, 2000–2013. Federal Bureau of Investigation, U.S. Department of Justice. Retrieved March 18, 2018, from www.fbi.gov/file-repository/active-shooter-study-2000-2013-1.pdf.

3. Fowler K, Dahlberg L, Halleyesus T, et al. Childhood firearm injuries in the United States. Pediatrics. 2017;140(1):e20163486.

4. Centers for Disease Control and Prevention. (Dec. 23, 2015.) Protect the ones you love: Childhood injures are preventable. Retrieved Feb. 17, 2018, from www.cdc.gov/safechild/child_injury_data.html.

5. American College of Surgeons. National Trauma Data Bank 2016: Pediatric report. Retrieved Feb. 17, 2018, from www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdb%20pediatric%20annual%20report%202016.ashx

6. Creamer K, Edwards M, Shields C, et al. Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: Learning from the first 2,000 admission. J Trauma. 2009;67(4):762–768.

7. U.S. Army Institute of Surgical Research. (2017.) TCCC Guidelines for Medical Personnel. 2017. Retrieved Feb. 17, 2018, from www.usaisr.amedd.army.mil/pdfs/TCCCGuidelinesforMedicalPersonnel170131Final.pdf.

8. Kragh J, Cooper A, Aden J, et al. Survey of trauma registry data on tourniquet use in pediatric war casualties. Pediatr Emerg Care. 2012;28(12):1361–1365.

9. NSW Institute of Trauma and Injury Management. (2018.) Injury Severity Score. Retrived Feb. 17, 2018, from www.aci.health.nsw.gov.au/get-involved/institute-of-trauma-and-injury-management/Data/injury-scoring/injury_severity_score.

10. Association for the Advancement of Automotive Medicine. (2018.) Overview: Abbreviated Injury Scale (AIS). 2018. Retrieved March 18, 2018, from www.aaam.org/abbreviated-injury-scale-ais.

11. Villamaria C, Morrison J, Fitzpatrick C, et al. Wartime vascular injuries in the pediatric population of Iraq and Afghanistan: 2000–2011. J Pediatr Surg. 2014;49(3):428–432.

12. Sokol K, Black G, Azarow K, et al. Prehospital interventions in severely injured pediatric patients: Rethinking ABCs. J Trauma Acute Care Surg. 2015;79(6):983–989.

13. Bobko J, Lai T, Smith E, et al. Tactical emergency casualty care—Pediatric appendix: Novel guidelines for the care of the pediatric casualty in the high-threat prehospital environment. J Spec Oper Med. 2013;13(4):94–107.

14. Callaway D, Puciaty A, Robertson J, et al. Case report: Life saving application of commercial tourniquet in pediatric hemorrhage. Prehosp Emerg Care. 2017;21(6):786–788.

15. Snyder R, Spender M, Owings C, et al. (1975.) Physical characteristics of children, as related to death and injury for consumer product design and use. Highway Safety Research Institute. Retrieved Feb. 19, 2018, from https://deepblue.lib.umich.eduƒtasbl/handle/2027.42/1556.

16. Wall P, Sahr S, Bulsing C. Different width and tightening system: Emergency tourniquets on distal limb segments. J Spec Oper Med. 2015;15(4):28–38.

17. Rescue Essentials. (n.d.) M2 Civilian RMT 1 1/2″ Yellow (for <120 lbs including pediatric). Retrieved Feb. 19, 2018, from www.rescue-essentials.com/m2-civilian-rmt-1-yellow-for-120-lbs-including-pediatric.

18. Mikrogianakis A, Grant V. The kids are alright: Pediatric trauma pearls. Emerg Med Clin North Am. 2018;36(1):237–257.

19. U.S. Department of Health and Human Services. (Sep. 29, 2017.) Pediatric Basic and Advanced Life Support. Retrieved March 12, 2018, from https://chemm.nlm.nih.gov/pals.htm.

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