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?
“’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?
With the publication of Dr. Harcke’s study1 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 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.
UPDATE 18 March 2020 : There has been another doppler-ultrasound study of 7th generation CATS on children aged 2-7 years. They showed 100% occlusion on both arms and legs.2
Real-world experience supporting the efficacy of tourniquets on children
Previously, 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.3 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.
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.
Once again, the medical literature supports that commercial tourniquets work just fine on children. Now we have one study showing successful application of commercially available tourniquets on kids in a lab setting and another showing similar efficacy in real-world, combat applications.
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.
For an improvised tourniquet using the kid’s own clothing, check out a video using the child’s pants as a tourniquet with a windlass. Works on adults too.
1Harcke HT, Lawrence BA, Gripp HK, et all. Adult Tourniquet Use in School-Age Emergencies. Pediatrics. 2019,143(6)
2 Kelly, JR, Levy, MJ, Effectiveness of the Combat Application Tourniquet for Arterial Occlusion in Young Children, J Trauma Acute Care Surg. 2020 Jan 21.
3 Kragh, JF, Survey of Trauma Registry Data on Tourniquet Use in Pediatric War Casualties, Pediatric Emergency Care, 2012.