Pediatric Tourniquet Designs for Life-threatening Extremity Hemorrhage (FA): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. There were no declared conflicts of interest

Task Force Scoping Review Citation

Charlton NP, Goolsby C, Singletary EM, Zideman DA, on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. Pediatric Tourniquet Designs for Life-threatening Extremity Hemorrhage Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, December 27, 2019. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

Trauma is a major cause of morbidity and mortality throughout the world and, in the United States, is a leading cause of mortality from accidental injury for those age 1-17. As pediatric limb circumferences can be much smaller than those of adults, current tourniquet styles that were traditionally designed for military use, and consequently primarily for individuals ≥ 18 years of age, may not apply adequate circumferential pressure to halt distal blood flow in pediatric individuals. While tourniquets have gained wide-spread acceptance in the pre-hospital setting for life-threatening bleeding in adults, little data is available to guide the use of tourniquets in pediatrics. Although the principles of bleeding control remain the same in both adult and pediatric subjects, body size may limit the use of tourniquets in smaller limb circumferences. For instance, some tourniquets employ a rigid mechanical advantage system (e.g. windlass or ratchet) that precludes the ability to fit limb circumferences that are smaller than that of the mechanism. As tourniquets rely on the ability to tighten sufficiently to occlude distal blood flow, these circumference limitations may prevent successful use of certain tourniquets on the smaller limbs of pediatric subjects.

This scoping review aims to evaluate what literature is available regarding the use of tourniquets in the pediatric population for life threatening extremity hemorrhage. No prior scoping or systematic review has been published on this topic.

Scoping Review

Webmaster to insert the Scoping Review citation and link to PubMed using this format when/if it is available.

PICOST

Search Strategies

(See Figure 1)

A special Ovid search filter for ‘Children’ (broad) has been applied to the search. In full, it is:

exp adolescent/ or exp child/ or exp infant/ or (infant disease* or childhood disease*).ti,ab,kf. or (adolescen* or babies or baby or boy? or boyfriend or boyhood or girlfriend or girlhood or child* or girl? or infan* or juvenil* or kid? or minors or minors* or neonat* or neo-nat* or newborn* or new-born* or paediatric* or peadiatric* or pediatric* or perinat* or preschool* or puber* or pubescen* or school* or teen* or toddler? or underage? or under-age? or youth*).ti,ab,kf. or (pediatric* or paediatric* or infan* or child* or adolescen* or young).jn,jw or (pediatric* or paediatric* or infan* or child* or adolescen* or young).in

Medline

1 exp Emergency Medical Services/ (132433)

2 Emergency Treatment/ (10388)

3 Emergencies/ (39415)

4 "Wounds and Injuries"/ (74755)

5 Amputation, Traumatic/ (4654)

6 Wounds, Penetrating/ (11447)

7 Wounds, Gunshot/ (14954)

8 Wounds, Stab/ (4353)

9 exp Arm Injuries/ (30071)

10 exp Leg Injuries/ (93066)

11 Hemorrhage/ (70599)

12 Exsanguination/ (334)

13 Shock, Hemorrhagic/ (11242)

14 (emergency or emergencies).tw,kf. (252303)

15 trauma*.tw,kf. (348234)

16 (wound or wounds).tw,kf. (201030)

17 (injury or injuries).tw,kf. (744340)

18 h?emorrhag*.tw,kf. (254548)

19 exsanguinat*.tw,kf. (2928)

20 bleed*.tw,kf. (198402)

21 blood loss*.tw,kf. (49530)

22 amputat*.tw,kf. (40133)

23 gunshot*.tw,kf. (9005)

24 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 (1881858)

25 Tourniquets/ (3729)

26 tourniquet*.tw,kf. (6119)

27 25 or 26 (7119)

28 24 and 27 (2918)

29 limit 28 to children (466)

30 limit 29 to yr="1966 -Current" (464)

31 hair.tw,kf. (68374)

32 30 not 31 (416)

