Survey of Trauma Registry Data on Tourniquet Use in Pediatric War Casualties John F. Kragh, Jr, MD,*Þ Arthur Cooper, MD, MS,þ James K. Aden, PhD,* Michael A. Dubick, PhD,* David G. Baer, PhD,* Charles E. Wade, PhD,§ and Lorne H. Blackbourne, MD, MC, USA* Objectives: Previously, we reported on the use of emergency tourni- quets to stop bleeding in war casualties, but virtually all the data were from adults. Because no pediatric-specific cohort of casualties receiving emergency tourniquets existed, we aimed to fill knowledge gaps on the care and outcomes of this group by surveying data from a trauma reg- istry to refine device designs and clinical training. Methods: A retrospective review of data from a trauma registry yiel- ded an observational cohort of 88 pediatric casualties at US military hospitals in theater on whom tourniquets were used from May 17, 2003, to December 25, 2009. Results: Of the 88 casualties in the study group, 72 were male and 16 were female patients. Ages averaged 11 years (median, 11 years; range, 4Y17 years). There were 7 dead and 81 survivor outcomes for a trauma survival rate of 93%. Survivor and dead casualties were similar in all independent variables measured except hospital stay duration (median, 5 days and 1 day, respectively). Six casualties (7%) had neither extremity nor external injury in that they had no lesion indicating tour- niquet use. Conclusions: The survival rate of the present study’s casualties is similar to that of 3 recent large nonpediatric-specific studies. Although current emergency tourniquets were ostensibly designed for modern adult soldiers, tourniquet makers, perhaps unknowingly, produced tour- niquets that fit children. The rate of unindicated tourniquets, 7%, implied that potential users need better diagnostic training. Levels of Evidence: Level 4; case series, therapeutic study. Key Words: first aid, resuscitation, damage control, hemorrhage, shock (Pediatr Emer Care 2012;28: 1361Y1365) T ourniquet use has been associated with improved survival by stopping traumatic bleeding, but virtually all the data have been from adults. Recent emergency tourniquet reports gave evidence of lifesaving benefit with low morbidity in battle ca- sualties, but those reports did not specifically focus on children, who have smaller limbs compared with adults. 1Y5 Although most war casualties are limb-injured adults, 6,7 specific knowledge gaps exist for the pediatric casualties. For example, no pediatric-specific cohort exists in a casualty study of emergency tourniquet use. Devices used on children may or may not fit, and there is no pediatric-specific data evidencing survival rates. No research findings guide tourniquet desig- ners as to what, if any, problems occur in children. The US military cares for some pediatric casualties that present to mil- itary treatment facilities on the battlefield, including those with tourniquets used, but the number is unknown. The military experts are in fact the world experts, and so the criteria to design the devices mainly come from the military. For example, the 1998 US Army Anthropometry helped guide military experts in consultation with device designers. 8 Designers used those data to guide development of their devices, but children were not included. Filling these knowledge gaps may help device makers improve designs and may help refine tourniquet training for use of tourniquets in children. Lessons learned from the epidemic of war casualties can inform civilian trauma care; bleeding from a traumatic amputation can differ little whether from a bomb, a car crash, or farm accident. The goal of this study was to measure tourniquet use in pediatric trauma care to help identify if a gap in device design or clinical training exists. METHODS This survey is a retrospective review of deidentified data extracted from the Joint Trauma System’s Joint Theater Trauma Registry at the US Army Institute of Surgical Research. A case count under a preparatory research agreement indicated that there were enough cases to proceed with a protocol. The pro- tocol was reviewed by the US Army Medical Research and Materiel Command’s Institutional Review Board staff, which de- termined that the protocol comprised research not involving human ORIGINAL ARTICLE Pediatric Emergency Care & Volume 28, Number 12, December 2012 www.pec-online.com 1361 From the *US Army Institute of Surgical Research, Fort Sam Houston, TX; †F. Edward He ´bert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; ‡Department of Surgery, Harlem Hos- pital Center, College of Physicians and Surgeons Columbia University, New York, NY; and §University of Texas Health Science Center at Houston, Houston, TX. Disclosure: The authors declare no conflicts of interest. Reprints: John F. Kragh Jr, MD, US Army Institute of Surgical Research, Damage Control Resuscitation, 3698 Chambers Pass, Bldg BHT2 Room 222-4, Fort Sam Houston, TX 78234-6315 (e-mail: john.kragh1@us.army.mil). Dr Kragh is an employee of the US Government and receives institutional support through the place where he works, the US Army Institute of Surgical Research. He has consulted at no cost with M2, Inc; Tiger Tourniquet, LLC; Tactical Medical Solutions, LLC; Combat Medical Systems, Inc; Composite Resources Inc; Delfi Medical Innovations, Inc; North American Rescue Products LLC; H & H Associates, Inc; Creative & Effective Technologies, Inc; TEMS Solutions, LLC; Blackhawk Products Group; Hemaclear; Tactical Development Group; Compression Works, LLC; Tier-One Quality Solutions; Kforce Government Solutions; CHI Systems; and Entrotech, Inc. He has received honoraria for work for the Food and Drug Administration for a device consultation. He has received honoraria for trustee work for the nonprofit Musculoskeletal Transplant Foundation. He has worked as a technical representative to the US Government’s contracting officer in agreements with Physical Optics Corporation; Resodyn Corporation; International Heart Institute of Montana Foundation; Daemen College; Noble Biomaterials, Inc; Wake Forest Institute of Regenerative Medicine; National Tissue Engineering Center; Pittsburgh Tissue Engineering Initiative; University of Texas Southwestern Medical Center; Arteriocyte, Inc; and Kelly Space and Technology, Inc. For the remaining authors nonewere declared. This project was funded with internal US Army Institute of Surgical Research funds and not from any of the following organizations: National Institutes of Health, Wellcome Trust, Howard Hughes Medical Institute, or other. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or United States Government. The authors are employees of the US Government. This work was prepared as part of their official duties, and as such, there is no copyright to be transferred. Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0749-5161 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.