The 2012 study Death on the battlefield (2001–2011) by Eastridge et al.demonstrated that 7.5% of the prehospital deaths caused by potentially survivable injuries were due to external hemorrhage from the cervical region. The increasing use of Tactical Combat-Casualty Care (TCCC) and other medical interventions have dramatically reduced the overall rate of combat-related mortality in US forces; however, uncontrolled hemorrhage remains the number one cause of potentially survivable combat trauma. Additionally, the use of personal protective equipment and adaptations in the weapons used against US forces has caused changes in the wound distribution patterns seen in combat trauma. There has been a significant proportional increase in head and neck wounds, which may result in difficult to control hemorrhage. More than 50% of combat-wounded personnel will receive a head or neck wound.
The iTClamp (Innovative Trauma Care Inc., Edmonton, Alberta, Canada) is the first and only hemorrhage control device that uses the hydrostatic pressure of a hematoma to tamponade bleeding from an injured vessel within a wound.
The iTClamp is US Food and Drug Administration (FDA) approved for use on multiple sites and works in all compressible areas, including on large and irregular lacerations. The iTClamp’s unique design makes it ideal for controlling external hemorrhage in the head and neck region. The iTClamp has been demonstrated effective in over 245 field applications.
The device is small and lightweight, easy to apply, can be used by any level of first responder with minimal training and facilitates excellent skills retention. The iTClamp reapproximates wound edges with four pairs of opposing needles. This mechanism of action has demonstrated safe application for both the patient and the provider, causes minimal pain, and does not result in tissue necrosis, even if the device is left in place for extended periods.
The Committee on TCCC recommends the use of the iTClamp as a primary treatment modality, along with aCoTCCC-recommended hemostatic dressing and direct manual pressure (DMP), for hemorrhage control in craniomaxillofacial
injuries and penetrating neck injuries with external hemorrhage.
Tactical Field Care:
3. Massive Hemorrhage
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2–3 inches above
the bleeding site. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible (external) hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice.
• Alternative hemostatic adjuncts:
– Celox Gauze or
– ChitoGauze or
– XStat (best for deep, narrow-tract junctional wounds)
– iTClamp (may be used alone or in conjunction with hemostatic dressing or XStat)
• Hemostatic dressings should be applied with at least 3 minutes of direct pressure (optional for XStat).
Each dressing works differently, so if one fails to control bleeding, it may be removed and a fresh dressing of the same type or a different type applied. (Note:
XStat is not to be removed in the field, but additional XStat, other hemostatic adjuncts, or trauma dressings may be applied over it.)
• If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a CoTCCC recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or
while the junctional tourniquet is being readied for use.
c. For external hemorrhage of the head and neck where the wound edges can be easily re-approximated, the iTClamp may be used as a primary option for hemorrhage control. Wounds should be packed with a hemostatic dressing or XStat, if appropriate, prior to iTClamp application.
• The iTClamp does not require additional direct pressure, either when used alone or in combination with other hemostatic adjuncts.
• If the iTClamp is applied to the neck, perform frequent airway monitoring and evaluate for an expanding hematoma that may compromise the airway. Consider placing a definitive airway if there is evidence of an expanding hematoma.
• DO NOT APPLY on or near the eye or eyelid (within1cm of the orbit).
Tactical Evacuation Care
2. Massive Hemorrhage
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life-
threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2 to 3 inches above the
bleeding site. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible (external) hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice.
• Alternative hemostatic adjuncts:
– Celox Gauze or
– ChitoGauze or
– XStat (best for deep, narrow-tract junctional wounds)
– iTClamp (may be used alone or in conjunction with a hemostatic dressing or XStat)
• Hemostatic dressings should be applied with at least 3 minutes of direct pressure (optional for XStat). Each dressing works differently, so if one fails to
control bleeding, it may be removed and a fresh dressing of the same type or a different type applied.
(Note: XStat is not to be removed in the field, but additional XStat, other hemostatic adjuncts, or trauma dressings may be applied over it.)
• If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or
while the junctional tourniquet is being readied for use.
c. For external hemorrhage of the head and neck where the wound edges can be easily re-approximated, the iTClamp may be used as a primary option for hemor
rhage control. Wounds should be packed with a hemostatic dressing or XStat, if appropriate, prior to iTClamp application.
• The iTClamp does not require additional direct pressure, either when used alone or in combination with other hemostatic adjuncts.
• If the iTClamp is applied to the neck, perform frequent airway monitoring and evaluate for an expanding hematoma that may compromise the airway. Consider placing a definitive airway if there is evidence of an expanding hematoma.
• DO NOT APPLY on or near the eye or eyelid (within 1cm of the orbit).
Eastridge BJ, RL Mabry, P Seguin, J Cantrell, T Tops, P Uribe, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg.2012;73(6 suppl 5):S431–S437.