33 Snake Bites/ (4458)

34 32 not 33 (391)

35 hypospadias.tw,kf. (5939)

36 34 not 35 (388)

37 arthroscop*.tw,kf. (29517)

38 36 not 37 (352)

All EBM Reviews (Cochrane)

1 exp Emergency Medical Services/ (3916)

2 Emergency Treatment/ (277)

3 Emergencies/ (1174)

4 "Wounds and Injuries"/ (2723)

5 Amputation, Traumatic/ (48)

6 Wounds, Penetrating/ (182)

7 Wounds, Gunshot/ (50)

8 Wounds, Stab/ (25)

9 exp Arm Injuries/ (1381)

10 exp Leg Injuries/ (3767)

11 Hemorrhage/ (3524)

12 Exsanguination/ (17)

13 Shock, Hemorrhagic/ (93)

14 (emergency or emergencies).ti,ab,hw. (25236)

15 trauma*.ti,ab,hw. (23975)

16 (wound or wounds).ti,ab,hw. (28392)

17 (injury or injuries).ti,ab,hw. (53976)

18 h?emorrhag*.ti,ab,hw. (32214)

19 exsanguinat*.ti,ab,hw. (130)

20 bleed*.ti,ab,hw. (42747)

21 blood loss*.ti,ab,hw. (12635)

22 amputat*.ti,ab,hw. (2801)

23 gunshot*.ti,ab,hw. (135)

24 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 (172265)

25 Tourniquets/ (490)

26 tourniquet*.ti,ab,hw. (1854)

27 25 or 26 (1854)

28 24 and 27 (783)

29 exp adolescent/ (102625)

30 exp child/ (55074)

31 exp infant/ (31466)

32 (infant disease* or childhood disease*).ti,ab,hw. (1480)

33 (adolescen* or babies or baby or boy? or boyfriend or boyhood or girlfriend or girlhood or child* or girl? or infan* or juvenil* or kid? or minors or minors* or neonat* or neo-nat* or newborn* or new-born* or paediatric* or peadiatric* or pediatric* or perinat* or preschool* or puber* or pubescen* or school* or teen* or toddler? or underage? or under-age? or youth*).ti,ab,kf. or (pediatric* or paediatric* or infan* or child* or adolescen* or young).jn,jw. (467677)

34 (pediatric* or paediatric* or infan* or child* or adolescen* or young).in. (34983)

35 29 or 30 or 31 or 32 or 33 or 34 (536747)

36 24 and 27 and 35 (211)

37 limit 36 to yr="1966 -Current" [Limit not valid in DARE; records were retained] (210)

38 hair.ti,ab,hw. (3270)

39 37 not 38 (210)

40 Snake Bites/ (76)

41 39 not 40 (210)

42 hypospadias.ti,ab,hw. (324)

43 41 not 42 (208)

44 arthroscop*.ti,ab,hw. (4386)

45 43 not 44 (187)

Embase

1 emergency health service/ (94885)

2 emergency treatment/ (17282)

3 emergency/ (59915)

4 injury/ (378899)

5 battle injury/ (5069)

6 exp limb injury/ (213827)

7 traumatic amputation/ (2173)

8 wound/ (38235)

9 gunshot injury/ (19139)

10 knife cut/ (793)

11 stab wound/ (5439)

12 wound hemorrhage/ (229)

13 bleeding/ (315546)

14 exsanguination/ (961)

15 hemorrhagic shock/ (17975)

16 (emergency or emergencies).tw,kw. (381443)

17 trauma*.tw,kw. (494947)

18 (wound or wounds).tw,kw. (261520)

19 (injury or injuries).tw,kw. (1000554)

20 h?emorrhag*.tw,kw. (382607)

21 exsanguinat*.tw,kw. (4140)

22 bleed*.tw,kw. (337696)

23 blood loss*.tw,kw. (82612)

24 amputat*.tw,kw. (57257)

25 gunshot*.tw,kw. (10152)

