Sweating the little things: Tourniquet application efficacy in two models of pediatric limb circumference

Background Current military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models. Methods Five different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet-Wide), SWAT-T (Stretch Wrap and Tuck-Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25" to 16.5". Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable). Results In both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75" circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25" and 15.5" circumference PVC pipes (age 7-12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes. Discussion The current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.