Bleeding Children

In this month’s issue of Pediatrics, Harcke et al¹ provide us with a simple and useful study to determine whether the adult-designed combat application tourniquet (CAT) can be safely and effectively used in school-aged children. The “Stop the Bleed” national campaign to teach bystanders how to manage a bleeding emergency uses the CAT, and the effective use of a tourniquet for exsanguinating extremity trauma in the prehospital setting is a key component of trauma readiness protocols advocated by the American Academy of Pediatrics and others.^2,3 

The study authors enrolled 60 healthy volunteers between the ages of 6 and 16 years who underwent CAT application on the upper and lower extremities, with concomitant Doppler assessment of distal pulses. To avoid pain, a maximum limit of 3 complete turns were allowed to tighten the tourniquet. The CAT was well tolerated in 56 of 60 patients and was found to be effective in all upper extremities and most (93%) lower extremities. The few failures of the CAT were in larger, older children and were likely a function of the 3-turn limit. In adults, a second tourniquet is used if the first proves insufficient. Although most pediatricians infrequently encounter acute traumatic injury, ensuring safe and efficacious care of injured children in an emergency or mass casualty setting is relevant to all.

The straightforward nature of this study and evidence that an adult tourniquet works well in children should not draw focus away from the wider issues it raises. The increasing frequency of mass shootings has been a driving force in efforts to improve prehospital care for both children and adults. The unspoken issue is the appalling social conditions that make an article on how to stop 6-year-olds from bleeding to death after gunshot wounds necessary in the first place. Almost as tragic is the inurement to school shootings and resultant ease with which we, the putative guardians of children’s health, can blithely read such articles with scarcely a second thought about the existence of the larger problem: repeated mass injuries from school shootings. The United States is the clear world leader in both absolute and relative frequency of school shootings, with >250 reported since 2009.^4,5 

Of course, hemorrhagic trauma can result from a wide variety of injuries. Readily available and effective devices for controlling extremity bleeding are critical. More than half of civilian deaths from bleeding could have been prevented with adequate hemorrhage control.^6,7 Provision of high-quality emergency care for children benefits us all.

CAT

combat application tourniquet