26 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 (2796821)

27 exp tourniquet/ (7502)

28 tourniquet*.tw,kw. (8503)

29 27 or 28 (10350)

30 26 and 29 (4744)

31 limit 30 to children (760)

32 limit 31 to yr="1966 -Current" (713)

33 hair.tw,kw. (94836)

34 32 not 33 (644)

35 snakebite/ (6449)

36 34 not 35 (620)

37 hypospadias.tw,kw. (8118)

38 36 not 37 (611)

39 arthroscop*.tw,kw. (37488)

40 38 not 39 (561)

41 limit 40 to embase (365)

Grey Literature

Google search terms executed on December 11, 2019

1. Pediatric AND tourniquet

First 100 Results reviewed

16 included for full website review

9 found to be duplicates or editorials of previously selected articles

3 had no pediatric specific data

4 included for review:

https://www.jems.com/2018/11/01/pediatric-extremity-hemorrhage-and-tourniquet-use/3

https://vector.childrenshospital.org/2013/05/tourniquets-go-from-combat-to-kids/

https://www.stopthebleed.com.au/2017/08/16/tourniquets-for-kids/

https://pediatrictraumasociety.org/meeting/abstracts/2018/68.cgi

Inclusion and Exclusion criteria

Inclusion / exclusion criteria:

Inclusion: <19 years of age, life-threatening hemorrhage of an extremity in the out of hospital or in hospital setting. Studies using child-sized models or manikins may be included.

Exclusion: Studies of tourniquets applied solely to maintain a bloodless surgical field or those relating only to education will be excluded.

Additional limits - language, publication type, study design, date limits:

All study types, English language only, no date exclusion

Information sources: Searches will be conducted in Medline, Embase, and Cochrane (OVID interface)

Suggested search terms/keywords: first aid, pediatric, hemorrhage, bleeding, tourniquet

Data tables

Task Force Insights

Why this topic was reviewed.

In 2017 ILCOR commissioned a Mega-PICO on the Control of Life-Threatening Bleeding. This Mega-PICO searched for evidence of bleeding control modalities for “Adults and children with severe, life-threatening external bleeding in out-of-hospital settings.” While human adult data was found for the use of direct pressure, hemostatic dressings and tourniquets in the adult population, there was very little literature found pertaining to the management of severe life-threatening external bleeding in the pediatric population. Although the use of direct manual pressure and hemostatic gauzes can be more easily extrapolated to the pediatric population, tourniquets often employ a rigid mechanism to apply a mechanical advantage in order to successfully stop blood flow. There is a concern that the smaller limb circumferences in children may limit the successful use of tourniquets, many of which are designed for use in adults. As the Control of Life-Threatening Bleeding Mega-PICO did not find enough data to answer this question, this Scoping Review was initiated to evaluate all available literature on tourniquet use in the pediatric population.

Narrative summary of evidence identified

A literature search identified 10 studies (two found in grey literature) and three websites for inclusion (See Data Table):

• Two articles were position statements from national pediatric trauma organizations
• Two studies were epidemiologic studies of tourniquet use in the pediatric population in conflict zones
• Three studies used models of pediatric limb circumferences to test the application of multiple different tourniquet modes
• Two studies were observational trials using healthy pediatric volunteers
• There was one case report of tourniquet use in a child.
  
  Of the 3 additional websites included, all summarized pre-existing data or expert opinion pertaining to pediatric tourniquet use and did not add any significant data to the studies already identified (data not in table).

The two observational studies enrolling pediatric participants only tested the Combat Application Tourniquet Generation 7 (C-A-T® GEN7), which is a strap and windlass model. One observational study (Harcke 2019 e20183447) enrolled healthy volunteers, 6-16 years of age, presenting to an outpatient clinic. The success rate in eliminating distal pulses was 100% (60/60) in the upper extremities and 93% (56/60) in the lower extremities. A second observational study (Kelly 2019 pending) enrolling children 2-7 years of age undergoing elective orthopedic surgery demonstrated successful application of the C-A-T® GEN7 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.

