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J Trauma Acute Care Surg. 2020 Jan 21. doi: 10.1097/TA.0000000000002594. [Epub ahead of print]

Effectiveness of the Combat Application Tourniquet for Arterial Occlusion in Young Children.

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The Johns Hopkins Hospital The Johns Hopkins Hospital Johns Hopkins University School of Medicine The Johns Hopkins Hospital.


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.


A convenience sample of pediatric patients, ages 1-8 years old, scheduled for elective orthopedic surgery at an academic hospital, were eligible for enrollment. Subject age, weight, height, blood pressure, arm and leg circumferences were obtained. Once under 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.


Thirteen children, ages 2-7 years were enrolled. Weights ranged from 12.8-23.9kg, mean 16.7kg. Leg circumferences were 24.5-34.5cm, mean 27.9cm and arm circumferences were 13-24cm, mean 16.3cm. Subject heights were 87-122cm, mean 103.4cm. 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%.


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.Level of Evidence II, therapeutic.

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