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.
“’The first-grader lost 75 percent of his blood from a bullet, which pierced his femoral artery in his thigh,’ officials said. He was rushed to Greenville Health System Children’s Hospital, where he had multiple surgeries after going into cardiac arrest.” NBC News, October 2016.
Tragically, Jacob ultimately succumbed to his wounds. No commercially available tourniquets were available at his school, leaving the school nurse with few good hemorrhage 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 of the DOD issued tourniquets, the CAT and SOFT-Wide should work on kids 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.
The question becomes will commercially available tourniquets work on kids?
Dr. John Kragh, an orthopedic surgeon and military researcher on tourniquet use, studied 88 children seen in US Military Hospitals in Iraq and Afghanistan on whom US DOD tourniquets were placed. Children ranged in age from 4 to 17 years old. 64% were injured by explosions and 30% gunshot wounds. 7 of the 88 died. They identified no pediatric-specific problems in applying the tourniquets on kids despite the tourniquets being designed for adult casualties. The tourniquets seemed to work on kids just fine.Learn MoreTactical Casualty Care course
That is not surprising. Commercial tourniquets are more prone to failure on larger circumference limbs where they cannot fully occlude arterial flow. Placing adult spec’d devices on kids 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.
How young of a kid might the tourniquet work on?
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.
What does all this mean?
Dr. Kragh’s study is the only prehospital review on commercial tourniquet use on kids. However, the CAT and SOF-T Wide would be expected to work as tourniquets on thighs as young as 6 to 12 months and arms beginning at about the 5-year-old range.
Just recently, the first case report of a commercially available tourniquet being placed on a child was published. A 7-year-old sustained a femoral artery laceration when a piece of metal flew out of a running lawnmower. Although in shock by the time prehospital providers arrived, he survived after a commercial tourniquet was placed, before transport to the hospital.
What do you do for massive hemorrhage on a kid’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 kid.
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