Studies in manikin and PVC models generally demonstrate that the tested windlass and ratcheting tourniquets have increasing failure rates as the model’s circumference diminish.

In one study (Vretis 2018 101) using PVC pipe as a model, the Stretch Wrap and Tuck Tourniquet (SWAT-T) (an elastic band model), Rapid Application Tourniquet System (RATS) (an elastic band model) and Child Ratcheting Medical Tourniquet (CRMT) (a ratcheting model) were successfully applied down to the smallest model of 11.9 cm circumference. In that same study the Mechanical Advantage Tourniquet (MAT) (a ratcheting model) failed on model sizes 23.9 cm circumference and smaller. The Tactical Mechanical Tourniquet (TMTä) (a strap and windlass model) and Special Operations Forces Tactical Tourniquet Wide (SOFTT-W) (a strap and windlass model) started failing on models with a 19.9 cm circumference and smaller. The C-A-T®, SAM Extremity Tourniquet (SAMXT) (a strap and windlass model), TMT, and SOFTT-W failed on models with a 16.0 cm circumference.

A separate study (El Sherif 2019 361), using different sized manikin models, found that windlass tourniquets (C-A-T^® GEN6, C-A-T^® GEN7, SOFTT, SOFTT-W) were only able to be successfully applied to the thigh in the infant model. While the SWAT-T was able to be properly tightened in both upper and lower extremities of the infant model, it was deemed a failure as the tourniquet width made it impossible to isolate a specific location on the limb. In the 1-year old child manikin, all tourniquets were successfully applied in the thigh area, however all windlass designs were unsuccessful in the mid-biceps or forearm. The SWAT-T was successfully applied in all areas tested. In the 5-year-old manikin, windlass tourniquets were successfully applied to lower extremities but there was varying success in upper extremities on the same manikin.

Altogether, in these two studies, elastic type tourniquets (SWAT-T and RATS) and pediatric-specific ratcheting tourniquets were the tourniquet designs that were able to be successfully tightened on the smallest models. The smallest model circumference was 11.9 cm for the CRMT and RATS and 10.8 cm for the SWAT-T (See Data Table).

Kragh (Kragh 2019 41) evaluated the ease of use of a single windlass tourniquet (C-A-T® GEN7) for two trained users in a pediatric model. No study in this review specifically evaluated ease of use for lay providers in the pediatric population.

Narrative Reporting of the Task Force discussions

The Task Force considered the position statements from both the Pediatric Trauma Society and the Committee for Tactical Emergency Casualty Care Pediatric Working Group, both recommending tourniquets for life-threatening extremity hemorrhage in the pediatric population (Bobko 2013 94, Cunningham 2018 665).

The First Aid Task Force acknowledged the positive results from two human pediatric studies that suggested that the use of a windless design of tourniquet (specifically the C-A-T® GEN7) can abolish distal pulses in both the upper and lower extremities in children as young as 2 years of age with a minimum limb circumference of 13 cm.

In manikin and PVC pipe models the overall trend was that the smaller the circumference of the model, the less likely the tourniquet was to be successfully applied. However, the overall results were inconsistent, and the Task Force believes the evidence provided by the studies using models is of lower certainty than that from human studies.

The Task Force recognized the importance of the early control of severe life-threatening bleeding in children under the age of 2 years, especially considering their relatively small blood volume. In the absence of evidence for the effective use of tourniquets in this age group the Task Force discussed using direct pressure to control life threatening bleeding. It agreed that more research is needed into the design and use of tourniquets, particularly for children less than 2 years of age.

Although evidence for tourniquet design and use in children is limited and of low or very low certainty (based on study design alone), the topic of tourniquet design and their use in children warrants a potential future systematic review.

