ORIGINAL ARTICLE

Effectiveness of the combat application tourniquet for arterial

occlusion in young children

Joseph R. Kelly, MD, Matthew J. Levy, DO, Jose Reyes, BS, and Jennifer Anders, MD, Baltimore, Maryland

BACKGROUND: Tourniquet use for extremity hemorrhage has become a mainstay in adult trauma care in last 15 years. The efforts of the Stop the
Bleed campaign have increased the distribution and use of tourniquets in civilian settings in response to mass shootings and as part of
disaster preparedness. Little research or published experience exists regarding the use of tourniquets in the pediatric population. This
study sought to determine the minimum patient age on which the combat application tourniquet (CAT) is able to control extremity
hemorrhage.
METHODS: A convenience sample of pediatric patients, ages 1 year to 8 years, scheduled for elective orthopedic surgery at an academic hospital,
were eligible for enrollment. Subject age, weight, height, blood pressure, and arm and leg circumferences were obtained. Once under
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general anesthesia, the pulse of an upper and a lower limb were obtained by Doppler, a CAT was then placed at the most proximal
practical location of the limb until the corresponding pulse was either no longer obtainable by Doppler or until the tourniquet was
as tight as its design allows. The tourniquet was removed after 30 seconds of arterial occlusion.
RESULTS: Thirteen children, ages 2 years to 7 years were enrolled. Weights ranged from 12.8 kg to 23.9 kg, with a mean of 16.7 kg. Leg
circumferences were 24.5 cm to 34.5 cm, with a mean of 27.9 cm and arm circumferences were 13 cm to 24 cm, with a mean
of 16.3 cm. Subject heights were 87 cm to 122 cm, with a mean of 103.4 cm. Twenty-four total extremities were tested, 11 arms
and 13 legs. Arterial occlusion was obtained on 100% of limbs tested (95% confidence interval, 85.8–100%).
CONCLUSION: This study is similar to previous adult tourniquet efficacy studies in design, size and outcomes. It is the first to show successful
arterial occlusion on preschool-aged children with a commercial tourniquet in a controlled setting. The results suggest that the
CAT can be used in school-aged children with severe extremity hemorrhage with a high likelihood of success. (J Trauma Acute
Care Surg. 2020;88: 644–647. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Therapeutic, level II.
KEY WORDS: Trauma; hemorrhage; pediatrics; tourniquet.

T ourniquet use for extremity hemorrhage is well studied and

has become a mainstay in adult trauma care in last 15 years.1
However, a paucity of research or published experience exists
The reviews did not look at tourniquets that failed in the field
due to fit or function or the role of the tourniquet in contributing
to patient survival.4,5 The single MTF study did attempt to evalu-
with the use of tourniquets in the pediatric population. Much ate how many children arrived with tourniquets placed in field,
of present-day experience with tourniquets has come from military appropriateness of the tourniquet use, and contribution to patient
conflicts in Afghanistan and Iraq, and thus, most research has survival.6 In addition, one review of pediatric trauma literature
focused on their use in combatants who are primarily 20 years suggests that prefabricated trauma tourniquets should not be used
to 34 years old.2,3 Three retrospective studies have described in children younger than 8 years.7 More recently, Harcke et al.8
the use of commercially manufactured tourniquets for injured demonstrated that the Combat Application Tourniquet (CAT)
children in conflict zones.4–6 Two of the studies from the Joint could be effective on children ages 6 to 16 years which supports
Theater Trauma Registry (JTTR) overlapped in the time periods the anecdotal experience from children injured in conflict zones
reviewed. The third reviewed pediatric cases seen at a single Co- suggests that one of most common commercially manufactured
alition Military Treatment Facility (MTF) in Afghanistan, of tourniquets, the CAT, would likely work on limbs smaller than
which who patients would also have been captured by the JTTR. those of the average soldier.4–6 This study sought to determine
The two JTTR retrospective studies looked at pediatric patients the minimum limb size and patient age on which the CAT is able
with extremity hemorrhage controlled by tourniquets seen at to stop hemorrhage, which was selected as it is the most ubiqui-
various Coalition MTFs in the Iraq and Afghanistan theaters. tous of the Committee on Tactical Combat Casualty Care ap-
proved tourniquets and the tourniquet used in the Department of
Submitted: September 21, 2019, Revised: January 10, 2020, Accepted: January 10, Homeland Security's “Stop the Bleed” Campaign.9 Such infor-
2020, Published online: January 21, 2020. mation can potentially be used to inform practices related to the
From the Johns Hopkins Hospital (J.R.K., M.J.L., J.A.); and Johns Hopkins University
School of Medicine (J.R.), Baltimore, Maryland.
use of tourniquets in injured children.
Prior Presentations of data: 22nd Annual Meeting of Mid Atlantic SAEM, March 30,
2019, Washington, DC, oral abstract presentation. EMS Europe 2019, April
26–29, 2019, Madrid, Spain, abstract poster. AAP National Conference and Expo METHODS
2019, Oct 25–29, 2019, New Orleans, LA, abstract poster.
Address for reprints: Joseph Kelly, MD, c/o Jennifer Anders, MD, CMSC-144, 600 Subjects eligible for enrollment were stable pediatric or-
North Wolfe St., Baltimore MD, 21287 email: joseph.kelly@childrenscolorado.org.
thopedic surgical patients aged 1 year to 8 years and scheduled
DOI: 10.1097/TA.0000000000002594 to undergo elective general anesthesia at the Johns Hopkins
J Trauma Acute Care Surg
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J Trauma Acute Care Surg
Volume 88, Number 5 Kelly et al.

