Abstract
Trauma is the leading cause of mortality in those aged 1-19, with hemorrhage accounting for up to 40% of all trauma deaths. Manufactured tourniquets are recommended for the control of life-threatening extremity hemorrhage in adults but their use in the pediatric population requires further investigation. We performed a systematic review to evaluate the most appropriate tourniquet design for use in the pediatric population. A literature search of Embase and the Cochran databases of trials and systematic reviews on October 1, 2020 identified 454 unique references, of which 15 were included for full-text screening. Two single-arm observational studies with a high risk of bias evaluated the use of windlass tourniquets in the pediatric population (73 patients, age 2-16 years). The certainty of the evidence was very low. In both studies, conducted on uninjured extremities, the use of a manufactured windlass tourniquet, specifically the Combat Application Tourniquet (C-A-T®) Generation 7, led to the cessation of Doppler detected pulses in 71/71 (100%) of upper extremities and 69/73 (94.5%) of lower extremities. Of the four failures, one participant withdrew due to pain and three tourniquet applications failed to occlude pulses after three turns of the windlass. No controls were used for comparison. In conclusion, two observational studies demonstrated that windlass tourniquets were able to abolish distal pulses in children as young as two years of age and with a minimum limb circumference of 13 cm. These preliminary findings may be helpful for organizations in the creation of guidelines for the management of life-threatening extremity bleeding in children.
Highlights
IntroductionTrauma is the leading cause of mortality in those aged 1-19 years old [1]
BackgroundTrauma is the leading cause of mortality in those aged 1-19 years old [1]
Manufactured tourniquets have recently been recommended for the control of life-threatening extremity bleeding in adults, but their use in the pediatric population requires further investigation [5,6,7]
Summary
Trauma is the leading cause of mortality in those aged 1-19 years old [1]. In the prehospital period, when injuries may be more amenable to interventions that control bleeding, hemorrhage contributes to mortality in 33% to 56% of all trauma cases, and in one small study, was the most common cause of death prior to the arrival of emergency medical services [3,4]. Manufactured tourniquets have recently been recommended for the control of life-threatening extremity bleeding in adults, but their use in the pediatric population requires further investigation [5,6,7]. Pediatric limb circumferences are typically much less than those of adults, raising the concern that currently available manufactured tourniquets may not apply adequate circumferential pressure to stop bleeding in smaller children [6]. For example, employ a rigid mechanical advantage system (e.g., windlass or ratchet) that precludes their ability to fit circumferences that are smaller than that mechanism
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