Adult tourniquets work for school-age kids in an emergency

By Lisa Rapaport

(Reuters Health) - Children bleeding from severe traumas like gunshot wounds can be treated with adult-sized tourniquets, a small study suggests.

Gun injuries are a leading cause of death among school-age U.S. children, and if these young patients don't die on the way to the hospital, they often require major surgery and blood transfusions. While first responders have long used child-size tourniquets to stanch the bleeding in the field, less is known about what happens when adult-size tourniquets are used on smaller bodies, researchers note in Pediatrics.

For the current study, researchers tested how well the adult-size Combat Application Tourniquet (CAT) stopped blood flow to the extremities in 60 volunteers 6 to 16 years old. None of these kids had severe bleeding or gunshot wounds; instead researchers tightened the tourniquet and checked to see if it successfully cut of blood flow to the limb.

The tourniquet halted blood flow in the arm for all 60 kids, and it also stopped blood flow in the leg for 56 out of 60 children. This suggests that tourniquets sized for adult limbs may be used on school-age children in an emergency, said lead study author Dr. Theodore Harcke of Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

"Application of the CAT tourniquet in pediatrics is similar to application in adults, from the standpoint of placement and operation," Harcke said by email. "We found that smaller extremities are likely to require fewer turns."

Like many types of emergency tourniquets, the CAT device has two main parts. It includes a strap that's wrapped around the bleeding limb and a rod that's inserted between the strap and the limb and twisted until the pressure is strong enough to halt excessive blood flow from the wound.

One concern with applying adult-size tourniquets to kids is that the devices may be too loose to work effectively on tiny limbs, especially the upper arm.

In the study, researchers used a Doppler ultrasound to measure blood flow after the tourniquet was applied.

They twisted the tourniquet no more than three times to avoid causing pain. The four children who didn't show halted blood flow in their legs all had larger, adult-size limbs, and it's possible they might have required more than three turns for the tourniquet to work, the study authors note.

Placing the tourniquet over loose, lightweight clothing didn't appear to change its effectiveness in the children.

Researchers did carefully follow the CAT manufacturer's guidelines, making sure to place the tourniquet tightly enough around the limb that a finger can't fit between the band and the limb. With smaller arms and legs, they also placed the device in a concave position to make it easier to get a tight fit.

The study cannot prove that the adult tourniquet would work as well as a child-size tourniquet in a true bleeding emergency. It also didn't look at using adult-size tourniquets in kids younger than 6 years old, and it's possible results would be different for preschoolers or toddlers.

Still, the results suggest that first responders might be able to use an adult-size tourniquet on an older child in an emergency, said the author of an accompanying editorial, Dr. Charles Snyder of Children's Mercy Hospital and the University of Missouri at Kansas City.

"In a real application, the device can be tightened further, or a second tourniquet applied to the same limb," if that's needed to halt the bleeding, Snyder said by email.

Beyond the potential for an adult-size tourniquet to be too large for tiny bodies, there are other risks.

"If any tourniquet is left in place for a prolonged interval, the absence of blood flow beyond it can potentially result in ischemia (tissue death) in the distal limb," Snyder said. "Intermittent brief release can mitigate the ischemia, and . . . uncontrolled bleeding often is the more significant risk (life before limb)."

SOURCE: and Pediatrics, online May 7, 2019.