Hospital (Baltimore, MD). Informed consent was obtained from RESULTS

the legal guardians of each subject, and additional assent was ob-
tained from children aged 7 years and 8 years. Patients whose Thirteen children were enrolled and a total of 24 extremi-
guardians required interpretation or were not available to con- ties were tested. Subjects ranged in age from 2 years to 7 years
sent were excluded. In the consent process, families were given (mean 4.2 years). Demographic and anthropometric measurements
options to consent for a single-limb tourniquet application or are displayed in Table 1. The mean weight correlated to the 50 per-
both upper- and lower-limb applications. This study was re- centiles for boys aged 4 years 2 months and for girls 4 years
viewed and approved for human subject research compliance 4 months. The sample group's mean height correlated to the 50 per-
by the Johns Hopkins Medicine Institutional Review Board. centiles for boys aged 4 years and girls 4 years 1 month. Mean arm
Following consent, demographic information and anthro- circumference in our group was on par with 50 percentiles for boys
pometric measurements were obtained including child's age, aged 4 years 4 months and girls 4 years 1 month (Table 1).
weight, height, blood pressure, arm and leg circumferences. Af- Twenty-four total limbs were tested, 11 upper extremities
ter the child was under general anesthesia, the pulse of the upper and 13 lower extremities. One hundred percent of limbs ob-
and/or lower limb to be studied was obtained by Doppler. Fol- tained distal arterial occlusion with loss of Doppler pulse for
lowing Doppler pulse acquisition in the test limb, a CAT tourni- the full 30-second test interval (95% CI, 86–100%). Considered
quet was placed at the most proximal possible location of the separately, the preschool age group had 12 tested limbs (5 UE
same limb and windlass twisted until either (1) the correspond- and 7 LE) in seven patients with 100% efficacy (95% CI,
ing pulse was no longer obtainable by Doppler or (2) the tourni- 73.5–100%) (Fig. 1). The school age group consisted of 12
quet was maximally tightened. The tourniquet was removed limbs (6 UE, 6 LE) tested in six patients with 100% efficacy
after 30 seconds of arterial occlusion. (95% CI, 73.5–100%) (Table 2).
A priori sample size calculation was 37 limbs to determine
a minimum circumference. During the study period, 100% of the DISCUSSION
limbs tested were noted to have arterial occlusion, and it was
decided to truncate study accrual early. Standard CDC age The success of commercial tourniquets on the battlefield
groups of 1 year to 4 years and 5 years to 9 years were chosen has led to widespread advocacy for their use in civilian popula-
to allow practical grouping of subjects. Binomial probability tions, by EMS and the lay public.10 In the United States, the Stop
analysis was used to calculate 95% confidence intervals (CI) the Bleed Campaign focuses on a grassroots approach to teach
for the two age groups, 1 year to 4 years (preschool age) point of injury hemorrhage control. The campaign is seen as
and 5 years to 8 years (school age). Patient accrual continued an important step in mitigating the number of preventable
until the lower limit of >70% for the 95% CI was achieved in trauma deaths for all types if traumatic mechanisms of injury.
the younger age group as determined the Clopper-Pearson The program relies heavily on the use of commercial tourniquets
method. To demonstrate the representative size of children and aims to make tourniquets as widely available to the public as
in our sample, the mean height, weight, and arm circumfer- Automatic Electronic Defibrillators.11 The use of tourniquets is
ences were compared with the World Health Organization not limited to the victims of penetrating injuries: Traumatic am-
(WHO) percentiles for age. putations from lawnmowers,12 motor vehicle collisions, and

Figure 1. Success Rate of Arterial Occlusion by the CAT with 95% CI.

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 J Trauma Acute Care Surg
Kelly et al. Volume 88, Number 5

TABLE 1. Patient Demographics and Anthropometrics

50% WHO Age 50% WHO Age
Range Mean Correlate, Boys Correlate, Girls
Age (y) 2–7 4 y 2 mo N/A
Weight (kg) 12.8–23.9 16.7 4 y 2 mo 4 y 4 mo
Height (cm) 87–122 103.4 4 y 0 mo 4 y 1 mo
Arm circumference (cm) 13–24 16.3 4 y 4 mo 4 y 1 mo
Leg circumference (cm) 24.5–34.5 27.9 N/A N/A