Knowledge Gaps

• There is an urgent need for additional human studies in the prehospital setting to determine which tourniquet designs are able to be used successfully in the pediatric population
• Human studies are needed to determine the lower age and size limits to which these tourniquets can be successfully applied in both upper and lower extremities
• Human studies are needed to determine the ease of application of tourniquets on children
• Studies are needed to further define complications of tourniquet use in children

References

Bobko J, Lai TT, Smith ER, Shapiro GL, Baldridge RT, Callaway DW. 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 Winter;13(4):94-107.

Callaway DW, Puciaty A, Robertson J, Hannon T, Fabiano SE. Case Report: Life Saving Application of Commercial Tourniquet in Pediatric Extremity Hemorrhage. Prehosp Emerg Care. 2017 Nov-Dec;21(6):786-788. doi: 10.1080/10903127.2017.1332126. Epub 2017 Jun 28.

Cunningham A, Auerbach M, Cicero M, Jafri M. Tourniquet usage in prehospital care and resuscitation of pediatric trauma patients-Pediatric Trauma Society position statement. J Trauma Acute Care Surg. 2018 Oct;85(4):665-667. doi: 10.1097/TA.0000000000001839.

El-Sherif N, Lowndes B, Franz W, Hallbeck MS, Belau S, Sztajnkrycer MD Sweating the Little Things: Tourniquet Application Efficacy in Two Models of Pediatric Limb Circumference. Mil Med. 2019 Mar 1;184(Supplement_1):361-366. doi: 10.1093/milmed/usy283.

Harcke HT, Lawrence LL, Gripp EW, Kecskemethy HH, Kruse RW, Murphy SG. Adult Tourniquet for Use in School-Age Emergencies.

Pediatrics. 2019 Jun;143(6). pii: e20183447. doi: 10.1542/peds.2018-3447. Epub 2019 May 7.

Howe S. Tourniquets go from combat to kids. Vector: Boston Children’s Hospital science and linical innovation blog. 2013; May 8. Available at: https://vector.childrenshospital.org/2013/05/tourniquets-go-from-combat-to-kids/ Accessed December 20, 2019.

Kelly J, Levy M, Reyes J, Anders J. Description of Penetrating Trauma in Children by Age and Location: A National Trauma Database Review. Special Operations Medical Association Scientific Conference. May 2019

Kragh JF Jr, Cooper A, Aden JK, Dubick MA, Baer DG, Wade CE, Blackbourne LH. Survey of trauma registry data on tourniquet use in pediatric war casualties. Pediatr Emerg Care. 2012 Dec;28(12):1361-5. doi: 10.1097/PEC.0b013e318276c260.

Kragh JF Jr, Wright-Aldossari B, Aden JK 3rd, Dubick MA.J Ease of Use of Emergency Tourniquets on Simulated Limbs of Infants: Deliberate Practice. Spec Oper Med. 2019 Summer;19(2):41-47.

Ross EM, Bolleter S, Simon E, Kharod CU. Pediatric Extremity Hemorrhage and Tourniquet Use. Journal of Emergency Medical Services 2018; November 1. Available at: https://www.jems.com/2018/11/01/pediatric-extremity-hemorrhage-and-tourniquet-use/ Accessed December 20, 2019.

Sokol KK, Black GE, Azarow KS, Long W, Martin MJ, Eckert MJ. Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs. J Trauma Acute Care Surg. 2015 Dec;79(6):983-9; discussion 989-90. doi: 10.1097/TA.0000000000000706.

Tourniquets for Kids. Stop the Bleed Australia. 2017; August 18. Available at: https://www.stopthebleed.com.au/2017/08/16/tourniquets-for-kids/ Accessed December 20, 2019.

Vretis, J. Comparison of commercial tourniquets in a pediatric trauma patient model. Prehosp Emerg Care. 2017 Oct 5:1-50. doi: 10.1080/10903127.2017.1377791. Abstracts for the 2018 NAEMSP Scientific Assembly. 2018;22:101-150.

Figure 1. FA-New-Prisma