agriculture accidents as well as severe soft tissue injuries from characteristics for a child with severe extremity hemorrhage.
animal bites may be amenable to initial treatment with However, further study is needed to validate use of other tourni-
tourniquets.13,14 quets to ensure effectiveness and account for variability specific
These results demonstrate the ability to achieve successful to individual device design. This information is of practical use
arterial occlusion using commercially available prefabricated for both first responders who find themselves caring for trau-
tourniquets on children as young as 2 years. The decision to re- matically injured children, as well as in support of preparedness
port these results prior to completing the intended enrollment and resilience efforts, such as the Stop the Bleed initiative. It is
was made based on the 100% efficacy and potential to signifi- our hope that these data will help inform a growing body of lit-
cantly extend the age range of children treated with the CAT. erature surrounding the use of tourniquets in children, with the
In the setting of ongoing conflicts and intentional mass trauma intent to help eliminate preventable deaths from trauma.
events, it was felt necessary to report meaningful results as early This study is limited by sample size, although the 100%
as possible, in hopes of saving future victims of exsanguinating experimental efficacy rate on a wide range of limbs sizes and
limb trauma. Correlation with WHO standards for height, ages is encouraging. While further data collection is needed to
weight and arm circumference suggest that our study design is ascertain a minimum effective limb circumference, if the upper
targeting an appropriate age range to validate CAT use in chil- extremities are analyzed as a group with a mean circumference
dren worldwide. This study is similar in size and design to other of 16.7 cm, the CAT could be used on limb circumferences of
live subject efficacy testing of various tourniquets with studies 16.7 cm or greater with high probability of success (95% CI,
typically consisting of 11 to 24 subjects where occlusion of distal 71.5–100%). Additional study on smaller limbs would poten-
arterial flow as measured by ultrasound was the primary tially demonstrate a minimum limb circumference, determine
outcome.15–18 Furthermore, the results of this study align with differences in efficacy between upper and lower extremities of
majority of the literature on the CAT which show efficacy of the same circumference and may provide a stronger recommen-
79% to 100%.19,20 There is one study of the CAT in which adult dation for the preschool age group.
volunteers applied the CAT to their mid-thigh which showed a This testing was done on otherwise well children undergoing
success rate of 16.7% with the application of a single tourni- general anesthesia and therefore does not reflect physiological
quet.17 Failures of the CAT applied adult thighs have generally changes that occur during traumatic injury. Furthermore, all testing
been felt to be due to the larger circumferences of adult thighs was done on intact limbs and thus did not look at changes in
which can be overcome by the application of second tourniquet. efficacy associated with traumatic amputation of the limb,
As this study is focused on the lower limit of efficacy, this form an important indication for tourniquet use. As tourniquet
of failure is not a concern in the target population of this study. use increases in children, morbidity and mortality benefits
We have not commented on the safety of commercial tourniquets should be studied to verify that the theoretical benefit trans-
in general or in the pediatric population, as it is beyond the scope lates into real benefit.
of this study. Commercial tourniquet use in adults has been well The CAT is highly likely to be effective for control of se-
studied and has been shown to be a safe, lifesaving intervention. vere extremity hemorrhage of both upper and lower limbs in
Further study of adverse effects of tourniquet use in pediatric pa- school aged children that are 4 years or older. Further data col-
tients is warranted as their use becomes more common place. lection is needed to better understand efficacy in preschool aged
The efficacy of the CAT demonstrated here firmly sup- children, determine minimum limb circumferences, and better
ports recommendation for use of the CAT to control severe ex- understand any differences in efficacy between upper and lower
tremity hemorrhage on any child old enough to attend grade extremities of similar size.
school. In addition, these findings suggest consideration for
use of commercially available windlass tourniquets with similar AUTHORSHIP
J.K. designed the protocol, provided instruction and oversight to study
members involved in study enrollment and measurement taking, and lead
TABLE 2. Success of Arterial Occlusion by the CAT in constructing the article. M.L. provided subject matter expertise on tour-
niquet use and advised in the design of the protocol and crafting of the
Successful Arterial
article. J.R. performed the majority of the subject enrollment and gather-
No. Subjects Arms Legs Occlusion (%) 95% CI
ing of the data. He also helped contributed content to the methods and
Total 13 11 13 100 85.8–100 results section of the article. J.A. acted as the principal investigator, provid-
1–4 y 7 5 7 100 73.5–100 ing invaluable counsel in the design of the study, writing of the article and
guiding the study through each step of the process.

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J Trauma Acute Care Surg
Volume 88, Number 5 Kelly et al.

ACKNOWLEDGMENTS terrorist attacks with multiple pediatric victims. Arch Pediatr. 2017;24(3):
280–287.
James Ficke, MD and The Johns Hopkins University, Department of
Orthopedic Surgery. 8. Harcke HT, Lawrence LL, Gripp EW, Kecskemethy H, Kruse R, Murphy S.
Adult tourniquet for use in school-age emergencies. Pediatrics. 2019;
DISCLOSURE 143(6):e20183447.
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C-A-T Resources made an in-kind gift of the tourniquets in return for 10. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital
non-exclusive use of published results. This study was supported by an in- guideline for external hemorrhage control: American College of Surgeons
kind donation of the tourniquets used by the manufacturer, CAT Resources, Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163–173.
Inc. The authors have no other conflicts of interested or funding to report.
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